Primary Care of the Family II

Bates' Clinical Skills Video Memory Loss

Narrator: This video is designed to help prepare you for objective structured clinical examinations, or OSCEs.

You are about to participate in the office visit of a 70-year-old woman with the complaint of memory loss. As you watch this encounter, you will be asked to answer questions while the image on the screen freezes. These questions will engage you in practicing the skills of focused history taking, physical examination, and clinical reasoning as you develop your preliminary differential diagnoses, based on the guidelines designated in the USMLE Step II Clinical Skills Examination.

You are expected to develop three diagnoses with supporting history and physical exam findings and list the diagnostic workup studies you would order. You will have time to record your findings and receive feedback.

Health History

Clinician: Good morning, Mrs. Wilson. Tell me about your special concerns today.

Mrs. Wilson: Well, I'm worried about forgetting things. My memory has always been good. But lately, I have to write everything down that I want to do each day. My family wants me to talk to you about this.

Narrator: What preliminary diagnoses are you considering at this time?

Press pause and list your answers. Resume when you are ready to receive feedback.

Clinician: Can you tell me more about how you're feeling?

Mrs. Wilson: Well, I retired four years ago from teaching, so I could spend more time with my grandchildren. They live here in the city. It's been great to have time to enjoy my family and friends, but I am worried about my memory.

Clinician: What kinds of problems with your memory have you noticed?

Mrs. Wilson: I've always been a little forgetful…"fuzzy," my husband used to call it. But I've made up for that by keeping lists and making a pile of things I'll need when I go out, right next to my purse. In the past few months, though, I haven't been able to remember names very well. Yesterday, in the grocery store, I tried to introduce two good friends to each other and I couldn't remember one of their names! And sometimes I miss appointments, even when I write them down in my appointment book.

Clinician: How are you at remembering the names of book titles, or items on your grocery list?

Mrs. Wilson: Usually that's OK, but I depend more on my grocery list than I used to.

Clinician: Would you say you have problems finding words?

Mrs. Wilson: Now and then, I have trouble with words. I seem to have the most trouble with names and remembering meetings. When I think about it, maybe doing my crossword puzzle is a little tougher than it used to be.

Clinician: What has your family noticed?

Mrs. Wilson: They say I'm forgetting to call at our usual times, and that I seem a little distracted sometimes when we get together, as if I'm not completely following the conversation.

Clinician: How about remembering events in the past month, compared to long ago, such as what you remember from college or your early years of your marriage.

Mrs. Wilson: I seem to have more trouble with recent events. My memories from childhood, college, and raising my children still seem crystal clear.

Clinician: Just to review, how old are you now?

Mrs. Wilson: I turned 70 last fall.

Clinician: Has life been hard for you since your husband passed away? Was it three years ago?

Mrs. Wilson: We were always close and yes, it's been quite an adjustment. I'm thankful my children and grandchildren are close by.

Clinician: How would you describe your spirits right now?

Mrs. Wilson: Do you mean, am I depressed? No, not really. I'm sad sometimes when I think about the past and I feel lonely. Most of the time I look forward to each new day and I'm volunteering quite a bit, and I exercise much more than I used to.

Clinician: Have you had any trouble balancing your checkbook or keeping track of your bank account?

Mrs. Wilson: So far, that's okay—no overdrawn checks yet.

Clinician: What about walking or driving? Have you had any trouble finding your way?

Mrs. Wilson: No, I've never really been lost.

Clinician: How is your health, in general? I see you've been treated for high blood pressure.

Mrs. Wilson: My health has been good except for that. I take the blood pressure medicine, and my blood pressure has been fine. I have some trouble sleeping, so I take some over- the-counter pills when I need to.

Clinician: Can you list all the pills you've been taking right now?

Mrs. Wilson: Just hydrochlorothiazide and Benadryl.

Clinician: Anything else? Do you take vitamins or herbal medication?

Mrs. Wilson: No, just those two drugs.

Clinician: What about your sleeping? Have you been drowsy at all during the day?

Mrs. Wilson: If I take the Benadryl, I'm fine. And I never really slept during the day.

Clinician: Do you drink alcohol? Many older patients drink when they're alone.

Mrs. Wilson: I have a glass of wine with dinner three or four times a week, but drinking has never been a problem for me.

Clinician: How about any changes in your weight, or recent infections?

Mrs. Wilson: No, but I'm committed to exercise so I stay in shape and I refuse to let myself go.

Clinician: That's great, and exercise is so import ant for your strength and balance. Has anyone in your family had memory problems or dementia?

Mrs. Wilson: My mother said that two of my grandparents were senile late in life, but that's all I know about.

Clinician: Is there anything we've missed that you want to add?

Mrs. Wilson: No, that's everything, but I hope I'm okay. I want to stay independent and do whatever I can to take care of this.

