Information
We are often asked to see people with cognitive symptoms, typically memory issues. Many such people are concerned about dementia but have other explanations for their symptoms for which a neurology assessment is not required. We have written this for primary care and patients who are receiving a letter of advice back from neurology rather than an appointment. Typically, this information is about people under the age of 65, although it may also apply to older people.
What types of cognitive symptoms can be managed in primary care without seeing a neurologist?
(also see Primary Care Management tab)
People who experience cognitive symptoms are often understandably concerned that they may be developing a neurological condition such as dementia or Alzheimer’s disease. However, these conditions only account for a minority of patients seen in memory clinics that focus on younger people and neurology clinics.
There are many common causes of cognitive symptoms which are NOT dementia and cognitive symptoms are very common in the general population (see below). So, any decision about seeing a neurologist needs to consider firstly – is there a cause ALREADY present which may explain the symptoms? and are the symptoms out of the ordinary compared to the general population? Research in Edinburgh shows how common symptoms are, such as forgetting conversations, losing things, or having word finding difficulty in HEALTHY people in their twenties (figure).
Common causes of Cognitive symptoms that are NOT dementia
Anxiety/ Depression/ PTSD
Sleep Apnoea
Chronic pain – especially fibromyalgia / chronic migraine
Persistent fatigue/stress
Sleep deprivation
Medication – especially opiates/gabapentinoids
Functional Cognitive Symptoms*
Alcohol/Substance misuse
Other known neurological conditions (eg MS, Epilepsy)
Traumatic Brain Injury**
* Evidence that someone has marked cognitive symptoms at times in contrast to good cognitive function at others (eg able to follow complex drama/fulfil work obligations), able to report memory lapses in detail. Not better explained by other conditions on this list
** If minor, then direct symptoms from head injury usually last no more than 3 months
Who can refer:
General practitioners
Who to refer:
Patients who are 65 or under where you are concerned about ‘red flags’ such as:
- Someone who is NOT concerned about their memory or concentration, but others are.
- Cognitive symptoms that interfere with ability to manage their finances.
- Objective evidence of poor performance at work related to cognitive symptoms.
- Getting lost in familiar places and having problems driving.
- Focal neurological symptoms or sign.
- Family history of early onset dementia or MND.
Who not to refer:
People who are >65 years of age, consider referral to Mental Health (see Cognitive difficulties (Adult) – RefHelp)
How to refer:
SCI gateway: RIE \ Neurology \ LI Basic Sign Referral
Recommendation for primary care colleagues prior to consideration for referral:
- A detailed clinical history is usually most helpful in sorting out the diagnosis, including family history e.g. early onset dementia, MND
- Look for the common causes listed in the information section and some of the ‘red flags’ below. If someone can carry out complex cognitive tasks sometimes but performs badly at others, this often suggests one of the causes above.
- Cognitive testing has some role (e.g. Montreal Cognitive assessment or 6CIT); if normal, that can be helpful but people with functional cognitive symptoms may score poorly on such tests.
- Treat any causes found, eg anxiety, depression, PTSD, sleep apnoea
- Reduce sedating medication, especially opiates and gabapentinoids
- Provide information if they have functional cognitive symptoms or cognitive symptoms after head injury – see resources and links tab
- Reduce sedating medication, especially opiates and gabapentinoids
What investigations can be done in primary care?
Some blood tests, including FBC, U&E, Ca, LFTs, TFTs, B12, HIV/Syphilis serology are often reasonable.
headinjurysymptoms.org has information about cognitive symptoms in the context of mild traumatic brain injury
