August 2014   |   Archive

Chief Complaint: “Doc, I’m Worried
About His Memory”

You’re 12 patients into your day and so far, so good. The EMR is only creeping along, but at least it’s up and running. Your medical assistant reports that the wife of the next patient is in the room with him, and though he said she should stay, he doesn’t seem happy about it. His wife insisted it was very important that she attend today, and you now learn she stopped in yesterday to drop off a note for you. The piece of paper holds the chief complaint that she would not repeat in front of the medical assistant—or her spouse—today. On the folded piece of loose-leaf paper is one word neatly centered: memory.

For most primary care providers, the patient’s report of the chief complaint is like the tipping of the first domino that leads to an orderly and clear path forward through diagnosis, treatment, and resolution. But what happens when the chief complaint is mentioned by the patient’s family member or friend rather than by the patient himself? (For discussion purposes, the person accompanying the patient has his permission to speak for him.) Even worse, what if the patient does not agree to or want an evaluation for memory loss? Now what? Clearly, this chief complaint cannot be ignored. But what if the patient is uncooperative or refuses to allow an evaluation? What can you do?

Often, to ease the tension of the moment, I will relay one of my own “senior moments” and affirm the universality of the complaint. In some cases, once the subject is brought up and we commiserate a bit, the patient will admit his memory is “not like it used to be” or “it’s no worse than anyone else my age” and grudgingly allow me to give him a “memory test.”

For others, this doesn’t work. There are three common rebuttals to my request to test a patient’s memory. Some may not recognize the need because they honestly do not see a change in their abilities or any problems it has caused. Some may fear the answer. And some may believe there is nothing that can be done and therefore feel no need to know whether they have Alzheimer’s disease.

For these common rebuttals consider these strategies:

Barrier Strategy


Lack of insight

Some may not see the need because they fail to see a change in their abilities or problems it has caused.

Acknowledge that it may not be a big issue now but could threaten his independence in the future. Stress the benefits of prevention. Point out that as we get older, our minds do change. Just as we all eventually need bifocals, it’s important to check memory even if a patient feels well. This provides a baseline and allows us to know how well the patient is doing now so he can try to stay healthy.

“I don’t want to know.”

Some may readily admit to memory lapses, but fear the answer.

Address the stigma. For some patients, all they know of aging and dementia is “crazy Aunt Bessie.” Point out that we know there are sometimes reversible causes that can be addressed to resolve the symptoms. The sooner we know why something is happening, the sooner we can address it with appropriate treatments. Point out that there are medications that may help.

“There’s nothing you can do about it, so why know?”

Some may readily admit to memory lapses, but believe there is nothing that can be done and feel there is no need to know whether they have Alzheimer’s disease.

Clarify the benefit of testing. First, you need to determine whether the symptoms stem from dementia or a reversible cause. If it is dementia, the sooner a patient knows, the sooner he can take medications. I tell patients there’s a 40% to 50% chance the medications will help and they are generally well tolerated and have a low risk overall. And there are other ways patients can help themselves. The sooner patients take care of the brain/take the medications, the better.

 

If those strategies fail, consider asking the patient’s wife to leave the room so you can have one-on-one time with him. Sometimes, letting a patient know you are on his side and not ganging up on him with his wife will win you some needed credibility and he may become surprisingly forthcoming. You may then be able to move through the necessary diagnostic testing and evaluation.

For the completely resistant patient, sometimes all you can do is preserve the physician/patient relationship and drop the subject for the time being. Document the issue and move on to complete the day’s encounter. Plan to spend a few minutes later reviewing the chart and evaluate the patient’s risk.

As you think about what the patient’s wife has told you, keep in mind what dementia really is. We think of memory loss as the main symptom, but in fact, it is a disease of memory making. In Alzheimer’s disease, by far the most common form of dementia, it is the hippocampus that begins to fail. The hippocampus’ job is to process information and send it for storage as working memory. If information is not processed, it is not remembered. Thus patients in the early stages of Alzheimer’s disease can remember their children’s names but cannot recall what they had for breakfast or whether they have had breakfast.

Here are some common early symptoms you may hear reported by family members:

  • financial mistakes: paying twice, forgetting to pay, misplacing bills;
  • language: word finding, missing nouns; and
  • change in social activities: canceling a bridge game, no longer attending club meetings.

Keep in mind age-specific prevalence statistics and risk factors. According to 2013 data, the prevalence of Alzheimer’s disease is 11% in those age 65 and older; 32% in those aged 85 and older; and 45% to 50% in those aged 90 and older. Additionally, the prevalence of all forms of dementia is 13.9% in those aged 71 and older.

