TESTS PERFORMED: Selected Wechsler Adult Intelligence Scale-III subtests and the Wechsler Memory Scale-III, California Verbal Learning Test, Clock Drawing, Trail Making Test, Semantic and Phonemic Verbal Fluency Tests, Boston Naming Test, Rey-Osterreith complex Figure with recall and recognition trials, Grooved Pegboard, Geriatric Depression Scale, and interview.
INTERIM HISTORY: The patient stated that his wife thinks that his memory has gotten worse over the last year. He gave the example of thinking about something with his eyes closed and forgetting what it was when he opens his eyes. He also finds that he forgets what he is thinking about when interrupted by any kind of activity or distraction. When asked about any changes in his temperament, as noted in past evaluations, he agreed that he does sometimes get impatient with his wife. He said that his wife has told him that his speech is not as loud as it used to be and that he mumbles. He continues to be independent with all of his activities of daily living, including driving and bill paying. He remembers to take his medications, and if on occasion he forgets, his wife will remind him. He was in the habit of golfing four days a week until he fell about a week ago and bruised his elbow. He said that he does not sleep that well. He only gets about 3 hours of sleep at night and will often take a nap in the afternoon. A few months back, he underwent left carotid endarterectomy with no apparent complications. He stopped using his CPAP machine at that time and has not resumed its use. He questions whether his apnea is that significant. He is not sure if the CPAP actually helped him.
BEHAVIORAL OBSERVATIONS: The patient was alert and fully cooperative. He presented as a neatly dressed and groomed man, appearing slightly younger than his age. He answered questions with an appropriate degree of elaboration. His affect was normal in range and intensity and his overall mood was good. In fact, he seemed to be in better mood at this evaluation than last year. He joked and laughed several times throughout the interview and formal testing. He was able to comprehend all the instructions, but occasionally they had to be repeated because of difficulty hearing. He does have a hearing aid in his left ear. His level of effort was felt to be good. He was able to establish rapport with the examiner. He understood the nature and the purpose of the examination.
RESULTS OF EXAMINATION: The patient demonstrated a mild decline on measures of attention and concentration, but improvement on measures of visual motor processing speed. Measures of verbal learning and memory are essentially unchanged for both paragraph length material and unrelated words. These scores fall into the average to below average range for his age. Immediate memory for a complex figure declined somewhat from the average to the below average range and delayed recall fell into the mildly impaired range. In contrast, his immediate and delayed recall of pictures of a family were essentially unchanged and in the normal range. Language functions declined somewhat from the previous visit, though not universally. His semantic verbal fluency declined from average to below average, whereas his phonemic verbal fluency actually improved slightly from impaired to below average. Confrontational naming still from superior to average. His visual-spatial functions were essentially unchanged. Fine motor speed and dexterity remained unchanged from last year, but declined slightly on the nondominant side. His clock drawing was unchanged, showing intact spatial planning and conceptualization. With respect to his mood, he endorsed about the same number of symptoms of depression as he did last year, with a score of 9 on the Geriatric Depression Scale as oppose to 8. This is in some contrast to his presentation, which was clearly more cheerful than last year.
CONCLUSIONS: Neuropsychological reevaluation shows some inconsistent results. There is an increase in processing speed, but a slight decrease on measures of attention and concentration and some aspects of language function. Also, his performance on a visual memory test decreased slightly. Overall, there is not enough evidence in the results to indicate a significant decline. I continue to feel that he has mild cognitive impairment that could be due to sleep apnea. Given the relatively stable performance over the last several years, the likelihood of early dementia of the Alzheimer's type is slim.
DIAGNOSTIC IMPRESSION: Mild cognitive impairment.
1. Encouraged the patient to continue using the CPAP.
2. Will discuss the results of the evaluation with him in a feedback session next week.
3. Unless he begins to experience significantly increased cognitive problems or his wife observes significant changes in his cognitive or behavioral functioning, there is no need for further neuropsychological followup. Should either of these occur, I would be happy to see him for further evaluation and consultation.