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Approach to Memory Loss Kevin Overbeck, DO Assistant Professor UMDNJ–SOM NJISA.

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Presentation on theme: "Approach to Memory Loss Kevin Overbeck, DO Assistant Professor UMDNJ–SOM NJISA."— Presentation transcript:

1 Approach to Memory Loss Kevin Overbeck, DO Assistant Professor UMDNJ–SOM NJISA

2 Approach to Memory Loss This medical student presentation is offered by the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3 Geriatrics Pre-Session Question 1 Self-reported memory loss has been well correlated with subsequent development of dementia. (a)True (b)False 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(11):1724.-1726.

4 Geriatrics Pre-Session Question 2 An elderly female who complains of a word finding difficulty thus displays a form of aphasia which is often exhibited during early stage Alzheimer’s disease. (a)True (b)False Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology.1999;52(7):1392-1396.

5 Geriatrics Pre-Session Question 3 An 82 year old man presents acutely to the hospital and is noted to have a fever 100.5 ◦ F. Which of the following is most suggestive of the diagnosis of delirium? (a)Inability to stay focused on questions (b)Word finding difficulty (c)Mini-Mental State Exam Score: 18/30 (d)Geriatrics Depression Scale Score: 6/15

6 Learning Objectives The learner will be able to recognize the presentation of delirium and understand the etiology of delirium The learner will be able to approach the clinical manifestation of memory loss in a systematically and evidence based approach The learner will be able to compare and contrast the common geriatric cognitive syndromes of delirium, depression, and dementia

7 Approach to Memory Loss Cognitive Assessment Tools

8 Assessment Tool Overview Dementia incidence 20-50% of those >85 yrs old Assessment Tools –“AAO x 3” –Clock Draw Test (CDT) –Mini-Mental State Exam (MMSE) –Sweet 16 –Neuropsychological Testing

9 Clock Draw Test (CDT) Complete circle – 1 point All 12 numbers – 1 point Numbers in correct positions – 1 point Hands properly displaying “ten after eleven” – 1 point Maximum Score 4 out of 4 (4/4) 1.Tuokko H, et al. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s disease. J Am Geriatr Soc. 1992;40(6):579-584. 2.Mendez MF, et al. Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(11):1095-1099. “Please draw the face of a clock and put the numbers in the correct positions. Draw in the hands at ten minutes after eleven.”

10 CDT: A Case How would you score this clock draw test? (a) 4/4 – abnormal (b) 3/4 – abnormal (c) 2/4 – abnormal (d) 1/4 – abnormal (e)0/4 – abnormal

11 CDT: Sample Documentation “Clock Draw Test 2/4 – abnormal score suggestive of memory impairment”

12 Mini-Mental State Exam (MMSE) Time Orientation (5 points) Place Orientation (5 points) Registration (3 points) Attention and Calculation (5 points) Recall (3 points) Naming (2 points) Repetition (1 point) Comprehension (3 points) Reading (1 point) Writing (1 point) Drawing (1 point) Distribute MMSE forms to students purchased @ www.parinc.com

13 MMSE: Capacity Max Score: 30 points <24 points: suggestive dementia or delirium 23 denotes capacity) Karlawish JHT, Casarett DJ, James BD, et al. The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment. Neurology. 2005;64(9):1514-1519.

14 Influenced by auditory, visual, and motor impairments Not sensitive for mild dementia Limited ability to assess progressive decline due to practice effect MMSE: Limitations Hensel A, Angermeyer MC, Riedel-Heller SG. Measuring cognitive change in older adults: reliable change indices for the Mini-Mental State Examination. J Neurol Neurosurg Psychiatry. 2007;78(12):1298-1313.

15 MMSE: Sample Documentation “MMSE Total Score of 25/30 –Time Orientation: 4/5 (deficit season) –Location Orientation: 4/5 (deficit county) –Attention/Calculation : 4/5 (serial sevens) –Repetition: 0/1 (missed first attempt but got it on the second attempt) –Drawing: 0/1 MMSE suggestive of cognitive impairment with deficits in orientation, attention, repetition, and drawing”

16 Cognitive Testing: The “Sweet 16” Time Orientation (4 points) Location Orientation (4 points) Registration (3 points) Digit Span Testing (2 points) Recall (3 points) Fong TG, Jones RN, Rudolph JL, et al. Development and validation of a brief cognitive assessment tool, the Sweet 16. Arch Intern Med. 2011;171(5):432-437.

