What is the best course of action for a patient with a new onset of difficulty with word finding, considering their age, medical history, and current medications?

Immediate Evaluation for New-Onset Word-Finding Difficulty

New-onset word-finding difficulty requires urgent evaluation to rule out acute stroke, with immediate neurological assessment using the NIH Stroke Scale and brain imaging within hours of symptom onset. 1

Acute Stroke Assessment (First Priority)

Word-finding difficulty (aphasia) is a cardinal sign of acute ischemic stroke and demands time-sensitive evaluation:

• Perform the NIH Stroke Scale immediately, specifically focusing on item #9 (Best Language), which assesses for aphasia by having the patient describe pictures, name objects, and read sentences 1
• Obtain brain imaging urgently (CT or MRI) within hours of symptom onset to identify acute stroke or other structural lesions requiring immediate intervention 1
• Document the time of symptom onset precisely, as this determines eligibility for thrombolytic therapy 1

Distinguishing Aphasia Subtypes

The pattern of language impairment helps localize the lesion:

• Wernicke's aphasia presents with severely impaired comprehension, fluent but nonsensical speech, and deficits in both reading and writing, associated with posterior temporal lobe damage 2, 3
• Broca's aphasia features hesitant, effortful speech with relatively preserved comprehension (though not completely intact), often accompanied by apraxia of speech, associated with frontal lobe damage 4, 3
• Logopenic aphasia manifests as word-finding difficulties with phonological working memory problems 3

Comprehensive Neurological Examination

Beyond stroke scale assessment, evaluate:

• All language domains systematically: comprehension, expression, repetition, reading, writing, and naming 1, 3
• Associated neurological signs: facial asymmetry, motor weakness, visual field defects, sensory loss, and gait abnormalities that suggest stroke or other structural pathology 1
• Cognitive domains beyond language: attention, executive function, memory, and visuospatial abilities using tools like the Montreal Cognitive Assessment (MoCA) if subacute presentation 1

Obtain Collateral History from Informant

Always interview a reliable informant separately from the patient, as insight is often impaired in cognitive disorders:

• Use structured tools like the AD8 or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) to assess cognitive changes 1
• Document the temporal profile: sudden onset (stroke), subacute progression over weeks (infection, autoimmune), or gradual decline over months (neurodegenerative) 1
• Assess functional impact on daily activities using the Pfeffer Functional Activities Questionnaire or Disability Assessment for Dementia 1
• Screen for behavioral and mood changes with the Neuropsychiatric Inventory-Questionnaire (NPI-Q) 1

Neuroimaging Protocol

MRI is superior to CT for detecting vascular lesions and subtle pathology:

• Obtain 3D T1 volumetric sequences, FLAIR, T2 (or susceptibility-weighted imaging), and diffusion-weighted imaging 1
• Use semi-quantitative scales: medial temporal lobe atrophy scale, Fazekas scale for white matter changes, and global cortical atrophy scale 1
• If MRI is contraindicated, obtain non-contrast CT with coronal reformations to assess hippocampal atrophy 1

Critical "Must-Not-Miss" Diagnoses

Beyond stroke, consider:

• Autoimmune encephalitis (particularly NMDA receptor antibody encephalitis in young women): presents with word-finding difficulty, confusion, psychiatric symptoms, seizures, and dyskinesias; requires CSF antibody testing and pelvic imaging for ovarian teratoma 5
• Seizures or postictal state: obtain EEG if clinical suspicion for seizure activity 6
• CNS infection: lumbar puncture if fever, headache, or altered mental status accompanies language difficulty 6
• Brain tumor or metastases: especially with history of cancer or progressive symptoms 1
• Normal pressure hydrocephalus: if gait disturbance and cognitive decline present 1

Functional Neurological Disorder Considerations

If structural pathology is excluded and symptoms show internal inconsistency:

• Positive features: symptom resolution during distraction, suggestibility, excessive struggle behaviors disproportionate to task difficulty 1
• Diagnosis requires positive clinical signs, not merely exclusion of other causes 1
• Treatment involves clear explanation of the diagnosis, symptomatic therapy, and behavioral interventions 1, 3

Common Pitfalls to Avoid

• Do not attribute new-onset aphasia to "normal aging" without thorough evaluation—this represents pathology requiring investigation 1
• Do not rely solely on patient report—diminished insight is common, making informant history essential 1
• Do not assume comprehension is intact in Broca's aphasia—comprehensive assessment of all language domains is mandatory 4
• Do not delay imaging while pursuing extensive cognitive testing if acute stroke is possible 1