Evidence-Based Reviews
New Alzheimer’s disease guidelines: Implications for clinicians
Focus is on early stages, biomarkers that may improve diagnostic accuracy
Memory and other cognitive complaints are common among the general population and become more prevalent with age.1 People who have significant emotional investment in their cognitive competence, mood disturbance, somatic symptoms, and anxiety or related disorders are likely to worry more about their cognitive functioning as they age.
Common complaints
Age-related complaints, typically beginning by age 50, often include problems retaining or retrieving names, difficulty recalling details of conversations and written materials, and hazy recollection of remote events and the time frame of recent life events. Common complaints involve difficulties with mental calculations, multi-tasking (including vulnerability to distraction), and problems keeping track of and organizing information. The most common complaint is difficulty with remembering the reason for entering a room.
More concerning are complaints involving recurrent lapses in judgment or forgetfulness with significant implications for everyday living (eg, physical safety, job performance, travel, and finances), especially when validated by friends or family members and coupled with decline in at least 1 activity of daily living, and poor insight.
Helping your forgetful patient
Office evaluation with brief cognitive screening instruments—namely, the Montreal Cognitive Assessment and the recent revision of the Mini-Mental State Examination—might help clarify the clinical presentation. Proceed with caution: Screening tests tap a limited number of neurocognitive functions and can generate a false-negative result among brighter and better educated patients and a false-positive result among the less intelligent and less educated.2 Applying age- and education-corrected norms can reduce misclassification but does not eliminate it.
Screening measures can facilitate decision-making regarding the need for more comprehensive psychometric assessment. Such evaluations sample a broader range of neurobehavioral domains, in greater depth, and provide a more nuanced picture of a patient’s neurocognition.
Findings on a battery of psychological and neuropsychological tests that might evoke concern include problems with incidental, anterograde, and recent memory that are not satisfactorily explained by: age and education or vocational training; estimated premorbid intelligence; residual neurodevelopmental disorders (attention, learning, and autistic-spectrum disorders); situational, sociocultural, and psychiatric factors; and motivational influences—notably, malingering.
Some difficulties with memory are highly associated with mild cognitive impairment or early dementia:
• anterograde memory (involving a reduced rate of verbal and nonverbal learning over repeated trials)
• poor retention
• accelerated forgetting of newly learned information
• failure to benefit from recognition and other mnemonic cues
• so-called source error confusion—a misattribution that involves difficulty differentiating target information from competing information, as reflected in confabulation errors and an elevated rate of intrusion errors.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.