What examination should be performed for a geriatric patient presenting with mild memory impairment?

Examination for Geriatric Patient with Mild Memory Impairment

Begin with the Mini-Cog test as your initial rapid cognitive screen, which takes only 2-3 minutes and has 76% sensitivity and 89% specificity for detecting dementia. 1

Initial Rapid Cognitive Screening

• Administer the Mini-Cog test consisting of three-word recall and clock drawing, which is validated in primary care settings, available in multiple languages, and endorsed by the Alzheimer's Association for Medicare annual wellness visits 1
• The test involves: presenting 3 unrelated words for the patient to remember, having them draw a clock face set to "10 past 11," then recalling the 3 words 1
• A score of less than 3 out of 5 points is concerning for possible dementia and requires further evaluation 1

Alternative rapid screens if the patient cannot perform clock drawing due to motor disabilities:

• Memory Impairment Screen (verbally administered) 1
• Picture-Based Memory Impairment Screen (overcomes educational and cultural limitations) 1
• AD8 questionnaire (informant-based, completed by family members if patient refuses testing) 1

Essential Screening for Mimics

Screen for depression immediately, as it commonly mimics dementia in older adults:

• Administer the PHQ-2 first (sensitivity nearly 100% in noninstitutionalized older adults) 1
• If PHQ-2 is positive for anhedonia or sadness, follow with PHQ-9 (though note it loses accuracy in patients with cognitive impairment) 1

Screen for delirium using the Confusion Assessment Method, particularly if symptoms fluctuate or the patient is in a care facility 1

Comprehensive Cognitive Assessment if Initial Screen is Abnormal

If Mini-Cog or other rapid screen is abnormal, proceed to a multidomain mental status test (10-15 minutes):

• Montreal Cognitive Assessment (MoCA) is preferred as it is more sensitive than MMSE for detecting MCI and assesses executive function, attention, and visuospatial abilities 1
• A MoCA score of <26/30 (adjusted for education) suggests cognitive impairment 1
• Alternative validated tests include: Kokmen Short Test of Mental Status or Saint Louis University Mental Status Examination 1

Structured History and Collateral Information

Obtain collateral history from a reliable informant to document whether there has been actual decline from the patient's previous level of functioning 1:

• Assess cognitive concerns reflecting change in cognition reported by patient, informant, or clinician 1
• Evaluate preservation of independence in functional abilities, particularly instrumental activities of daily living (financial management, medication management, work responsibilities, household tasks) 1
• Document whether the patient has memory complaints or is partially dependent on IADL 2

Key domains to assess systematically 1:

• Cognition (episodic memory, executive function, language, visuospatial skills, attention)
• Daily function and IADL performance
• Mood and behavioral changes
• Sensorimotor function

Neurologic Examination

Perform a dementia-focused neurologic examination 1:

• Assess for focal neurological signs
• Evaluate gait and balance
• Test for peripheral neuropathies and proximal motor strength 1
• Examine for signs suggesting vascular, traumatic, or other medical causes of cognitive decline 1

Physical Assessment Components

Evaluate fall risk and mobility, as these commonly coexist with cognitive impairment 1:

• Perform orthostatic blood pressure measurements 1
• Assess grip strength (weaker grip strength is associated with MCI) 2
• Observe walking speed (slower than usual walking speed is associated with MCI) 2

Clinical Criteria Application

For Mild Cognitive Impairment diagnosis, document 1:

1. Cognitive concern reflecting change in cognition
2. Objective evidence of impairment in one or more cognitive domains on formal or bedside testing
3. Preservation of independence in functional abilities
4. Not demented

Common pitfall: The MMSE is relatively insensitive to MCI (missing many cases), so avoid relying on it as your primary cognitive assessment tool 3, 4. The MoCA or other newer screening tests detect MCI and mild dementia with higher sensitivity (≥80%) 4.

Subsequent Evaluation if Screening is Abnormal

An abnormal cognitive screen mandates 1:

• Neurologic examination (as described above)
• Multidomain mental status test (if not already performed)
• Appropriate laboratory studies (thyroid-stimulating hormone, vitamin B12 levels at minimum) 5
• Structural neuroimaging (noncontrast CT or MRI) 5

Consider neuropsychological testing when screening tests are normal or equivocal but high clinical concern remains for cognitive impairment 5, 4, or to predict progression risk from MCI to dementia (predictive accuracy 80-100%) 4.