A 65-year-old woman comes to the office due to memory impairment. The patient's memory difficulties began 2 months ago, and she is concerned her symptoms have recently worsened. She often forgets parts of recent conversations and has misplaced her car keys multiple times. The patient sleeps without issue and feels well rested upon awakening. She is a retired accountant and recently moved across the country to care for her parents, preparing meals for them and managing their finances. The patient regularly eats out at restaurants and drinks a glass of wine 3-4 times a week. Medical history includes allergic rhinitis, for which she has been taking over-the-counter medications. Temperature is 36.9 C (98.4 F), blood pressure is 130/82 mm Hg, and pulse is 76/min. The patient is alert and oriented. Physical examination shows no abnormalities. Which of the following is the most appropriate statement?
This patient has memory impairment that began recently and had a relatively abrupt onset, with no significant functional decline and a normal physical examination. This presentation should prompt consideration of reversible causes, including a careful review of medications. Many over-the-counter (OTC) allergy medications (eg, antihistamines) have anticholinergic effects that can contribute to memory impairment, especially in older patients. Memory impairment caused by medications with anticholinergic properties may be mistakenly attributed to normal aging or the mild cognitive impairment characteristic of early dementia.
In general, many medications (both prescription and OTC), supplements, and substances may contribute to memory impairment; therefore, obtaining a thorough social and medication history is an important step in identifying modifiable causes of cognitive change. Physicians should prioritize discontinuing nonessential medications that may be contributing to cognitive impairment and monitor for resolution of symptoms prior to pursuing further workup or interventions.
(Choice A) Recommending a healthy lifestyle before investigating reversible causes of memory impairment (eg, medications, substance use) would be inappropriate and would not address possible underlying contributors.
(Choice B) This statement is unnecessarily alarming and mistakenly assumes the patient's memory impairment is due to Alzheimer disease. Alzheimer disease is typically associated with signs of functional impairment and less likely to develop abruptly and progress quickly (eg, few weeks).
(Choices D and E) Although stress can cause memory impairment, it would be premature to attribute this patient's memory impairment to stress or normal aging without first performing a careful review of her current medications to identify potential offending agents. Normal aging is also less likely to cause abrupt, rapidly progressive symptoms.
Educational objective:
Review of medications should be prioritized in evaluating new-onset or worsening cognitive impairment. Medications with anticholinergic properties are strongly associated with risk for cognitive impairment, particularly in the elderly.