A part of any good memory evaluation needs to address practical skills in addition to a thorough work up for treatable causes of memory loss and a thorough testing of cognitive skills. These questions take many forms and should be asked of both the person being assessed as well as someone who knows him or her well such as a spouse. Why ask an informant? Simply because the person with memory decline may forget that they forget. This is a major problem in early detection as forgetfulness extends to one’s own deficits.

The best way to describe the changes that reflect Alzheimer’s disease is “first in last out.” This means that skills such as complex reasoning and problem-solving change much earlier in the course of the disease than personal care and orientation skills. With the current diagnostic push to identify Alzheimer’s disease earlier and earlier, we need tools that are able to differentiate normal changes from aging, those that involve slowing and reduced efficiency. Aging slows and reduces the efficiency of memory; it does not in itself cause memory loss. The earliest changes are not detected through simple screenings.

My concern arises from a study reporting that four questions (from a set of 21 questions in a questionnaire) are all that may be needed to identify a form of Mild Cognitive Impairment which may be the first stage of Alzheimer’s disease in some. The questions include:

1. Does the client repeat questions/statements in the same day?
2. Does the client have trouble remembering the date, year, and/or time?
3. Does the client have trouble managing finances?
4. Does the client have a decreased sense of direction?

The article goes on to state that “tests need to be short, easy to administer, and easy for clinicians to understand.” But here is the rub. Screening questions are not tests. There are too few items. Asking the client alone doesn’t work in many cases as they aren’t aware of changes. The intention is to find something a primary care clinician can use easily and reliably. How much can you really accomplish in a 20 minute visit (the normal time a physician has with each client)?

If we are going to detect Alzheimer’s disease earlier in its course we need to spend time and effort. The simple questions above reflect changes in mild Alzheimer’s disease, (changes in functional skills) not the changes in Mild Cognitive Impairment (no changes in functional skills). The questionnaire that I use has 60 items that reflect major functional areas (e. g., managing finances, meal preparation, use of appliances) as well as areas of concern that do not yet reflect functional changes (are you concerned about your memory, is your spouse?).

Changes need to be detected while you have control to improve your own outcome. It feels to me that there is a push to get people in clinical trials sooner at the cost of diagnosing someone with Alzheimer’s disease who does not. Until medical treatments are reliably available the goal should be to help clients and spouses who need more aggressive treatment of memory and planning for the future.