Memory Complaints in a 72-Year-Old: Depression, MCI, or Early Dementia?
Dr. Lin evaluates a 72-year-old retired teacher who reports two years of worsening memory and word-finding problems. Her spouse says she repeats questions and sometimes forgets a recent appointment, but she still manages medications, finances, and driving without difficulty. Medical history includes hypertension and hypothyroidism, both controlled; there is no history of stroke or head injury. She scores 24/30 on the MoCA, with points lost on delayed recall, semantic fluency, and a clock-drawing item. On list-learning testing she recalls few words after encoding, improves modestly with cueing, and shows relatively preserved recognition. Processing speed is below expectation; performance on a standalone effort measure is valid. Her PHQ-9 is 14, and she describes low energy and anhedonia since her husband's retirement. The referring physician asks whether this is depression, mild cognitive impairment, or early dementia.
1. Interpret the neuropsychological pattern and explain how depression, effort, and base rates should affect the diagnostic conclusion.
Read the worked answer
The pattern is mixed but not a classic amnestic profile. Encoding is weak, delayed recall is low, cueing produces only modest improvement, and recognition is relatively preserved. A prominent encoding deficit with preserved recognition is more consistent with attentional and mood-related inefficiency than with the rapid forgetting and poor recognition seen in typical Alzheimer's disease. Low semantic fluency and slowed processing speed can also reflect depression, hypothyroidism, or vascular burden. The PHQ-9 of 14 indicates clinically significant depressive symptoms that could inflate memory complaints.
Effort must be considered because poor effort can mimic memory impairment; here the standalone effort measure is valid, so the profile is probably not explained by feigning. The psychologist should still interpret scores cautiously because base rates matter: in a 72-year-old with subjective complaints, some low scores are expected simply from normal aging and measurement error. A single MoCA of 24 is not diagnostic.
The conclusion should be provisional: depressive symptoms are likely contributing, mild cognitive impairment cannot be ruled out, and dementia is not established. Serial assessment after treating depression and repeating testing with alternate forms is more informative than a single label.
2. What recommendations and caveats should the psychologist provide to the referring physician?
Read the worked answer
The psychologist should recommend treating the depressive symptoms first-psychotherapy and/or antidepressant review by the physician-and reassessing cognition in about three to six months with reliable alternate forms. Meanwhile, the spouse should keep a structured log of functional changes: medication management, financial errors, driving incidents, and repeated questions. A sleep and thyroid review is reasonable, and hearing should be checked because it can depress test performance.
The psychologist should not tell the family that this is Alzheimer's disease. The current data are insufficient, and a premature dementia label can cause distress, stigma, and unnecessary driving restrictions. Conversely, dismissing the complaints as "just depression" is also unsafe because depression can be a prodrome of dementia and because the informant reports real changes.
The report should state the differential, the contributing factors, the limits of a single evaluation, and clear triggers for earlier reevaluation-such as getting lost, medication errors, or unsafe driving. Recommendations should include cognitive engagement, aerobic exercise if medically cleared, sleep hygiene, and caregiver support. The psychologist should also note that the effort measure was valid but that effort can fluctuate, so future testing should include validity checks.
3. How should the psychologist handle the possibility that the MoCA score alone will be used to deny the patient driving privileges?
Read the worked answer
The psychologist should proactively address this in the report and with the physician. A MoCA of 24 is a screening result, not a fitness-to-drive determination. Driving competence requires an individualized functional assessment, often including a road test, caregiver report, and review of actual driving behavior. Denying privileges on a single cognitive screen would be an overreach and could harm the patient's independence and treatment engagement.
The psychologist should explain the limits of the instrument, document that the patient still manages medications and finances, and recommend a formal driving evaluation only if functional concerns emerge. If the physician or family asks the psychologist to make the driving decision, the psychologist should clarify role boundaries and refer to an appropriate evaluator. This preserves the validity of the neuropsychological opinion and protects the patient from a decision based on an isolated score.