What is the initial evaluation and management approach for a 70-year-old former alcoholic (alcohol use disorder) with memory loss?

From the Guidelines

The initial evaluation for a 70-year-old former alcoholic with memory loss should include a comprehensive cognitive assessment, thorough medical history, physical examination, and laboratory testing, as outlined in the most recent guidelines 1.

Key Components of Initial Evaluation

• Comprehensive cognitive assessment using standardized tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA)
• Thorough medical history, including onset of complaint, pace of decline, and nature of cognitive loss
• Physical examination, including neurologic examination
• Laboratory testing, including complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12, folate levels, and syphilis serology
• Neuroimaging with MRI or CT scan to identify structural abnormalities

Management Approach

• Address potentially reversible causes first, such as thiamine deficiency, medication side effects, or depression
• Screen for Wernicke-Korsakoff syndrome and treat with thiamine if necessary
• Consider cognitive rehabilitation, memory strategies, and environmental modifications for alcohol-related dementia
• If Alzheimer's disease is diagnosed, consider cholinesterase inhibitors like donepezil
• Maintaining sobriety is crucial, so addiction counseling and support groups should be recommended
• Family education and caregiver support are also important components of the management plan

Importance of Accurate Alcohol History

• Quantification of alcohol use is essential, using standardized measures like grams per week 1
• Consider local standard drink definition and ask about drinking patterns, past alcohol use, and potential socio-economic consequences of alcohol use
• Use of alcohol biomarkers, such as phosphatidylethanol, may aid in detection and quantification of alcohol use 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Evaluation

• The initial evaluation of a 70-year-old former alcoholic with memory loss should follow a guideline for early identification of Alzheimer's disease and related dementias, as described in the study by 2.
• This guideline includes patient history, physical examination, mental status testing, functional assessment, and some laboratory tests to identify and treat many "reversible" causes of memory problems.
• Information from an informed family member can be very helpful in this process, as noted in the study by 2.

Management Approach

• For patients with moderate to severe Alzheimer's disease, a fixed-dose combination of memantine and donepezil may be an effective treatment option, as shown in studies by 3, 4, and 5.
• Donepezil and memantine have been shown to be effective in treating behavioral and psychological symptoms of dementia (BPSD) in individuals with moderate AD, as demonstrated in the study by 3.
• The combination of memantine and donepezil has been found to be well tolerated, with mostly mild and transient adverse effects, as reported in studies by 3, 4, and 5.
• However, the efficacy of the combination of donepezil and memantine over donepezil alone is not significantly different, as found in the study by 6.

Treatment Considerations

• The treatment approach should be individualized, taking into account the patient's medical history, current symptoms, and response to treatment.
• The study by 6 suggests that continued treatment with donepezil is associated with cognitive benefits and significant functional benefits over the course of 12 months in patients with moderate or severe Alzheimer's disease.
• The use of memantine and donepezil in combination may be considered for patients with moderate to severe Alzheimer's disease, as supported by studies by 3, 4, and 5.