When to Refer Patients With New Memory Loss

Marcia Frellick

May 05, 2021

Asking a patient who has concerns about memory loss particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) Internal Medicine Meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

Dr Megan Richie

These questions "will help get at how pervasive and how likely the memory loss is affecting their lives, vs a subjective complaint that doesn't have much impact on the day-to-day function," she said.

It's also important to ask whether other neurocognitive symptoms accompany the memory loss, Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

"When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?" Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

"These are all going to help you determine the acuity of the workup," she said.

After a thorough history, cognitive screening is the next consideration.

Cognitive Screening Can Be Performed in Minutes

One of the tests Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer's Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Richie said it's important to eliminate some key causes first: "Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients," she pointed out.

Systemic medical conditions can also lead to memory loss.

If there's an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that's key in questioning.

Richie explained that the American Academy of Neurology recommends a very limited workup.

"It's really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.

"You do not routinely need spinal fluid testing or an EEG," she emphasized.

Signs that a neurologist should be involved include a rapid decline or signs of potential seizures or that the patient doesn't seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don't cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Richie said.

Dr Celine Goetz

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told Medscape Medical News that it's easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

"Richie's talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we're all terrified of losing our memory and the social and functional impairment that comes with that," she said.

Although cognitive impairment and dementia aren't curable or reversible, Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Goetz emphasized that resources are plentiful and can be effective in combination.

"Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care," she said.

Richie and Goetz report no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine Meeting: Presented April 29, 2021.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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