Risk factors for the complaint proving to be a chronic dementia include the following:

  • age;
  • family history;
  • cerebrovascular risk factors, especially in mid-life;
  • hypertention, obesity, hypercholesterolemia, and smoking;
  • atrial fibrillation;
  • sleep apnea;
  • traumatic brain injury or other injury; and
  • depression.

Other factors in my experience that make a patient high risk include a history of recent delirium during surgery or other medical illness.

Important note: These must have diagnostic evaluation. You can even skip the memory testing if it’s upsetting to the patient, but get labs and brain imaging (MRI with contrast if possible or head CT).

Factors that make reversible causes likely include the following:

  • recent onset (past six to 12 months);
  • abrupt onset;
  • medication-related symptoms; and
  • onset of memory symptoms accompanied by mood changes/personality changes/gait changes.

Consider Your Patient

Assess the baseline risk based on prevalence and risk factors. Then do what you can to assess whether there’s evidence of a change in cognitive ability. If he adamantly refuses formal testing, your skills of informal observation can be useful.

Informal Cognitive Assessment
Is he repeating himself?

Is he contradicting himself?
Does he make errors in speaking or appear to be word-seeking?

Has he missed appointments or shown up on the wrong day/time? (Sometimes staff will observe and report this.)

Has he made medication errors, failed to follow instructions, or failed to recall instructions from a prior visit?

 

If he allows you to pose any historical questions regarding what’s been occurring, consider using the AD8. It’s a terrific tool to use; it is nonthreatening and is performance based rather than tasked based. Patients are likely to be more open to disclosing whether they perceive a change than attempting to subtract backward from 100 by sevens. Originally designed for a family member or other caregiver to report observed behavior, it has been validated for use by patients as well. (The AD8 is available at: http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf)

Often information gathered in the AD8 will allow you to assess the risk for dementia. Based on this assessment, you can plan your management.

High: AD8 > 2, Risk Factors > 2, Highly credible report(s)/observed change in ability/performance

Explain your concern, address any barriers (see above), and try to find common ground.

1. Obtain the recommended diagnostic tests including CBC chem panel for glucose, BUN/creatinine, liver function, TSH, B12. Less, but emerging evidence for vitamin D (http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf).

2a. Ask him to return for a visit by himself during which you’ll perform the memory assessment without family present.

2b. If you have specialists in your area (eg, geriatricians, memory disorder clinics, neurologists, psychiatrists) ask whether he’d prefer to see a specialist.

3. Encourage the patient to practice good brain health with 30 minutes per day of physical exercise: a 30 minute walk five days per week; cognitive exercise: my favorite is a word search for 30 minutes five days per week; and socialization: three social engagements per week.

4. Refer the spouse to a local resource. Provide the family with a local resource such as a memory disorder clinic or Alzheimer’s support group. The Alzheimer’s Association is a good resource in most locales (1-800-272-3900, www.alz.org). You might also plan ahead and ask one of your team members to find the contact information for the chapters in your area.

Low: AD8 < 2, Risk Factors < 2, Minimal credible report(s)/observed change in ability/performance

Keep in mind the wife’s concern and plan to revisit the issue every six months via questions of both the patient and his wife.

1. Include cognitive testing of some sort in the patient’s planned annual physical to create a baseline. He may not object if it is done as part of the routine testing in an annual checkup.

2. Encourage him to practice good brain health with 30 minutes per day of physical exercise: a 30 minute walk five days per week; cognitive exercise: my favorite is a word search for 30 minutes five days per week; and socialization: three social engagements per week.

3. Refer the spouse to a local resource. Provide the family with a local resource such as a memory disorder clinic or Alzheimer’s support group. The Alzheimer’s Association is a good resource in most locales (1-800-272-3900, www.alz.org). You might also plan ahead and ask one of your team members to find the contact information for the chapters in your area.

If you follow the above advice, you will have started that domino down a clear orderly path and won’t lose track of this important concern for your patient and his family. Keep in mind that there are reversible causes of cognitive change, so sooner follow-up and diagnostic evaluation may be indicated until a clear etiology is identified. If it is a dementia, remember that these are chronic illnesses that will change over time. As they say, timing is everything. In three, six, or perhaps 12 months, the same patient who didn’t want an evaluation may be more open to it.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, medical director of the Health First Aging Institute, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for Someone With Memory Loss.