17 Sweet 16: Sample Documentation “Sweet 16 Score of 9/16 –1/4 – Time Orientation (deficit year, date, day) –3/4 – Location Orientation (deficit town) –3/3 – Registration –1/2 – Digit Span –1/3 – Recall Sweet 16 cognitive test suggestive of cognitive impairment and correlates with an MMSE of 16.9/30)”

18 Approach to Memory Loss The Case of Mrs. Roberts

19 A Case: Mrs. Roberts Mrs. Roberts is a 75 year old widowed female who sustained a fall and hip fracture 2 weeks ago with a subsequent adult failure to thrive presentation pattern highlighted by poor participation in rehabilitation efforts. Not only is she not eating, but she is sleepy during the day and restless at night The son is upset about this and wants to know why she is not improving and what you are doing about it. Lisinopril 10mg daily Sertraline 100mg daily Lorazepam 2mg qHS PRN Acetaminophen 650mg q4h PRN mild pain Celecoxib 100mg po daily Oxycodone/acetaminophen 5mg/325mg one tablet po q4h prn severe pain

20 A Case: Mrs. Roberts The concerned son reports that his mother is confusing him for her deceased husband (i.e. son’s father). He goes on to report that he has been diligently trying to be present during meal time to support her intake but she falls asleep while he’s trying to have a conversation with her. Although her son witnessed this behavior since the surgery, he reports, “I thought it would’ve gone away by now.” During the day she has been kept in a recliner chair by the nurse’s station because of poor safety awareness (i.e. getting up out of bed without assistance). Nurse’s notes indicate that she has been agitated at night – demanding to go home and threatening to call the police if she is not taken home immediately.

21 A Case: Mrs. Roberts Her son admits that she was forgetful before the surgery, but “never to this degree.” His mother moved in to live with him after the death his father (her spouse). Functional History ADLS – preoperatively independent [6/6 Katz ADL Scale] IADLS – preoperatively dependent on shopping, transportation, finances [5/8 Lawton IADL Scale] Upon further review her son reports that she was still capable of cooking basic meals but less frequent and less fancy. She has complaints of fatigue and naps a lot. She seems to have no desire to leave the house.

22 A Case: Mrs. Roberts Mrs. Roberts has had a history of depression and had previously taken anti-depressants intermittently. She has been taking sertraline (Zoloft®) 100mg since his death just over a year ago. Due to her grief, she moved in with her son shortly after the funeral. Prior to her hip fracture, her appetite had been fair; he also admits that she was an avid reader but had become “more of a television watcher since my dad died.” She has a long history of insomnia taking lorazepam at bedtime nearly every night “for as long as I can remember.” He agrees that she has been taking this medication to help her sleep “for more than 10 years.”

23 A Case: Mrs. Roberts Time Orientation: 1/5 Location Orientation: 2/5 Registration: 1/3 Attention: serial sevens 0/5 Naming: 2/2 Short-term Memory: 0/3 3-step Command: 2/3 Read and Obey: 1/1 Sentence: 1/1 Visual Spatial: 0/1 TOTAL SCORE=10/30

24 A Case: Mrs. Roberts Her hip incision is clean, dry, well-approximated and without evidence of cellulitis. During your performance of standardized cognitive testing instruments, you note Mrs. Roberts to be difficult to engage with questioning. At times you must repeat the instructions 3-4 times to get her to respond. You have the opportunity to watch her during physical therapy and note that she requires considerable assistance and cuing in order to stand but she performs this task she is able to do so without pain. In between exercise sets she is noted to be picking and readjusting her clothing.

25 A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with delirium? (a)Yes (b) No

26 A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with depression? (a)Yes (b) No

27 A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with dementia? (a)Yes (b) No

28 A Case: Mrs. Roberts Would you order “discontinue lorazepam?” (a)Yes (b) No

29 A Case: Mrs. Roberts Would you order “discontinue oxycodone/ acetaminophen?” (a)Yes (b) No

30 A Case: Mrs. Roberts Reduce and taper lorazepam Discontinue oxycodone/acetaminophen (Percocet®) Continue sertraline (Zoloft®) Discontinue celecoxib (Celebrex®) Continue acetaminophen PRN Continue lisinopril Ensure (nutritional supplement) daily Next week (after taper lorazepam) consider start of mirtazapine at bedtime

