What is the proper way to write a chief complaint for a patient with dementia?

Writing a Chief Complaint for Dementia

A chief complaint for dementia should document the specific cognitive, functional, or behavioral changes reported by the patient or informant, rather than simply stating "dementia" or "memory loss." 1, 2

Components of an Effective Dementia Chief Complaint

Primary Elements to Include:

• Specific cognitive symptoms reported by patient or informant
• Duration of symptoms
• Pattern of progression
• Impact on daily functioning

Examples of Well-Structured Chief Complaints:

• "Progressive difficulty remembering recent conversations and appointments for the past 6 months, now requiring assistance with medication management"
• "Gradual decline in ability to manage finances and household tasks over the past year, with increasing confusion about day-to-day activities"
• "Family reports 8-month history of repetitive questioning, misplacing items, and getting lost while driving familiar routes"

Documentation Framework

1. Source of Information

   • Clearly indicate whether complaints come from patient, informant, or both
   • Note reliability of informant (e.g., spouse, adult child, caregiver)
   • Document any discrepancies between patient and informant reports 1

2. Cognitive Domain Specifics

   • Memory (e.g., forgetting recent conversations, appointments, events)
   • Executive function (e.g., difficulty planning, organizing, problem-solving)
   • Language (e.g., word-finding difficulties, reduced vocabulary)
   • Visuospatial skills (e.g., getting lost in familiar places)
   • Attention/concentration issues 2

3. Functional Impact

   • Document specific instrumental activities of daily living (IADLs) affected
   • Note progression from IADLs to basic ADLs if applicable
   • Include examples of functional decline (e.g., "now requires assistance with medication management") 1, 2

4. Behavioral/Neuropsychiatric Symptoms

   • Document any mood changes, anxiety, apathy, irritability
   • Note presence of hallucinations, delusions, or agitation if reported 1

Common Pitfalls to Avoid

• Avoid vague terminology like "confusion" or "memory problems" without specific examples
• Don't use diagnostic labels as the chief complaint itself (e.g., "Alzheimer's disease")
• Don't omit informant input when available, as patient insight may be limited 1
• Avoid focusing solely on cognitive symptoms without documenting functional impact
• Don't neglect to document duration and progression pattern of symptoms 2

Clinical Pearls

• Obtaining corroborative history from a reliable informant is essential and has prognostic significance 1
• Document both new onset symptoms and changes from chronic/longstanding symptoms 1
• Include specific examples of cognitive or functional decline rather than general statements 2
• When possible, document the patient's baseline cognitive function before decline began 1
• Assessment of decline should be individualized and patient-specific, based on deterioration from the patient's own baseline level of function 1

By following this structured approach to documenting a chief complaint for dementia, you will create a foundation for proper assessment, diagnosis, and ongoing monitoring of cognitive changes over time.