What history should be taken in a geriatric patient presenting with mild memory impairment?

History Taking for Mild Memory Impairment

Begin with an open-ended question asking both the patient and their companion what brings them in and what they hope to accomplish, as divergent perspectives between patient and informant provide critical diagnostic clues. 1

Initial Interview Strategy

• Interview the patient and informant separately to encourage honest reporting, as patients with cognitive impairment often have diminished insight into their condition. 1, 2
• Recognize that family members or close friends typically initiate the evaluation rather than the patient, making informant reports essential for accurate diagnosis. 1
• Informant reports provide added value beyond patient history alone in neurodegenerative disorders. 1, 2

Specific Cognitive Symptom Questions

Memory-Specific Inquiry

• Ask for concrete examples of memory difficulties, as patients may use terms like "memory loss" to describe word-finding problems, attention deficits, or other non-memory issues. 1, 2
• Inquire specifically about difficulties learning and recalling newly acquired information and recent life events (episodic memory), which is the hallmark of Alzheimer's-type cognitive impairment. 1, 2
• Determine if the patient forgets conversations, repeats questions, or misplaces items more than previously. 2

Other Cognitive Domains

• Ask about word-finding difficulties, attention problems, geographic disorientation, and difficulties performing step-by-step tasks. 2
• Assess for impairments in executive function, language, and visuospatial abilities beyond memory. 1, 2

Temporal Course and Onset

• Establish when symptoms first began and document the baseline cognitive level before symptom onset. 1, 2
• Determine how symptoms have evolved over time in frequency, duration, and intensity—progressive decline strongly suggests neurodegenerative disease. 2
• Ask about triggering events such as surgery, trauma, or acute illness that coincided with symptom onset. 2
• Document whether decline has been gradual or stepwise (suggesting vascular etiology). 3

Functional Impact Assessment

• Ask specifically about instrumental activities of daily living: managing finances, medications, transportation, household tasks, and shopping. 1, 2
• Inquire about missed appointments, showing up at incorrect times, difficulty following instructions, or medication management errors. 2
• Determine if the patient takes more time, is less efficient, or makes more errors at complex tasks while still maintaining independence. 1
• Ask about victimization by financial scams, which indicates impaired judgment. 2
• Assess whether there has been any decrease in self-care or unexplained decline in daily activities. 2

Associated Symptoms and Behavioral Changes

• Screen for mood changes including new-onset depression or anxiety, as more than half of patients who develop dementia had depression or irritability before cognitive impairment became apparent. 2
• Ask about personality changes, apathy, disinhibition, or socially inappropriate behavior (suggesting frontotemporal dementia). 2, 3
• Inquire about gait problems, tremor, balance issues, falls, swallowing difficulties, or urinary incontinence. 2
• Ask about visual hallucinations, fluctuating alertness, or REM sleep behavior disorder (suggesting Lewy body dementia). 3, 4

Medical and Vascular Risk Factor History

• Document vascular risk factors: history of stroke, TIA, hypertension, hyperlipidemia, diabetes, and cardiovascular disease. 2, 5
• Ask about sleep disorders, particularly untreated sleep apnea. 2, 5
• Inquire about history of head trauma, delirium episodes, or recent hospitalizations. 2, 5
• Screen for Parkinson's disease or other neurological conditions. 2

Medication Review

• Review all medications including over-the-counter preparations and supplements, as polypharmacy and anticholinergic medications can impair cognition. 2, 5
• Identify potentially cognitive-impairing medications (benzodiazepines, anticholinergics, opioids). 5

Informant-Specific Questions

• Establish how long the informant has known the patient and frequency of interaction to gauge reliability. 2
• Ask the informant to provide specific examples of memory lapses or cognitive difficulties they have observed. 2
• Inquire about changes in the patient's ability to perform everyday activities from the informant's perspective. 2
• Determine if the informant has noticed personality or behavioral changes. 2

Critical Diagnostic Distinctions

Concern About Change

• Document evidence of concern about cognitive change compared to the person's previous level, which can come from patient, informant, or clinician observation. 1
• Establish that impairment represents intraindividual decline rather than lifelong low functioning. 1

Preserved vs. Impaired Independence

• Determine if the patient maintains independence in daily life with minimal aids, which distinguishes MCI from dementia. 1
• Assess whether cognitive changes cause significant impairment in social or occupational functioning (indicating dementia rather than MCI). 1

Common Pitfalls to Avoid

• Do not focus exclusively on memory—assess all cognitive domains including executive function, language, and visuospatial abilities. 2
• Do not attribute cognitive symptoms solely to depression or anxiety without thorough evaluation, as depression often coexists with or heralds neurodegenerative disease. 2
• Avoid assuming memory complaints in older adults are "just depression" without objective cognitive testing. 2
• Do not delay dementia workup while treating depression, as both conditions frequently coexist. 2

Documentation of Severity

• Establish whether cognitive performance is 1 to 1.5 standard deviations below age and education-matched norms for impaired domains, which characterizes MCI. 1
• Document whether symptoms are sufficiently mild (MCI) or severe enough to impair social/occupational functioning (dementia). 1