What is the most appropriate screening test for a 72-year-old woman with worsening forgetfulness, hypertension managed with metoprolol (beta blocker), and hypothyroidism managed with levothyroxine (thyroid hormone replacement), who lives alone and has safety concerns?

Montreal Cognitive Assessment is the Most Appropriate Screening Test for This Patient

The Montreal Cognitive Assessment (MoCA) is the most appropriate screening test for this 72-year-old woman with worsening forgetfulness, safety concerns, and inability to recall words during examination.

Clinical Presentation Analysis

The patient presents with:

• Worsening forgetfulness over three months
• Safety concerns (forgetting to turn off stove, leaving door open)
• Inability to recall any of three words during examination
• Medical history of hypertension (on metoprolol) and hypothyroidism (on levothyroxine)
• Normal vital signs and physical examination

Screening Test Selection Rationale

Why MoCA is Most Appropriate:

1. Superior Detection of Mild Cognitive Impairment:

   • MoCA has significantly better sensitivity (80.48%) and specificity (81.19%) for detecting mild cognitive impairment compared to other screening tools 1
   • MoCA demonstrates superior psychometric properties with an area under the curve (AUC) of 1.00 compared to MMSE's 0.92 2

2. Comprehensive Assessment:

   • MoCA evaluates multiple cognitive domains including memory, attention, language, visuospatial abilities, and executive function 3
   • This is particularly important for this patient who demonstrates memory impairment (inability to recall words) and executive dysfunction (safety concerns)

3. Guideline Recommendations:

   • MoCA has 90% sensitivity for MCI detection, making it particularly valuable when cognitive impairment is suspected but not yet confirmed 3
   • The U.S. Preventive Services Task Force acknowledges MoCA as an appropriate screening instrument for cognitive impairment 4

4. Clinical Context Considerations:

   • The patient's safety concerns (forgetting to turn off stove, leaving door open) suggest possible executive function impairment, which MoCA assesses more thoroughly than other screening tools
   • Given her inability to recall any words during examination, a comprehensive cognitive assessment is warranted

Why Other Tests Are Less Appropriate:

1. Geriatric Depression Scale:

   • While depression can cause cognitive symptoms, the patient shows no mood symptoms or changes in sleep, appetite, or weight
   • Her primary symptoms are cognitive with functional impairment

2. Mood Disorder Questionnaire:

   • No evidence of mood fluctuations, elevated mood, or other bipolar symptoms
   • Her symptoms are primarily cognitive rather than mood-related

3. Scale for Assessment of Negative/Positive Symptoms:

   • These scales assess symptoms of schizophrenia and psychotic disorders
   • No evidence of hallucinations, delusions, or thought disorders in this patient

Medical Considerations

1. Medication Effects:

   • Metoprolol (beta-blocker) can potentially affect cognition, but there's no evidence this is causing her symptoms 5
   • Levothyroxine replacement therapy has not been shown to have adverse effects on memory or attention when appropriately dosed 6

2. Next Steps After Screening:

   • If MoCA score is <26, further diagnostic evaluation is warranted 3, 7
   • A score ≥26 has a high negative predictive value (94%) for excluding MCI 7

Common Pitfalls to Avoid

1. Overreliance on MMSE:

   • MMSE has lower sensitivity for detecting mild cognitive impairment compared to MoCA 1
   • Using MMSE alone could miss early cognitive decline in this patient

2. Attributing Symptoms to Age Alone:

   • Cognitive decline is not a normal part of aging and requires proper evaluation
   • The patient's functional impairment (safety concerns) indicates this is not normal aging

3. Overlooking Medical Causes:

   • While the patient's hypothyroidism is being treated, thyroid function should still be assessed as part of the workup
   • Other metabolic, vascular, and neurological causes should be investigated after screening

The MoCA provides the most comprehensive and sensitive assessment for this patient's presentation, allowing for appropriate diagnosis and management planning to address her cognitive decline and safety concerns.