Case Scenario from Assignment: A 75 year-old female presents with short-term memory loss, with family noting that she forgets conversations and appointments and repeats herself often, with symptoms present for 6+ months but increasing in frequency. Long-term memory is intact.
A full diagnostic process includes six steps: collecting patient history, gathering information from family and/or caregivers, a physical examination, brief cognitive tests, laboratory work up, and imaging studies for patients that meet indicated standards (Chertkow et al., 2008).
A simple cognitive assessment test such as the Self-Administered Gerocognitive Examination (SAGE) test takes about 10to 15 minutes to administer. Assuming there is no language or literacy barrier, the patient can be given the SAGE form and can complete it on her own in the examining room (OSU, 2010). Scoring on that test is an indicator (but not a diagnosis) of whether memory is operating in the normal ranges (a score from17 to 22 on SAGE), or whether the patient is likely to have either mild (score 15 or 16) or more severe memory or thinking problems (score 14 or lower) (OSU, 2010). This test can determine whether further diagnostic testing is needed.
If the cognitive test indicates a possibility of mild cognitive impairment (MCI), it is important both to recognize that an extended period of MCI may indicate an increased risk of development of dementia, but not to advise patients that such a condition is equivalent to dementia; thus, such patients should be monitored closely (Chertkow et al., 2008). There is limited evidence that some risk factors may increase the likelihood of developing dementia from MCI and thus addressing these risk factors may make such progression less likely (Chertkow et al., 2008). Thus, the patient should be encouraged to take more physical activity (within their capabilities), and any vascular comorbidities should be treated, especially hypertension (Chertkow et al., 2008).
If the cognitive tests indicate a possibility of dementia, specific laboratory tests should include running a complete blood count to ensure that anemia is not present, and testing of thyroid stimulating hormone to rule out hypothyroidism, which can also impact cognitive functions (Feldman et al. 2008). Other checks should be made on the patient’s serum electrolytes, serum calcium, and serum fasting glucose to rule out hyponatremia, hypercalcemia, and hypergycemia respectively. In addition a check on the patient’s B12 level should be made and, if low, the patient should receive B12 either via an injection or orally. Low levels of this vitamin can cause cognitive disruptions (Feldman et al., 2008). If the patient has celiac disease (as determined by the patient history), or appears to have an inadequate diet, it would be worthwhile to also check serum folic acid (Feldman et al., 2008). While other blood tests for Alzheimer’s are under development, none have yet achieved the 80% accuracy minimum specified to bring them into clinical use (Rye, 2011).
In cases of suspected dementia, magnetic resonance imaging (MRI) can be used to help diagnose Alzheimer’s or other dementia causes. Determining rates of whole brain and hippocampal atrophy tests for dementia-inducing conditions (Frisoni, Fox, Jack Jr., Scheltens & Thompson, 2010). CT and MRI scans are primarily used in cases where the patient has at least one of : age <60 years old, showing a relatively rapid cognitive decline over only 1 or 2 months, has shown dementia symptoms for less than 2 years, has had recent head trauma, has a history of cancer that may have metastasized to the brain, or have difficulty walking (Feldman et al., 2008).