Prior to proceeding with a full evaluation of suspected cognitive impairment, it is important to perform a quick review of the patient’s problem list/PMH in their medical record to identify if they have been previously diagnosed with cognitive impairment, psychiatric disease, or active cancer. Additionally, consider whether the patient may be experiencing delirium. This review will help you decide if, and when, to proceed with the full evaluation for suspected cognitive impairment.

Previous diagnosis of cognitive impairment: Occasionally, a person has already been diagnosed with mild cognitive impairment or dementia by a provider, but the diagnosis was not communicated to the patient and/or family and may not have been carried forward in notes in the patient’s medical chart. Review the previous evaluation to determine what steps you may need to perform (or repeat) now.

Psychiatric illness: While a current diagnosis of psychiatric illness, such as major depression, schizophrenia, or bipolar disorder, does not rule out a concomitant disorder of cognitive impairment, understand that these conditions may alter your evaluation. If you or the family suspect significantly uncontrolled psychiatric illness, referring for urgent psychiatric services may be necessary prior to a full cognitive evaluation. 

Active cancer: If the person has an active cancer, and the onset of cognitive decline is in the days-to-weeks-to-months timeframe, evaluating for metastatic disease in the CNS is imperative. Obtain head imaging (brain MRI if patient is able) in this scenario ASAP. You can return to the full evaluation after obtaining imaging and ruling out CNS lesions.

Delirium: Review a patient’s chart to know whether they have had any recent hospitalizations, major illnesses, or surgeries. These events may place the patient at higher risk of presenting with delirium. If there is a recent medical event and/or ongoing physical symptoms, focus your evaluation on these and consider screening for delirium prior to proceeding with a full evaluation for cognitive impairment. Have a high suspicion for delirium if the primary impairment is in attention.

If now, or at any point during an evaluation for cognitive impairment, you feel that you are beyond your expertise and/or time, do not hesitate to stop there and refer the patient to a memory specialist!