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Diagnostic Evaluation of Elderly Patients with Mild Memory Problems
- Jason Karlawish, MD; and
- Christopher M. Clark, MD
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IN RESPONSE:
To apply the label of “neurodegenerative dementia” to a patient, a clinician needs to show declines in a person's cognition that explain changes in the person's ability to perform usual and everyday activities, such as managing a checkbook or preparing a cup of tea (1). The point of showing deficits in at least 2 domains of cognition is to reduce the chance that the problem could be due to a single brain lesion rather than diffuse neurodegenerative pathology. As elegant as these criteria are in linking disease with a set of signs and symptoms, several challenges hinder clinicians putting them into clinical practice. Chief among these challenges is the lack of a coherent language to measure the presence and severity of both functional and cognitive deficits (2). Unlike diseases such as hypertension or diabetes, no set of measures exist that have the same power as measurement of systolic and diastolic blood pressure or glycosylated hemoglobin. Such measures are powerful because they appear objective, are critical in making the diagnosis, and establish efficacy of an intervention both in clinical trials and clinical practice. In this context, the letters from Drs. Hirsch, Horton, and Schillerstrom are a welcome addition to the dialogue over what measures will best comprise a clinically useful language to talk about dementia. Hirsch refines the set of functional measures presented in our case report, reinforces the role of the physician to partner with a family member to assess them, and illustrates the interrelated goals of an assessment. These goals are to document that there is clinically significant cognitive decline and to identify the patient's functional needs. Functional assessment and advance planning are perhaps the most important reasons to pursue early diagnosis of dementia. The longer unappreciated cognitive losses progress, the more the person suffers from unmet needs. We fully agree with Horton and Schillerstrom that unlike CLOX1 and EXIT25, the MMSE is not a test of executive function. It tests a smattering of cognitive functions. Nonetheless, it is one of the few cognitive tests that is widely used in clinical practice. Whether the scoring, administration, and norms of CLOX1 and EXIT25 can become part of usual and everyday clinical practice is a challenge to the expert medical community and clinician-educators.
Jason Karlawish, MD
Christopher M. Clark, MD
University of Pennsylvania
Philadelphia, PA 19104
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