31 Delirium, Dementia, Depression ALL presentations of ‘memory loss’ are due to one (and sometimes combinations) of the following conditions: DELIRIUM DEPRESSION DEMENTIA NORMAL AGING Normal Aging Delirium Dementia Depression

32 Dementia, Depression, Delirium Wellcome Images. Wellcome Library, London © Wellcome Trust

33 Delirium, Dementia, Depression Distinguishing Feature(s) Associated SymptomsCourse DeliriumAcute Onset and Fluctuating Levels of Confusion/ Consciousness Inattention, Memory Loss, Disorientation, Agitation, Delusions, Apathy, Withdrawal, Disturbed Sleep Cycle, Disorganized Thinking Acute, Due to an Underlying Condition DementiaMemory ImpairmentDisorientation, Agitation, Disturbed Sleep Cycle Chronic, Insidiously Progressive DepressionSadness, Loss of InterestDisturbed Sleep Cycle, Appetite, Difficulty Concentrating, Decreased Energy, Hopelessness, Worthlessness, Suicidal Ideation/Attempt(s) Single Episode or Recurrent/Chronic Episodes

34 Self Reporting versus Informant Most demented patients do not present with a chief complain of “memory loss” Most often spouse/daughter/son brings it to the attention of the clinician Family are often delayed in recognizing the dementia signs (i.e. cooking/finances) 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(11):1724.-1726.

35 Aging Masquerading as Disease Encoding (slowed speed of processing; slightly less able than normal to concentrate and more easily distracted by external stimuli) Storage (unchanged) Retrieval (word-finding difficulty) Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology. 1999;52(7):1392.-1396.

36 Delirium, Depression, Dementia: Memory Loss Responding to Treatment Data from: Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7):446-471. Diseasen Depression40 Drugs31 Metabolic27 NPH16 Neoplasm11 Subdural hematoma10 Alcohol8 Infection4 Not Specified/Other21 Depression Drugs Metabolic

37 Delirium, Depression, Dementia: Fully Reversed Memory Loss Data from: Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7):446-471. Diseasen Depression4 Drugs13 Metabolic2 NPH1 Neoplasm0 Subdural hematoma1 Alcohol1 Infection0 Not Specified/Other1 Drugs Depression

38 Algorithm Patient with Known or Suspected Memory Loss CAM Identify Underlying Cause of Delirium & Treat GDS No Delirium SWEET 16/ MMSE Treat Depression or Discuss Options Lab Brain Imaging Re-evaluate After Treatment No Action NormalAbnormal Equivocal or Inconsistent with Depression Consistent with Depression ImpairedNot Impaired

39 A Case: Mrs. Windfelder Day 1: Mrs. Windfelder is an 81 year old female who continues to live independently despite ambulating with a rolling walker. She presents to the emergency room for an evaluation of chest discomfort. She feels a chest pressure that lasts for just a few moments but wanted to get it checked despite having a recent negative stress test. She goes on to admit “I lives alone and I thought I should get checked out.” BP @ Triage: 180/70 mmHg BP 30 minutes later: 150/70 mmHg [prior to any treatment] EKG: normal sinus rhythm 1 st Set Cardiac Biomarkers: “negative” Anderson JL, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007;50(7):e1-e157.

40 A Case: Mrs. Windfelder She is treated with O2, aspirin, metoprolol, nitroglycerine, morphine, and omeprazole. A bladder catheter is ordered because she has been ordered “bed rest” until cleared by cardiology. Should Mrs. Windfelder get a cardiac catheterization? (a)Yes (b)No

41 A Case: Mrs. Windfelder Day 2: Despite a third negative set of cardiac biomarkers, Mrs. Windfelder had a similar episode of vague chest discomfort during the early morning and agrees with her treating cardiologist that a cardiac catheterization is the next best plan of care. Day 3: Cardiac catheterization results in essentially normal coronary vasculature. In evening, Mrs. Windfelder develops confusion and begins pulling at IV lines and insisting that she needs to urinate. Despite reassurance that the catheter is collecting her urine she is unable to be re-directed. She is managed with restraints, lorazepam and haloperidol.

42 A Case: Mrs. Windfelder Day 4: Mrs. Windfelder develops urinary tract infection with fever and increased confusion. Bladder catheter discontinued; patient incontinent. Day 9: Patient remains incontinent, but is unable to walk safely due to deconditioning. She is transferred to subacute rehabilitation; sacral breakdown is noted on the transfer paperwork.