Clinician: Just to summarize, in the past few months you and your family have noticed that you are more forgetful with names and recalling words. On our next visit, you should ask one of your family members to come in with you. That will help us better understand your family's concerns. For now, let's do your physical examination and some basic tests, then we'll talk more.

Physical Examination

Narrator: With the patient's health history in mind, and after good hand hygiene, you are ready for the physical examination.

Clinician: Your blood pressure is 135 over 85, which is good, and your heart rate and temperature are normal.

Narrator: What areas of physical examination are important for this patient?

Press pause and list your answers. Resume when you are ready to receive feedback.

Test the patient's vision.

Clinician: Read this row of numbers.

Mrs. Wilson: 3, 7, 4, 2, 5, 8

Narrator: Test the patient's hearing.

Clinician: 1.

Mrs. Wilson: 1.

Clinician: 3

Mrs. Wilson: 3.

Clinician: 2.

Mrs. Wilson: 2.

Clinician: 7.

Mrs. Wilson: 7.

Clinician: 9.

Mrs. Wilson: 9.

Clinician: Now I'm going to ask you to do the "Get Up and Go Test" When I tell you please stand up from the chair, walk to the mark on the floor, turn around, come back and sit down. Ready? Go.

[Patient performs test]

Clinician: Next, I'm going examine your lungs, heart, and abdomen. I want to make sure you don't have any bruits, or rushing sounds, in the arteries in your neck. I'll listen to the arteries in your abdomen for sound as well.

Narrator: The mental status examination is a key element in assessing mental function and memory. The complete examination tests:

There are special screening tests for dementia, which are shorter and easier to use during a general office assessment, and well - validated. Geriatricians now commonly use the Montreal Cognitive Assessment. Scores less than 22 are consistent with dementia.

Clinician: Now, draw a line in order from each number to each letter without taking your pen off of the paper.

Narrator: The Montreal Cognitive Assessment includes a trail-making test, a clock-drawing test, a word-finding test, and brief 5-item tests for memory, attention, language, and orientation.

Clinician: Alright, now I'm going to read a list of five words. You listen to them and then repeat them. In 5 minutes, I will ask you to tell me these words again. Ready? Rose, chair, velvet, church, daisy.

Mrs. Wilson: Rose, chair, velvet, church, and daisy.

Clinician: Mrs. Wilson, please subtract 7 from 100.

Mrs. Wilson: 93.

Clinician: And subtract 7 from that.

Mrs. Wilson: 86.

Clinician: Keep going.

Mrs. Wilson: 79m 74…68…

Rose, chair, church?.I can't, I don't know the others.

Clinician: You recalled three out of the five items after five minutes, and missed two of the subtractions, so your score on the Montreal Cognitive Assessment is 26. This means you may have some early memory loss, but it's mild.

Narrator: The Mini-Cog is another validated screening tool. The Mini-Cog tests three-item recall and clock-drawing.

After assessing mental status, carefully examine the nervous system, including cranial nerves, motor and sensory systems, and reflexes, comparing the left and right sides.

Clinician: I'll start your neurological examination and check what we call the 12 cranial nerves, which supply important structures in your face and neck that affect vision, hearing, and speech.

Narrator: Examine the 12 cranial nerves:

Clinician: All 12 cranial nerves are fine.

Narrator: Test motor and sensory function and reflexes, including the plantar reflex.

Clinician: I'm going to check the strength in some of your muscles, sensation, and reflexes. Arms out just like this, pull them in.

Narrator: Test muscle strength, comparing the left and right sides. Test the biceps.

Clinician: And patellar reflexes.

Mrs. Wilson: My reflexes seem pretty good!

Clinician: Yes. Now I'm going to check the reflex on the bottom of your feet, which we call the plantar reflex. This can feel a little uncomfortable. Your plantar reflexes are normal. Is that sharp?

Mrs. Wilson: Mhm.

Clinician: Is that about the same?

Mrs. Wilson: Same.

Clinician: Mrs. Wilson, please walk across the room, now turn around and walk back. Good. Your neurological examination, except for the memory and subtraction changes on the Montreal Cognitive Assessment score, is normal. Let's review some of the details of this examination.

Diagnostic Considerations

Narrator: In this 70-year-old retired teacher and widow, what are your 3 diagnostic considerations in order of priority? Press pause and list your answers. Resume when you are ready to receive feedback.

Diagnosis 1: Dementia: Memory loss is a common concern among older patients. The challenge is to distinguish the benign forgetfulness of aging from mild cognitive impairment, the several types of dementia, and depression, and to assess any adverse effects from medication or polypharmacy.

Dementia is "an acquired cognitive condition that is characterized by a decline in at least two cognitive domains (e.g., loss of memory, attention, language, or visuospatial or executive functioning) that is severe enough to affect social or occupational functioning."

