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Feature Article

Forgetfulness, stress or mild dementia? Cognitive assessment of older patients

ANNA TAKÁCS, REBECCA KONCZ, ADITH MOHAN, Perminder Sachdev
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Abstract

Cognitive complaints are common among older people and have many causes, including the normal changes of ageing. A detailed history and cognitive screening are essential for diagnosis, and screening for medical and psychiatric conditions may identify a treatable cause. All older patients presenting with forgetfulness may benefit from neuroprotective advice. Specialist referral should be considered in complex cases or when dementia is suspected.

Key Points

  • Concerns about memory are common in older patients.
  • Cognitive changes are normal for almost all people as they age, and assessment should focus on differentiating the normal changes of ageing from abnormal cognitive functioning.
  • Primary cognitive problems should be differentiated from secondary disorders, such as those caused by a medication, medical condition or psychiatric problem.
  • Assessment and follow up should include use of a cognitive screening tool such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) or General Practitioner Assessment of Cognition (GPCOG).
  • The management of mild cognitive impairment includes good medical care and general neuroprotective advice, which is relevant to all older patients presenting with memory concerns.

    Picture credit: © Ivanastar/iStockphoto.com
    
Model used for illustrative purposes only

Memory or cognitive impairment is common among older patients in general practice. The presentation may be direct or covert and the person presenting may be the patient, a  carer or a concerned family member. Example presentations include:

  • an older patient complains of difficulty remembering names, finding words or misplacing things
  • a family member worries that their loved one seems confused or struggles to do previously routine tasks such as cooking or paying bills
  • a patient with a chronic illness who is well known to the practice appears less ‘on the ball’ than usual, or their previously stable disease becomes difficult to control or deteriorates unexpectedly
  • a patient who is usually regular in attending the practice misses appointments
  • a patient presents for review after an unexpected car accident while driving.

Although memory or cognitive impairment can herald a diagnosis of early or mild dementia, it may be a presentation of a psychiatric condition such as depression or anxiety or a part of normal ageing. This article aims to provide guidance for GPs to aid confident assessment of patients with potential cognitive impairment.

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Terminology

Cognitive difficulties

When patients complain of memory problems, they could be referring to difficulties in a number of possible cognitive domains (Table 1). Although learning and memory is often the most salient of these domains, the problems could also be in:

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  • attention (ability to sustain or shift focus)
  • language (naming, producing words, comprehension, grammar or syntax)
  • perceptual and motor skills (construction, visual perception)
  • executive function (planning, reasoning, decision making, mental flexibility)
  • social cognition (reading others’ emotions and intentions, regulating behaviour).

It is thus often more appropriate to refer to cognitive rather than memory complaints or deficits.

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Dr Takács is a Psychiatry Registrar at NorthWestern Mental Health, Melbourne, Vic. Dr Koncz is a Neuropsychiatry Fellow at the Neuropsychiatric Institute, Prince of Wales Hospital, Sydney; and a PhD Student at the Centre for Healthy Brain Ageing (CHeBA), UNSW Sydney. Dr Mohan is a Senior Lecturer and Research Fellow at CHeBA, UNSW Sydney; and a Neuropsychiatrist at the Neuropsychiatric Institute, Prince of Wales Hospital, Sydney; Professor Sachdev is Professor of Neuropsychiatry at UNSW Sydney; and Director of the Neuropsychiatric Institute at the Prince of Wales Hospital, Sydney, NSW.