43 Delirium DSM-IV Criteria - Delirium Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Develops over a short period of time (usually hours to days) Mental status tends to fluctuate during 24 hour period Evidence the disturbance is caused by a medical condition, substance intoxication, or medication side effect.

44 Delirium (Epidemiology) 1.Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(15):1157-1165. 2.American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(Suppl 5):1-20. 3.Moran JA, Dorevitch MI. Delirium in the hospitalized elderly. Aust J Hosp Pharm. 2001;31(1):35-40. Delirium Rates 1 Hospital: Prevalence (on admission) 14-24% Incidence (in hospital) 6-56% Postoperative: 15-53% Intensive care unit: 70-87% Nursing home/post-acute care: 20-60% Palliative care up to 80% Mortality Hospital mortality 2 : 22-76% One-year mortality 3 : 35-40%

45 Confusion Assessment Method (CAM) Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. Symptoms Symptoms Rating 1 Acute onset or Fluctuating Course NegPos 2 Inattention NegPos AND 3 Disorganized Thinking NegPos OR 4 Altered Level of Consciousness NegPos

46 Delirium Perceptual disturbances Psychomotor agitation Psychomotor retardation Altered-sleep wake cycle

47 A Clinical Question A stuporous patient can also have psychomotor agitation. (a)True (b)False

48 Delirium: Documentation Example 1 – Incorrect - “patient disoriented to place.” – Correct - “patient thought she was at a bowling alley” Example 2 (perseveration) – Incorrect - “patient repeated answers.” – Correct - “patient ‘1922’ to each of the orientation questions on cognitive function testing (i.e. month, date, day, state, town).”

49 Delirium: Etiology Dementia Electrolytes Lungs, liver, heart, kidney, brain Infection Rx - Treatment & withdrawal (ETOH, Benzos, Sleepers) Injury, pain, stress Unfamiliar environment Metabolic Inouye SK. AGS Henderson Lecture, Delirium: applying research to transform care at the bedside, Talks & Slides presented at: American Geriatrics Society, 2010; http://www.americangeriatrics.org/files/documents/annual_meeting/2010/handouts/thursday/ henderson/ s_inouye_henderson.pdf. Accessed October 5, 2011.

50 Delirium: High Yield Rx Sedatives Hypnotics “sleepers” Barbiturates Opiates Anticholinergics (including benztropine) Digoxin Steroids Psychotropics Anticonvulsants

51 Delirium: Yale Delirium Prevention Program Risk FactorIntervention Cognitive ImpairmentReality orientation Therapeutic activities protocol Sleep deprivationNonpharmacologic sleep protocol Sleep enhancement protocol ImmobilizationEarly mobilization protocol Minimizing immobilizing equipment Vision impairmentVision aids Adaptive equipment Hearing impairmentAmplifying devices Adaptive equipment and techniques DehydrationEarly recognition and volume repletion Inouye SK. Cleve Clin J Med. 2004;71(11):890-896.

52 Delirium: Yale Delirium Prevention Trial Results Outcome Intervention Group (N=426) Usual Care Group (N=426) Matched OR (CI) or p-value Incident delirium, n (%)42 (9.9%)64 (15.0%).60 (.39-.92) p=.02 Total delirium days105161p=.02 # delirium episodes6290p=.03 Delirium severity score3.93.5p=.25 Recurrence rate13 (13.0%)17 (26.6%p=.62 Inouye SK. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676.

53 Hospital Elder Life Program (HELP) Delirium is the leading risk factor for falls in hospital HELP instituted at 29 hospitals – falls reportedly reduced at 95% of sites Hospital at Home 1.Inouye SK. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. N Engl J Med. 2009;360(23):2390-2393. 2. Inouye SK. AGS Henderson Lecture, Delirium: applying research to transform care at the bedside, Talks & Slides presented at: American Geriatrics Society, 2010; http://www.americangeriatrics.org/files/documents/annual_meeting/2010/handouts/thursday/henderson/ s_inouye_henderson.pdf. Accessed October 5, 2011.

54 Algorithm Patient with Known or Suspected Memory Loss CAM Identify Underlying Cause of Delirium & Treat GDS No Delirium SWEET 16/ MMSE Treat Depression or Discuss Options Lab Brain Imaging Re-evaluate After Treatment No Action NormalAbnormal Equivocal or Inconsistent with Depression Consistent with Depression ImpairedNot Impaired

55 PHQ-2 1.Thibault JM, Prasaad Steiner RW. Efficient identification of adults with depression and dementia. American Family Physician. 2004;70(6). 2.Kroenke K et al. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-1292. Adapted from the PHQ-9 A score of 3 or more had a sensitivity of 83% and specificity of 92% for major depression GDS is better suited for elderly patients  Pfizer, Inc.

