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

ANNA TAKÁCS, REBECCA KONCZ, ADITH MOHAN, Perminder Sachdev
OPEN ACCESS

Discussion of wills and power of attorney is relevant for all older patients irrespective of the diagnosis.

Safe driving should be addressed. Dementia is a reportable medical condition to licensing authorities. When dementia is diagnosed then the patient needs to notify the licensing authority of this. Driving problems should be sought in the history. If difficulty with driving is suspected or unclear then a driving assessment with an occupational therapist should be recommended and the licensing authority notified.

Support organisations such Alzheimer’s Australia can be invaluable sources of information and support for patients with concerns about cognition or actual cognitive decline.

Optimising treatment of comorbid conditions

In addition to the above advice, patients with a diagnosis of MCI or mild dementia with comorbid medical conditions should have their treatments optimised, aiming to address any reversible causes of dementia. Obstructive sleep apnoea and atrial fibrillation should be treated.16

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Medications should be rationalised, with particular attention to reducing or ceasing medications that are known to cause cognitive impairment. These include (but are not limited to) opioids, benzodiazepines, anticonvulsants, antihistamines, tricyclic antidepressants, anticholinergics, corticosteroids and beta-blockers.

Pharmacological treatments

There are currently no evidence-based recommendations on medications to treat MCI.17 If dementia is suspected then specialist referral is recommended, as described above, for confirmation of the diagnosis. If Alzheimer’s disease is confirmed then PBS-covered pharmacological treatment can be considered (e.g. acetylcholinesterase inhibitors such as donepezil, galantamine or rivastigmine, or the N-methyl-D-aspartate receptor antagonist memantine).11

Patients with simple anxiety or depression are treated with standard therapies. A psychiatric or psychogeriatric referral should be considered for:

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  • patients who do not respond to 
  • first- or second-line treatment
  • patients with atypical mental health presentations
  • patients with significant psychiatric histories, including complicated depression and/or anxiety or comorbid severe mental illnesses such as schizophrenia and bipolar affective disorder.

Follow up

If the diagnosis remains unclear after a detailed assessment then provide general advice as described above and watchfully wait. All patients should have a cognitive review with a screening instrument every 12 months, or sooner if deterioration is detected by the patient or their family.

Risk factors for progression of MCI to dementia include older age, less education, stroke, diabetes and hypertension. Patients who are younger, more educated with higher baseline cognitive function and a nonamnestic domain of cognitive impairment are more likely to revert from MCI to normal cognition. Even after 10 years, between 40 and 70% of patients with MCI may not have developed dementia.17,18

Conclusion

Memory or cognitive complaints are common in older patients, although the cause of this presentation can be manifold. A detailed history from the patient and a carer can elucidate the particular nature of the cognitive problems and their functional impact. Screening for medical and psychiatric conditions may identify treatable causes. Cognitive assessment is essential, and screening tools are available that can be used to objectively track cognition over time.

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Specialist referral should be considered when patients have complex medical or psychiatric histories or new neurological signs, or dementia is suspected. There are no medications indicated to treat mild cognitive impairment, but neuroprotective advice is appropriate for all ageing patients. All patients should be followed up and rescreened within 12 months, as often dementia is disgnosed over an extended period of surveillance.  MT

COMPETING INTERESTS: None.

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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.