Is an electroencephalogram (EEG) indicated for a [AGE] year old patient with memory amnesia, forgetting, and social withdrawal?

EEG is NOT Indicated for Memory Loss and Social Withdrawal Alone

EEG should not be routinely ordered for a patient presenting with memory amnesia, forgetting, and social withdrawal without additional features suggesting seizure activity or epilepsy. 1, 2

Clinical Reasoning

The symptoms described—memory impairment, forgetting, and social withdrawal—are classic presentations of cognitive decline or dementia, not epilepsy. The appropriate diagnostic pathway follows dementia evaluation protocols, not seizure workup.

When EEG is NOT Useful

• EEG is not recommended for patients in whom syncope or transient loss of consciousness (not epilepsy) is the most likely diagnosis 1
• Electroencephalographic monitoring was conclusively shown to be of little use in unselected patients without a high likelihood of epilepsy 1
• International guidelines on Alzheimer's disease diagnosis do not recommend the use of EEG biomarkers for diagnostic purposes in routine clinical practice 1
• EEG currently has no established role in the clinical workup of individual dementia patients 3

Appropriate Initial Workup Instead

For memory complaints with social withdrawal, the correct diagnostic approach includes: 2

• Obtain detailed history from a close family member or friend to corroborate cognitive decline and assess functional impairment in IADLs and ADLs 2
• Administer validated cognitive screening tools such as MoCA, MMSE, or 3MS 2, 1
• Order targeted laboratory tests: CBC with differential, comprehensive metabolic panel, TSH, free T4, vitamin B12, folate, and homocysteine levels 2
• Obtain brain MRI (preferred) or CT scan to identify structural causes 2

The Rare Exception: When EEG IS Indicated

EEG becomes appropriate only when specific features suggest epilepsy rather than dementia: 1, 4

• History of witnessed seizures with tonic-clonic movements 1
• Episodes of transient loss of consciousness with epileptiform features 1
• Repetitive questioning during episodes, preserved personal identity, brief duration attacks (suggesting transient epileptic amnesia) 5, 6
• Postictal focal deficits that do not quickly resolve 4
• Patient has not returned to baseline within several hours after an episode 4

Important Clinical Pitfall

Do not confuse gradual progressive memory decline with episodic transient amnesia. Progressive memory loss with social withdrawal suggests neurodegenerative disease (dementia), while episodic discrete attacks of amnesia lasting hours with complete recovery between episodes may suggest transient epileptic amnesia (TEA), which would warrant EEG. 5, 6

Research Context (Not for Routine Clinical Use)

While research shows EEG abnormalities are common in established dementia (60-90% of patients with MCI and dementia have abnormal EEGs) 7, and visual EEG assessment may have prognostic value for conversion from MCI to dementia 7, these findings are for research stratification in clinical trials, not routine diagnostic workup 1. The diagnostic specificity of stand-alone EEG measures remains insufficient for clinical decision-making in individual patients. 1

Bottom Line Algorithm

1. Does the patient have discrete episodic attacks of amnesia with witnessed seizure-like features?

   • YES → Consider EEG 1, 4
   • NO → Proceed with dementia workup (cognitive testing, labs, MRI), NOT EEG 2, 1

2. Is there progressive decline in memory and social function over months?

   • YES → This is dementia evaluation, NOT seizure workup 2
   • NO EEG indicated 1