56 Geriatric Depression Scale (GDS) 15 “Yes/No” Items Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are? Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention 165-173, NY: The Haworth Press, 1986.

57 Geriatric Depression Scale (GDS) A score > 5 points is suggestive of depression A score > 10 pints is almost always indicative of depression Any score greater than 5 should prompt a discussion about suicidal ideation Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention 165-173, NY: The Haworth Press, 1986.

58 Depression Depressed mood Loss of interest or pleasure in most or all activities Insomnia or hypersomnia Change in appetite or weight Psychomotor retardation or agitation Low energy Poor concentration Thoughts of worthlessness or guilt Recurrent thoughts about death or suicide American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

59 Dementia Defined “A disorder that is characterized by impairment of memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.” American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

60 Dementia (Diagnosis) DSM-IV Criteria - Dementia Memory Impairment One of the following: –Apraxia –Aphasia –Agnosia –Disturbance in executive function Disturbance in effects work, social activities, relationships Disturbance does not occur exclusively during delirium American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

61 USPSTF Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: A summary of the evidence for the U.S. Preventive services task force.. Ann Intern Med. 2003;138(11):927-937. Year >2 >4 9

62 Cognitive Testing: A Review Clock Draw Test (CDT) Mini-Mental State Examination (MMSE) Sweet 16 Neuropsychiatric Testing

63 Cognitive Testing Neuropsychological Testing Distinguish mild dementia from age-associated memory loss Detect focal neuropsychological manifestations Distinguish organic dementia from depression Fully characterize cognitive capacity Make appropriate recommendations regarding competence (i.e. financial responsibility, vehicle operation) Provide longitudinal assessment (i.e. rates of decline, efficacy of medical interventions)

64 Cognitive Testing Assessment of Pre-morbid Ability NART Scores (National Adult Reading Test) Pronunciation of 50 Irregular English Words The more words a patient can read the higher the estimate of pre-morbid ability If initial IQ is controlled, scores to do not differ between those with and without mild to moderate dementia Example Ache Thyme Debt Bouquet Heir Nausea Chord Psalm Depot McGurn B, Starr JM, Topfer JA, et al. Pronunciation of irregular words is preserved in dementia, validating premorbid IQ estimation. Neurology. 2004;62(7):1184-1186.

65 Cognitive Testing Executive Function Testing Ability to comprehend all details of an activity AND Convert that information to an adequately perform a given behavior Example: Trail-making

66 Cognitive Assessment Incongruent with History Cog Suggests Dementia Acute Confusion (Delirium) Low Intelligence/ Education Primary Language not English Inadequate recognition by informants History Suggests Dementia Mild Dementia High Intelligence/ Education Depression Misrepresentation by informants Knopman, DS. The initial recognition and diagnosis of dementia. Am J Med. 1998;104(4A):2S-12S.

67 Algorithm Patient with Known or Suspected Memory Loss CAM Identify Underlying Cause of Delirium & Treat GDS No Delirium SWEET 16/ MMSE Treat Depression or Discuss Options Lab Brain Imaging Re-evaluate After Treatment No Action NormalAbnormal Equivocal or Inconsistent with Depression Consistent with Depression ImpairedNot Impaired

68 Laboratory & Radiological Studies An 80 year old male brought for an evaluation by his son for a progressive deterioration has an MMSE 22/30 and GDS 4/15. He has even experienced delusions in which he accused his son of stealing his important VA papers. He exhibits no focal deficits on neurological exam and takes only an aspirin every day. Which of the following items can be omitted from the initial work up of this patient’s progressive memory loss? (a)Serum TSH (b)Radiological brain imaging (c)Carotid Doppler (d)B12 Level (e)Folate Level

69 Laboratory & Radiological Studies BMP CBC LFTs B12/Folate TSH Brain imaging (MRI preferred) +/- RPR 1.Knopman DS, et al. Practice parameter: Diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1143-1153. 2.Knopman DS, et al. Incidence and causes of nondegenerative nonvascular dementia: A population-based study. Arch Neurology. 2006;63(2): 218-221.

70 Other Testing Other considered studies – RPR, UDS, EtOH level, EEG, CXR, EKG, HIV


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