The growing threat to transgender health care: implications for patients, providers, and trainees Carson Hartlage | Policy.This patient’s memory difficulties are greater than what is expected with normal aging, and her score on the Montreal Cognitive Assessment is not in the normal range. Patients with memory problems due to normal aging have symptoms, most notably memory loss, that are commonly associated with cognitive impairment, but cognitive testing shows functioning within the normal range. Therefore, depression is unlikely to be the cause of her symptoms. This patient, who describes her mood as upbeat and says she enjoys her life, has neither depressed mood nor anhedonia. If either depressed mood or anhedonia is present, further inquiry or employing a second tool to diagnose depression should be pursued. Using a two-item questionnaire that assesses for the presence of depressed mood or anhedonia is a quick way to screen for depression. Depressed mood and anhedonia are cardinal symptoms, and the presence of either is highly sensitive but not specific for major depression. The evaluation must establish whether the patient meets established criteria for major depression, dysthymia, or a different psychiatric condition and also assess for substance abuse. The diagnosis of clinical depression is based on patient history and exclusion of alternative diagnoses no additional tests can confirm the diagnosis. This patient does not meet the criteria for dementia. A detailed history of the patient’s abilities to perform activities of daily living, such as paying bills, managing financial records, assembling tax records, shopping alone, working on hobbies, taking medications, driving, and remembering recent holidays or family events, should be obtained to elicit any change in function. In order to meet criteria for dementia, a patient’s cognitive deficits must interfere with daily functioning and result in some loss of independence.
Occasionally, a formal battery of neuropsychological testing beyond the standard mental examination is needed to distinguish particularly mild cases of cognitive impairment from normal aging. In clinical practice, a careful history and results of a standard mental examination are often sufficient to make a diagnosis of MCI, and extensive cognitive testing is not routinely required. A score lower than 26/30 generally suggests cognitive impairment, especially in patients with 16 years of formal education. The Montreal Cognitive Assessment is a screening tool that is more sensitive than the Mini–Mental State Examination in the detection of MCI because it has more cognitively challenging tests of memory/recall and executive function. For most patients, the onset is insidious, and for some, the course may be progressive 10% to 15% of patients with MCI transition to dementia per year, compared with 1% to 2% per year of the general population. MCI is a cognitive state between normal aging and dementia characterized by a decline in cognitive functioning that is greater than what is expected with normal aging but has not resulted in significant functional disability. The most likely underlying cause of this patient’s symptoms is mild cognitive impairment (MCI). The correct answer is C: Mild cognitive impairment.
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