Dr. Sharma is a Geriatric Psychiatry Fellow, Department of Psychiatry, Division of Geriatric Psychiatry, Mount Sinai Beth Israel, New York, NY; and Dr. Lantz is Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY.
With the growth of the elderly population has come increased pressure on psychiatrists to offer timely access to quality care that is specific to the needs of the elderly, particularly the recognition of cognitive loss and dementia. Up to 40% of patients with moderate degrees of cognitive impairment remain unrecognized and undiagnosed by physicians.1 It has been postulated that some clinicians simply believe early detection does not change the trajectory of illness; some may feel that the tests are too time consuming or difficult to administer; still others may assume that their patients will resist the testing, without attempting to suggest it to their patients. However, the benefits of early detection of cognitive loss include counseling patients and their families regarding advanced care planning, preparation for financial needs, treatment of comorbid medical conditions, and maximizing functional status to promote better quality of life.
The cognitive assessment
Cognitive impairment is not always associated with dementia. For this reason, a full comprehensive history is an integral component of any cognitive assessment. Presenting complaints of memory loss or changes in behavior, demeanor, or activity in the elderly population may be reflective of a psychiatric illness including a mood or anxiety disorder, a response to a new medication or a change of dosing, or an underlying medical condition. In some cases, what may appear to be a cognitive impairment may actually be an underlying depression or anxiety disorder in which attention and concentration become difficult. The following Case Vignette illustrates how complex presenting memory loss can be when complicated by both medical and psychiatric comorbidities.
Related content: Mini Quiz: Evaluating Dementia
Case Vignette 1
Mr. B is a 76-year-old man with multiple medical problems including diabetes mellitus, hypertension, hyperlipidemia, glaucoma, and obstructive sleep apnea. He is referred by his primary care physician (PCP) because of a decline in cognition over the past 6 months; his Mini Mental State Examination (MMSE) score decreased from 23 to 15. On interview, Mr. B appears tired and complains of poor sleep with frequent awakening during the night. He explains that he has difficulty filling his prescriptions and has not been taking his medications for many months. He also does not regularly use his continuous positive airway pressure device.
Mr. B describes feeling overwhelmed by his medical problems and depressed by his financial state. He is referred back to his PCP for care, given a referral for homecare services, and seen for follow-up. After 3 months of better adherence to his medical regimen, his MMSE score is 20/30. He remains depressed and is treated with sertraline, with follow-up visits at regular intervals that his daughter takes him to.
Complex medical and psychiatric comorbidities need to be identified as part of the cognitive screening examination in order to create an appropriate treatment plan. It is important to consider and rule out metabolic, vascular, and endocrine illness and to consider causes of acute confusional states. Often, identifying and appropriately treating a medical disturbance can improve or restore the level of cognitive function. Cognitive impairment may relate to language, executive functioning, social cognition, perceptual/motor functioning, or complex attention (Table 1).
The authors report no conflicts of interest concerning the subject matter of this article.
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