What is the plan of care for a patient with daily forgetfulness?

Plan of Care for Daily Forgetfulness

Initial Assessment

Begin with a comprehensive cognitive and functional assessment to differentiate between normal age-related forgetfulness, mild cognitive impairment, and dementia, as this distinction fundamentally determines the treatment approach. 1

• Perform validated cognitive screening using tools such as the Mini-Mental State Examination to establish baseline cognitive function and detect subtle cognitive alterations 1, 2
• Obtain detailed history about the onset, course, and trajectory of forgetfulness—specifically whether this represents a change from baseline or lifelong pattern 1
• Assess functional impact on activities of daily living, work performance, and social functioning to determine severity 3
• Evaluate for reversible causes: pain, urinary tract infections, metabolic disorders, medication side effects (particularly anticholinergic agents), depression, and substance use 1, 4, 2
• Screen for comorbid psychiatric conditions including depression and anxiety, which commonly present with subjective memory complaints 3, 1

Non-Pharmacological Interventions (First-Line Treatment)

Implement structured non-pharmacological strategies before considering any medications, as these form the foundation of management for forgetfulness. 4

Cognitive and Behavioral Strategies

• Establish predictable daily routines with regular schedules for physical exercise, meals, and sleep 4
• Implement memory compensation strategies including use of reminder systems (smartphone applications, written checklists, calendars) for patients with mild memory deficits 3
• Provide cognitive stimulation therapy for patients with mild to moderate cognitive impairment 4
• Encourage participation in cognitively stimulating activities tailored to the patient's interests and current abilities 4

Addressing Psychological Determinants

• Target memory self-efficacy and anxiety through psychoeducational interventions, as low memory self-efficacy and high memory-related anxiety are the strongest correlates of perceived forgetfulness 5
• Provide education about normal versus pathological forgetfulness to reduce excessive worry 5

Lifestyle Modifications

• Address modifiable risk factors including obesity, smoking, and alcohol consumption, which are associated with cognitive decline 3
• Recommend cardiac rehabilitation or structured exercise programs if cardiovascular disease is present, as these improve cognitive function and medication adherence 3

Pharmacological Management (When Non-Pharmacological Strategies Fail)

Consider pharmacological treatment only after non-pharmacological strategies have proven ineffective, and only if cognitive assessment confirms objective impairment consistent with dementia. 4, 2

For Confirmed Dementia

• Cholinesterase inhibitors (donepezil, rivastigmine) for patients with mild to moderate Alzheimer's disease or features of Lewy body dementia 2, 6
• Memantine can be considered for moderate to severe dementia 2
• Evaluate response within 30 days; discontinue if no clinically meaningful benefit or intolerable side effects develop 4, 2
• Consider dose reduction or discontinuation after 6 months of symptom stabilization 4

Monitoring and Follow-Up

• Reassess cognitive function periodically using the same validated tools to track progression or improvement 1
• Monitor for medication side effects closely in patients receiving psychotropic medications 4
• Refer to specialist for atypical symptoms, complex cognitive-behavioral syndromes, or lack of response to initial interventions 1

Critical Pitfalls to Avoid

• Do not prescribe medications with significant anticholinergic effects, which worsen cognitive symptoms 4
• Do not rely exclusively on pharmacological interventions without implementing non-pharmacological strategies first 4
• Do not overlook pain and discomfort as treatable causes of cognitive complaints 4, 2
• Do not assume all forgetfulness represents dementia—subjective memory complaints often reflect anxiety, depression, or normal aging rather than objective cognitive impairment 3, 5
• Do not miss transient epileptic amnesia in patients with sudden changes in memory pattern, particularly if they have pre-existing attention difficulties 7