How to assess memory in an older adult with confusion?

From the Guidelines

To assess memory in an older adult with confusion, start with simple cognitive screening tests like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA), as recommended by the most recent guidelines 1. These tests are widely used and take about 10-15 minutes to administer, assessing orientation, recall, attention, language, and visual-spatial skills with a maximum score of 30 points.

• Scores below 24 on the MMSE or 26 on the MoCA generally indicate cognitive impairment.
• The Clock Drawing Test is another quick assessment where you ask the person to draw a clock showing a specific time; this evaluates executive function and visual-spatial abilities.
• For a more thorough evaluation, the Saint Louis University Mental Status (SLUMS) examination is particularly sensitive for mild cognitive impairment. When administering these tests, choose a quiet environment without distractions, ensure the person is comfortable and not fatigued, and approach the assessment with patience and reassurance to reduce anxiety. It's essential to consider factors that may affect performance, such as:
• Medication side effects (particularly anticholinergics, benzodiazepines, or opioids)
• Delirium from acute illness
• Depression
• Sensory impairments like hearing loss If cognitive impairment is detected, follow up with a comprehensive medical evaluation, including:
• Blood tests for vitamin B12, thyroid function, and metabolic disorders, as these can cause reversible confusion
• Brain imaging may also be necessary to rule out structural causes like stroke or tumors, as suggested by previous studies 1. Annual screening is indicated for adults 65 years of age or older for early detection of mild cognitive impairment or dementia, according to the latest standards of care in diabetes-2023 1.

From the FDA Drug Label

The ADAS-cog examines selected aspects of cognitive performance including elements of memory, orientation, attention, reasoning, language, and praxis. The ADAS-cog scoring range is from 0 to 70, with higher scores indicating greater cognitive impairment. The SIB, a multi-item instrument, has been validated for the evaluation of cognitive function in patients with moderate to severe dementia. The SIB evaluates selective aspects of cognitive performance, including elements of memory, language, orientation, attention, praxis, visuospatial ability, construction, and social interaction.

To assess memory in an older adult with confusion, the Alzheimer's Disease Assessment Scale (ADAS-cog) or the Severe Impairment Battery (SIB) can be used, as they evaluate cognitive performance including elements of memory. These instruments have been extensively validated in longitudinal cohorts of Alzheimer's disease patients and can provide a comprehensive assessment of cognitive function, including memory. 2, 2

From the Research

Assessing Memory in Older Adults with Confusion

To assess memory in an older adult with confusion, several steps can be taken:

• Obtain a thorough history, including onset of symptoms, corresponding illness, medication use, and time of day that the confusion occurs 3
• Use mental-status exams as a screening tool, but also assess judgment and abstraction by evaluating the client's ability to interpret proverbs and plot a sensible course of action 3
• Assess special cortical function by asking the client to draw a house, a clock, and a person 3
• Use a functional pattern assessment specific to the confused elder, and rule out systemic or mechanical problems in the brain 3
• Consider using the NEECHAM Confusion Scale for rapid and unobtrusive assessment and monitoring of acute confusion 4

Importance of Accurate Assessment

Accurate assessment of memory in older adults with confusion is crucial, as confusion can be a symptom of many different and often unrelated disease entities, many of which are preventable, curable, or arrestible 3, 5

• A diagnosis of irreversible presenile dementia should never be made without thorough evaluation 3
• Clinicians should be cautious when relying on patients' memories for accurate recall of their medical conditions, drug regimens, and number of drugs they are taking 6

Cognitive Testing and Brain Imaging

Cognitive testing and brain imaging may also be useful in assessing memory in older adults with confusion:

• Cognitive testing can reveal significant memory deficits, as seen in a case report of a 72-year-old man with progressive short-term memory loss and confusion 7
• Brain imaging, such as MRI, can show cortical microbleeds and areas of siderosis consistent with cerebral amyloid angiopathy (CAA) 7