As a primary care physician, should I refer a patient with a Saint Louis University Mental Status (SLUMS) score of 18 who reports memory loss and wants her driver's license reinstated, or start her on dementia medication?

Refer to Neurology for Comprehensive Evaluation Before Starting Medication

You should refer this patient to neurology for comprehensive diagnostic workup rather than initiating dementia medication at this time, as a SLUMS score of 18 indicates significant cognitive impairment requiring formal diagnosis, functional assessment, and safety evaluation—particularly given her request for driver's license reinstatement. 1, 2

Understanding the SLUMS Score of 18

• A SLUMS score of 18 falls in the dementia range using revised cutoff scores (≤17 indicates dementia), suggesting major neurocognitive disorder rather than mild cognitive impairment 3
• The USPSTF notes that SLUMS has limited evidence with only 2 or fewer validation studies, making it less reliable than instruments like MMSE or MoCA for definitive diagnosis 4
• You cannot diagnose dementia based on a screening test alone—this requires comprehensive clinical correlation including functional assessment, informant history, and exclusion of reversible causes 2

Critical Safety Concern: Driving

• The combination of SLUMS score of 18 and memory complaints raises immediate safety concerns about driving capability that must be addressed before license reinstatement 5
• The Alzheimer's Association recommends documenting driving status and conducting formal safety assessment when cognitive screening suggests impairment 5
• Do not support license reinstatement until comprehensive evaluation is complete, as cognitive impairment at this level typically impairs judgment and reaction time necessary for safe driving 1

Why Referral to Neurology is Essential

The American Academy of Neurology and Alzheimer's Association require the following before dementia diagnosis or treatment initiation: 4, 1, 2

• Detailed history from both patient AND reliable informant regarding cognitive and functional decline (patient self-report is unreliable with cognitive impairment) 4, 2
• Formal functional assessment using validated tools like the Pfeffer Functional Activities Questionnaire (FAQ) or Disability Assessment for Dementia (DAD)—dementia diagnosis requires documented functional impairment in activities of daily living 1, 2
• Comprehensive neurological examination including dementia-focused assessment of cranial nerves, motor function, and gait 4
• Laboratory workup to exclude reversible causes: complete blood count, comprehensive metabolic panel, thyroid function (TSH), vitamin B12, and consideration of other metabolic causes 1, 2, 5
• Brain MRI (preferred over CT) to evaluate for stroke, white matter disease, structural abnormalities, and atrophy patterns that help differentiate dementia subtypes 1, 2, 5

What You Can Do as PCP Before Referral

Initiate the following immediately while awaiting neurology consultation: 1, 2, 5

• Obtain collateral history from family member or close contact about memory problems, functional decline, and behavioral changes 5
• Assess functional status using ADL and IADL scales to document specific impairments in daily activities 5
• Screen for depression using PHQ-9 or Geriatric Depression Scale, as depression can mimic or coexist with dementia 2, 5
• Order baseline laboratory tests: CBC, CMP, TSH, vitamin B12 to begin excluding reversible causes 2, 5
• Document current medications and review for anticholinergic burden or other cognitive-impairing drugs 1
• Address cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) aggressively, as these contribute to cognitive decline 1

Why Not Start Medication Now

Starting cholinesterase inhibitors or memantine before formal diagnosis is inappropriate for several reasons: 4, 6

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) show only modest benefit (1-3 point improvement on ADAS-cog) with uncertain clinical significance 1
• These medications have significant adverse effects including gastrointestinal symptoms, central nervous system disturbances, and arrhythmias that require monitoring 4
• The USPSTF found inadequate evidence that early treatment affects long-term cognitive outcomes for mild to moderate dementia 4
• You need confirmed Alzheimer's disease diagnosis before initiating Alzheimer's-specific medications, as other dementia subtypes (vascular, Lewy body, frontotemporal) may require different management approaches 1, 2

Common Pitfalls to Avoid

• Do not diagnose dementia based solely on screening test scores without comprehensive clinical evaluation 2
• Do not assume all dementia is Alzheimer's disease—vascular dementia, Lewy body dementia, and frontotemporal dementia require different diagnostic and management approaches 2
• Do not overlook depression as a contributor or mimic of cognitive impairment 2
• Do not support driving without formal assessment, as this creates liability and safety risks 5
• Do not delay referral while attempting to complete full workup yourself if you lack expertise in dementia diagnosis 4, 1

Specific Next Steps

Your immediate action plan should be: 1, 2, 5

1. Refer to neurology or geriatric psychiatry for comprehensive dementia evaluation
2. Inform patient that license reinstatement cannot be supported until cognitive evaluation is complete
3. Order baseline labs (CBC, CMP, TSH, B12) before neurology visit
4. Obtain informant-based history from family member
5. Screen for depression and treat if present
6. Document baseline functional status using ADL/IADL scales
7. Schedule follow-up after neurology evaluation to coordinate ongoing care