The predominant form is Alzheimer disease, which affects 11% of Americans older than 65. Onset is usually gradual and often goes unrecognized.

Key initial features include the following:

Progression is indicated by problems with:

The spectrum of cognitive decline includes:

In mild cognitive impairment, daily function is preserved, but there is cognitive decline in one or more cognitive domains. Each year, 10% to 15% of these patients progress to Alzheimer disease.

Alzheimer disease is one of several dementias. These include Lewy body disease, vascular dementia, and frontotemporal dementia. Lewy body disease affects 15% to 25% of patients with dementia, making it the second most common cause of dementia. Clues are signs of parkinsonism, visual hallucinations, delusions, and gait disorder.

This healthy, 70-year-old retired teacher is on the spectrum of cognitive decline. Her symptoms, normal neurologic examination, and Montreal Cognitive Assessment score are most consistent with mild cognitive impairment. Regular follow-up with family members present will be important.

Optimization of hearing, vision, vascular risk factors, and family engagement and social supports should be encouraged.

Depression affects 3% to 7% of community-dwelling older adults and is often undiagnosed. Presentation in older adults is often atypical, often in the form of somatic symptoms. Look for delayed verbal responses and psychomotor slowing.

The prevalence of depression is higher in patients who are isolated, bereaved, and have multiple medical problems, especially chronic pain, Parkinson disease, cancer, and alcohol abuse.

Screening is straightforward. Two screening questions have a sensitivity as high as 100% and specificity up to 77 %. These questions are: "During the past 2 weeks, have you felt down, depressed, or hopeless?" and "During the past 2 weeks, have you felt little interest or pleasure in doing things?"

This patient has a positive affect and denies feeling depressed. She also lacks evidence of delirium, another common contributor to changes in mental status, often arising from infection. Delirium is an acute confusional state with fluctuating attention, concentration, and orientation.

Older Americans, who use prescribed medications at the highest rates, are highly subject to polypharmacy. Among older adults, 90% take at least one medication a day, and almost 50% take five or more medications daily. This accounts for more than half of adverse drug reactions that lead to hospitalization.

The Beers criteria provide widely used guidelines for drugs that are contraindicated in older adults. These drugs include diphenhydramine, which this patient is taking.

Although occasional use of diphenhydramine is not likely to cause memory changes in this patient, a careful sleep history is warranted, and diphenhydramine should be discontinued. Over-the-counter "PM" products should be avoided.

Diagnostic Workup

List the three next steps in your diagnostic workup. Press pause and list your answers. Resume when you are ready to receive feedback.

Neuropsychologic testing entails formal testing of multiple cognitive domains. These include:

In general, neuropsychologic testing is reserved for more advanced stages of memory loss. So it can be deferred in this patient. A diagnosis of dementia requires evidence of cognitive decline, so input from family members at future visits will be essential. If cognitive function is intact, then clinical causes of memory loss other than dementia should be pursued.

Laboratory serologic tests.

The diagnosis of dementia rests on demonstrating the progression of cognit ive change and neurologic findings over time. Reversible causes of dementia are rare, so serologic tests are of uncertain value.

The following laboratory tests are recommended, although supporting evidence is limited:

Head CT or MRI

The use of neuroimaging varies by clinical setting, and clinical guidelines are not uniform. In primary care and geriatric practices, patients c an be followed over several visits, whereas neurologists may see patients only once. Neuroimaging is helpful for patients with atypical presentations, acute change in mental status, or in need of immediate reassurance. Head CT and MRI can demonstrate diffuse brain atrophy and ventricular enlargement typical of Alzheimer disease. Neuroimaging can also exclude vascular disease, subdural hematoma, and mass lesions. On MRI, diffuse white matter lesions are suspicious for Alzheimer disease. In this patient, however, neuroimaging probably can be deferred until there is more evidence of cognitive decline.

Summary

In summary, this 70-year-old retired teacher reports recent problems with memory. She notes loss of names, dates, and sometimes names of objects. Doing crossword puzzles takes more time, and her family has noticed that she sometimes seems confused.

She is in good health, with the exception of hypertension, for which she takes hydrochlorothiazide as prescribed. The patient exercises regularly and has moder ate alcohol intake. She also takes diphenhydramine for insomnia. However, this medication has cholinergic adverse effects and is contraindicated in older adults according to the Beers criteria and should be discontinued.

On physical examination, her vital signs are normal. Vision, hearing, leg mobility, and "Get Up and Go" testing on the 10 - Minute Geriatric Screener are normal. She has a score of 26 on the Montreal Cognitive Assessment. Her remaining neurologic function is intact, with no evidence of focal findings.

Possible diagnostic studies include:

[See references]