What is the recommended workup for a geriatric patient with cognitive decline and potential underlying medical conditions such as hypertension, diabetes, or cardiovascular disease, suspected of having dementia?

Dementia Workup in Geriatric Patients

For a geriatric patient with cognitive decline and comorbidities like hypertension, diabetes, or cardiovascular disease, conduct a structured workup that includes corroborative informant history, validated cognitive testing (MoCA preferred), comprehensive laboratory screening for reversible causes, medication review for anticholinergic burden, and MRI neuroimaging when vascular risk factors are present. 1

Initial Clinical Assessment

History Taking

• Obtain corroborative history from a reliable informant about changes in cognition, function, and behavior using structured tools like AD8, IQCODE, or Quick Dementia Rating System—this is essential because patients often lack insight into their deficits 1, 2
• Document baseline functioning and compare with current status to establish decline 2
• Specifically inquire about:
  • Instrumental activities of daily living (managing finances, medications, transportation, household tasks, cooking, shopping) 2
  • Missed appointments or showing up at incorrect times 3
  • Difficulty following instructions or taking medications 3
  • New onset behavioral changes including depression or anxiety 3

High-Risk Conditions Requiring Heightened Vigilance

In patients with the following conditions, actively ask about cognitive concerns even if not volunteered 3:

• History of stroke or TIA 3
• Late-onset or lifetime history of major depressive disorder 3
• Untreated sleep apnea 3
• Unstable metabolic or cardiovascular disease 3
• Recent delirium episode 3
• Recent head injury 3
• Parkinson's disease 3

Cognitive Testing

Primary Screening Tools

• Use the Montreal Cognitive Assessment (MoCA) with cutoff of 26/30 for suspected mild cognitive impairment or dementia (sensitivity 90%, specificity 87%)—this is more sensitive than MMSE for mild impairment 1, 3
• Alternative rapid screening: Mini-Cog (3-word recall plus clock drawing, takes 2-3 minutes, sensitivity 76%, specificity 89%) 1
• For moderate dementia or when more time allows, MMSE remains widely used with high sensitivity/specificity for separating moderate dementia from normal cognition 3

Common Pitfall: MMSE lacks sensitivity for mild dementia or MCI—use MoCA when mild impairment is suspected 3

Laboratory Testing for Reversible Causes

Obtain the following screening tests in all patients 1, 4:

• Complete blood count (rule out anemia) 1
• Comprehensive metabolic panel including sodium, calcium, glucose, liver function 1, 4
• Thyroid function tests (TSH, free T4) 1, 4
• Vitamin B12, folate, and homocysteine levels 1
• HIV testing if risk factors present 1

These tests identified treatable causes in 11 patients with hypothyroidism, hyponatremia, hyperparathyroidism, and hypoglycemia in a prospective study of 200 elderly patients 4

Medication Review

• Have caregiver bring in all medication bottles including prescription, over-the-counter drugs, and supplements 1
• Minimize or avoid anticholinergic medications—these are a common reversible cause of cognitive impairment 1
• Assess for drug interactions and side effects contributing to cognitive symptoms 1

Drug toxicity accounted for 9.5% of dementia diagnoses in one prospective study 4

Neuroimaging

MRI is preferred over CT, especially for detecting vascular lesions 1, 2

Obtain anatomical neuroimaging when 1, 2:

• Onset of cognitive symptoms within past 2 years 1
• Unexpected decline in cognition or function 1
• Recent significant head trauma 1
• Unexplained neurological manifestations 1
• Significant vascular risk factors (hypertension, diabetes, cardiovascular disease) 1

Given your patient has hypertension, diabetes, or cardiovascular disease, neuroimaging is particularly indicated 1

Assessment of Contributing Factors

Sleep Evaluation

• Take careful sleep history including sleep time, insomnia, daytime sleepiness, napping, and REM sleep behavior disorder 3
• Assess for sleep apnea symptoms and refer for polysomnography if suspected 3
• Sleep disorders are both a risk factor for and contributor to cognitive impairment 1

Sensory Assessment

• Assess hearing impairment—ask if patient has difficulty hearing in everyday life (not "do you have hearing loss") 3
• If hearing symptoms reported, confirm with audiometry and consider audiologic rehabilitation 3
• Hearing impairment is associated with dementia development 3
• Vision assessment and correction may improve cognitive functioning 3

Mood and Behavioral Symptoms

• Screen for depression and anxiety using validated tools 1
• Assess neuropsychiatric symptoms using NPI-Q or Mild Behavioural Impairment Checklist 3

Diagnostic Formulation

Dementia is diagnosed when 2:

1. Cognitive or behavioral symptoms interfere with ability to function at work or usual activities
2. Symptoms represent a decline from previous functioning
3. Not explained by delirium or major psychiatric disorder

Distinguish MCI from dementia based on whether there is significant interference with daily functioning 3, 2

Referral Indications

Refer to memory clinic or specialist for 1, 2:

• Patients with mild cognitive impairment at high risk for progression 1
• Cases requiring detailed neuropsychological testing to establish extent and severity 1
• Later life emergent and sustained neuropsychiatric symptoms 3
• Atypical presentations or rapid progression 5

Follow-up and Monitoring

• Schedule follow-up visits every 6-12 months for stable patients 1, 5
• Use multi-dimensional approach assessing: cognition, functional autonomy, behavioral symptoms, and caregiver burden 1, 5
• Consider more frequent visits (every 3-4 months) for patients with behavioral symptoms or rapid decline 5
• All domains must be evaluated at least annually 2, 5

Common Pitfall: Relying solely on patient self-report without informant corroboration leads to missed diagnoses—most patients with dementia do not report memory complaints 6, 2