What is the recommended management for an elderly woman with worsening forgetfulness and inability to recall recently learned information, suggestive of dementia?

Management of Suspected Dementia in an Elderly Woman with Memory Impairment

For an elderly woman unable to recall three words during cognitive testing, you should immediately conduct a comprehensive dementia workup including corroborative history from a family member, formal cognitive assessment with validated tools, laboratory testing to exclude reversible causes, and brain neuroimaging to identify structural pathology. 1

Initial Diagnostic Evaluation

Corroborative History and Functional Assessment

• Obtain detailed history from a close family member or friend to corroborate cognitive decline and assess functional impairment in daily activities. 2 This is essential because patients with dementia often lack insight into their deficits.
• Specifically inquire about decline in instrumental activities of daily living (IADLs) such as managing medications, finances, appointments, and basic activities of daily living (ADLs) including self-care. 1
• Ask about behavioral changes including new-onset depression, anxiety, personality changes, or abandonment of hobbies. 1

Formal Cognitive Testing

• Administer a comprehensive validated cognitive screening tool beyond the failed three-word recall. 1 The inability to recall three words suggests significant memory impairment requiring thorough evaluation.
• Use the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), or Modified Mini-Mental State (3MS) for comprehensive assessment. 3, 1
• The MMSE remains the most extensively validated instrument, with a cut point of 23/24 or 24/25 demonstrating reasonable sensitivity and specificity for dementia. 4

Laboratory Workup for Reversible Causes

Order targeted laboratory tests to identify treatable conditions that may mimic or contribute to dementia: 1

• Complete blood count with differential
• Comprehensive metabolic panel
• Thyroid function tests (TSH, free T4)
• Vitamin B12, folate, and homocysteine levels 1

Medication Review

• Compile a complete medication list and identify anticholinergic medications, potentially inappropriate medications, and drug interactions that may impair cognition. 1 This is a common and reversible cause of cognitive symptoms in elderly patients.

Neuroimaging

Obtain brain MRI (preferred) or CT scan to identify structural causes of cognitive impairment. 4 Neuroimaging is indicated for:

• Recent onset of cognitive symptoms (within past 2 years)
• Unexpected decline in cognition or function
• Recent significant head trauma
• Unexplained neurological manifestations 4

If MRI is performed, include 3D T1 volumetric sequence with coronal reformations for hippocampal assessment, FLAIR, T2, and diffusion-weighted imaging. 4 Use semi-quantitative scales including medial temporal lobe atrophy (MTA) scale, Fazekas scale for white matter changes, and global cortical atrophy (GCA) scale. 4

Diagnostic Classification

Based on testing results, classify the patient into one of three categories:

• Subjective cognitive decline (SCD): Cognitive complaints without objective impairment on testing
• Mild cognitive impairment (MCI): Objective cognitive impairment without significant functional decline
• Dementia: Cognitive impairment severe enough to interfere with social or occupational functioning 1, 2

Management Based on Diagnosis

If Dementia is Confirmed

Initiate both pharmacologic and nonpharmacologic interventions immediately. 2

Pharmacologic Treatment

• For mild to moderate Alzheimer disease, start an acetylcholinesterase inhibitor such as donepezil. 2 This provides modest symptomatic benefit.
• For moderate to severe dementia, add memantine (alone or combined with acetylcholinesterase inhibitor). 5, 2 Memantine is FDA-approved for moderate to severe Alzheimer-type dementia.

Nonpharmacologic Interventions

• Recommend cognitively engaging activities (reading, puzzles)
• Encourage regular physical exercise (walking)
• Promote socialization and family gatherings 2
• Implement behavior modification strategies, scheduled toileting, and graded assistance with positive reinforcement for functional tasks 4

Ongoing Monitoring

Schedule comprehensive follow-up visits every 6-12 months for stable patients, or every 3-4 months if behavioral symptoms or rapid decline occur. 3

At each follow-up visit, assess:

• Cognition using standardized tools (MMSE, MoCA, Clock Drawing Test) 3
• Functional status using validated instruments (Disability Assessment in Dementia, Functional Activities Questionnaire, Barthel Index) 3
• Behavioral symptoms using NPI-Q, Geriatric Depression Scale, or PHQ-9 3
• Caregiver burden using structured scales such as Zarit Burden Interview, as this is a major determinant of hospitalization and nursing home placement 3

Special Considerations

Screening Recommendations

• The U.S. Preventive Services Task Force found insufficient evidence to recommend routine population screening for dementia. 4 However, when cognitive impairment is suspected (as in this case with failed word recall), mental status testing should be conducted. 4
• For adults 65 years or older, screening should be performed at the initial visit, annually, and as appropriate when concerns arise. 4

Referral Indications

Consider specialist referral for:

• Atypical presentations (age <65-70 years, rapid onset, focal neurological deficits)
• Complex behavioral symptoms
• Uncertain diagnosis requiring neuropsychological testing 1, 2

Common Pitfalls to Avoid

• Do not dismiss memory complaints as "normal aging" without objective assessment. 6 The inability to recall three words during examination warrants thorough evaluation.
• Do not delay workup waiting for symptoms to worsen. Early diagnosis allows patients to participate more actively in disease management and improves quality of life for patients and caregivers. 7
• Avoid attributing all cognitive symptoms to dementia without excluding reversible causes such as depression, delirium, medication effects, or metabolic disturbances. 8