What is the initial work-up for a patient presenting with memory issues in a primary care setting?

Initial Work-up for Memory Issues in Primary Care

The initial work-up for a patient presenting with memory issues in primary care should include a structured, multi-tiered approach beginning with validated cognitive screening tools, comprehensive history, physical examination, basic laboratory testing, and structural brain imaging to identify potential causes and determine appropriate management. 1, 2

Step 1: Initial Assessment and Screening

Cognitive Screening Tools

• If an informant is available: Use AQ (Alzheimer's Questionnaire) or AD8 (Alzheimer's Disease 8) 1
• If no informant is available: Use MIS (Memory Impairment Screen), Mini-Cog, or MoCA (Montreal Cognitive Assessment) 1, 2

Key History Elements

• Document specific cognitive complaints (avoid vague terms like "confusion") 2
• Determine onset (recent vs. chronic; abrupt vs. gradual) and progression pattern 1
• Assess impact on instrumental activities of daily living (IADLs):
  • Managing finances/balancing checkbook
  • Cooking
  • Driving
  • Medication management
  • Use of electronic devices 1, 2
• Evaluate for neuropsychiatric symptoms (mood changes, anxiety, apathy, irritability) 2

Step 2: Basic Diagnostic Assessments

Physical Examination

• Complete neurological examination 1
• Assess for risk factors for cognitive decline:
  • Cerebrovascular risk factors
  • Medication review (especially anticholinergics and sedatives)
  • Psychiatric conditions 1, 2

Laboratory Testing (Tier 1)

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Thyroid function tests (TSH, free T4)
• Vitamin B12 level
• Folate level
• Glucose level
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP) 1, 2

Brain Imaging

• Structural brain imaging with MRI (or head CT if MRI contraindicated) 1, 2
  • Assess for:
    • Regional brain atrophy patterns
    • Vascular injury
    • Infarcts and microhemorrhages
    • Non-degenerative conditions

Step 3: Follow-up and Specialty Referral Considerations

When to Consider Specialty Referral

• Atypical presentation or rapid progression
• Age under 65 years
• Significant behavioral or psychiatric symptoms
• Complex medical comorbidities
• Need for neuropsychological testing 1

Specialty Investigations (if indicated)

• Neuropsychological evaluation
• Advanced imaging (volumetric MRI, FDG-PET)
• Biomarker testing:
  • CSF analysis (Aβ, tau, p-tau)
  • Amyloid PET
  • Blood-based biomarkers (emerging option for triaging) 1

Common Pitfalls and Caveats

1. Avoid routine screening of asymptomatic individuals - Evidence does not support screening in asymptomatic adults 1

2. Don't attribute all memory complaints to dementia - Consider potentially reversible causes:

   • Depression and other mood disorders
   • Sleep disorders (especially sleep apnea)
   • Medication effects
   • Metabolic abnormalities
   • Vitamin deficiencies 2

3. Don't stop at screening - A positive cognitive screening test is not a diagnosis and requires comprehensive evaluation 1

4. Serial assessment is valuable - Conduct follow-up assessments with the same instrument at 6-month intervals to track progression 1

5. Mixed etiology is common - Many older adults with cognitive impairment have multiple contributing conditions 1

6. Consider blood-based biomarkers - Emerging blood tests may help triage patients before more invasive or expensive testing 1

By following this structured approach, primary care providers can effectively evaluate patients with memory concerns, identify potentially reversible causes, and determine appropriate timing for specialty referral when needed.