Primary Care Doctors: How to Talk to Patients About Memory Loss

Primary care physicians are often the first health care provider to see memory problems in their patients, often when symptoms are obvious.  However, detecting cognitive issues earlier is challenging because only a small number of patients will proactively talk about their subjective memory complaints (SMC’s) during an office visit.

This gap in addressing memory concerns was highlighted in an eye-opening 2016 study and published in “Preventing Chronic Disease,” a journal affiliated with the Centers for Disease Control and Prevention (CDC).

Conducted by Mary Adams, a public health consultant at the Connecticut-based firm On Target Health Data, the study analyzed data extracted from a 2011 CDC national survey of 21 states. While 10,276 respondents, age 45 and older, indicated they had subjective memory complaints (SMCs), only 22.9 percent said they reported these concerns to their doctor.

“Routine check-ups may be a missed opportunity for discussions of SMCs,” said Adams, MS, MPH. “The Affordable Care Act requires a cognitive assessment for Medicare recipients during their annual wellness visit, but these results suggest that adults younger than 65 might also benefit from such an assessment.”

Since many patients show a reluctance to broach the topic of memory loss, primary care providers are encouraged to take the initiative.

They can start by assessing a patient’s risk factors, including age, gender, family history and genetics, and prior head injuries. Assessment should also note the person’s general health, cholesterol, and blood pressure levels, significant weight loss or gain, and visible signs of confusion, anxiety or agitation.

Creating a list of questions for the patient is helpful. The National Institute on Aging has created a comprehensive online handbook about how to talk with aging patients.

Set the stage with a general statement, such as: Lots of people have problems with their memory as they age.  Then, ask the patient (not the family member):

• How is your memory?
• Do memory problems interfere with daily life?
• Do you feel like yourself?

If family members are present, ask their opinion about their loved one’s cognition. Inquire if there have been incidents that worried them.

If you do not detect any cognitive impairment that needs further attention, then reassure the patient and family members.

On the other hand, if there are legitimate concerns, take the time to probe deeper for signs of aphasia, agnosia, apraxia, sundowning, or psychosis.  Again, primarily address the patient.

If a memory test is warranted, conduct it later in the appointment as the patient may have some initial anxiety. A general cognition test such as the SAGE and the Mini-Cog can be administered in a few minutes, and requires only pen and paper. Family members may observe during testing, but should be cautioned not to prompt the patient.

If cognition problems are indicated, explain to the patient and family members that not all memory loss is permanent. Some causes may include drug interactions, severe depression, B-12 deficiency, UTI infections and even thyroid, liver and kidney disorders can cause issues with cognition and must be ruled out through testing. Many of these conditions are treatable, and memory can be improved or even restored.

If underlying conditions are ruled out and Alzheimer’s or another form of degenerative memory loss is suspected, then conduct further memory testing or refer the patient to either a neurologist or a memory screening center for a comprehensive evaluation.

Explain to both patient and family what may happen at that appointment, such as neuropsychological testing.

It is not unusual for the patient and family to initially show a sense of relief after cognition issues are talked about openly.  After this reaction, most will ask, ‘what happens next?’

Rachel Eastman, who resides in northern New Jersey, can relate to this feeling. She recalls taking her then 81-year-old mother to see her doctor about cognitive problems.  During their second appointment, Eastman’s mother failed a memory test.  Eastman recalls leaving their appointment with a prescription for Aricept, but nothing more.

In retrospect, Eastman says advice on how to move forward would have been beneficial.  “A suggestion that you get POA and health care directives taken care of immediately – that kind of thing,” Eastman said.

She also wishes the physician would have talked to them about critical safety issues, such as living arrangements.

“I think a lot of people need to be told by the doctor they can no longer live alone,” said Eastman.

The National Institute on Aging encourages physicians to provide direction about services and programs that may be helpful to patients and families who are seeking answers, reassurance and a plan of action.