What could be behind your elderly patient’s subjective memory complaints?

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Clinical Inquiries

What could be behind your elderly patient’s subjective memory complaints?

J Fam Pract. 2008 May;57(5):333-334

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References

1. St John P, Montgomery P. Is subjective memory loss correlated with MMSE scores or dementia? J Geriatr Psychiatry Neurol. 2003;16:80-83.

2. Lautenschlager NT, Flicker L, Vasikaran S, et al. Subjective memory complaints with and without objective memory impairment: relationship with risk factors for dementia. Am J Geriatr Psychiatry. 2005;13:731-734.

3. Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry. 2000;15:983-991.

4. Mol ME, van Boxtel MP, Willems D, et al. Do subjective memory complaints predict cognitive dysfunction over time? A six-year follow-up of the Maastricht aging study. Int J Geriatr Psychiatry. 2006;21:432-441.

5. Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc. 2004;52:2045-2051.

6. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology. 2000;55:1724-1726.

7. Birks J, Flicker L. Donepezil for mild cognitive impairment. Cochrane Database Syst Rev. 2006;(3):CD006104.-

8. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and demetia. Cochrane Database Syst Rev. 2007;(2):CD003120.-

9. Etminan M, Gill S, Samii A. Effect of nonsteroidal anti-inflammatory drugs on risk of Alzheimer’s disease: systematic review and meta-analysis of observational studies. Br Med J. 2003;327:128-131.

10. Aisen P, Schafer K, Grundman M. Effects of rofecoxib or naproxen vs placebo on Alzheimer disease progression: a randomized controlled trial. JAMA. 2003;289:2819-2826.

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12. Malouf R, Grimley Evans J. Vitamin B6 for cognition. Cochrane Database Syst Rev. 2003;(4):CD004393.-

13. Malouf M, Grimley Evans J, Areosa SA. Folic acid with or without vitamin B12 for cognition and dementia. Cochrane Database Syst Rev. 2003;(4):004514.-

14. Scott HD, Laake K. Statins for the prevention of Alzheimer’s disease. Cochrane Database Syst Rev. 2001;(3):003160.-

15. US Preventive Services Task Force. Postmenopausal hormone replacement therapy for the primary prevention of chronic conditions: recommendations and rationale. Am Fam Physician. 2003;67:358-364.

16. Lim WS, Gammack JK, Van Niekerk JK, et al. Omega 3 fatty acid for the prevention of dementia. Cochrane Database Syst Rev. 2006;(1):CD005379.-

17. Valenzuela MJ, Sachdev P. Brain reserve and dementia: a systematic review. Psychol Med. 2006;36:441-454.

18. Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry. Illustrated ed. Arlington, Va: American Psychiatric Publishing, Inc; 2006.

19. US Preventive Services Task Force. Screening for dementia: recommendation and rationale summary for patients. Ann Intern Med. 2003;138:925-926.

20. Durso SC, Gwyther L, Roos B, et al. Clinical Practice Guidelines. Abstracted from the American Academy of Neurology’s dementia guidelines for early detection, diagnosis and management of dementia. New York: American Geriatrics Society; 2006. Available at: www.americangeriatrics.org/products/positionpapers/aan_dementia.shtml. Accessed April 9, 2007.

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Recommendations

There is no consensus regarding the nomenclature applied to reported memory loss and mild cognitive impairment. The Clinical Manual of Geriatric Psychiatry provides definitions that can be used in the clinical setting (TABLE).¹⁸

The US Preventive Services Task Force concludes that evidence is insufficient to recommend for or against routine screening for dementia in older adults (I recommendation).¹⁹ However, the Task Force notes that clinicians should assess cognitive function whenever they suspect impairment or deterioration based on direct observation, patient report, or concerns raised by family members, friends, or care-takers.

FAST TRACK

No consistent evidence supports drug treatment of reported memory loss that is not corroborated by objective findings

The American Geriatrics Society²⁰ and American Academy of Neurology (AAN)²¹ acknowledge the subtle difference between age-associated memory impairment and mild cognitive impairment, and the difficulty of differentiating normal changes of aging from abnormal changes. The AAN’s guidelines for early detection of dementia emphasize the importance of diagnosing mild cognitive impairment or dementia early. However, the guidelines specifically exclude patients with subjective memory loss unaccompanied by objective cognitive deficits and offer no further discussion about these patients.

TABLE
Features of age-associated memory impairment vs mild cognitive impairment

FEATURE	AGE-ASSOCIATED MEMORY IMPAIRMENT	MILD COGNITIVE IMPAIRMENT
Clinical presentation	≥50 years of age with reported memory complaint (40% of people in their 50s and 85% of people ≥80 years of age) Normal mental status Intact ADLs and IADLs	Reported memory complaint or memory problems noted by an informant Learning and recall most often affected Normal mental status Intact ADLs and subtle changes in IADLs (such as managing finances)
Memory test results	Within 1 SD of the average level for young adults on a standardized memory test	More than 1.5 SD below the average level for age peers on a standardized memory test
Clinical course	Generally stable for periods of at least 4 years	Progresses to dementia at the rate of 10% to 12% per year; some patients remain free of dementia for at least 10 years
ADLs, activities of daily living; IADLs, instrumental activities of daily living; SD, standard deviation.
Source: Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry.¹⁸

Evidence-based answers from the Family Physicians Inquiries Network