A 64-year-old man is brought to the clinic by his husband for a 9-month history of progressive memory impairment, worsening apathy, and newly developed difficulty managing their household finances. His husband notes that the patient experienced a severe major depressive episode following an early retirement a year ago, which was partially responsive to a selective serotonin reuptake inhibitor. Physical and neurologic examinations reveal no focal deficits. The physician suspects a neurocognitive disorder but must carefully differentiate this from other etiologies, particularly given the prominent psychiatric history.
Arrange the following diagnostic steps in the most appropriate sequential clinical order, proceeding from the initial baseline evaluation to the most advanced, specialized investigations.
- 1Administer an office-based objective cognitive screening instrument (e.g., Montreal Cognitive Assessment).
- 2Obtain basic laboratory screening (e.g., TSH, vitamin B12) and structural neuroimaging (e.g., MRI of the brain).
- 3Refer for formal neuropsychological testing to differentiate major neurocognitive disorder from a primary psychiatric etiology.
- 4Order advanced molecular imaging (e.g., amyloid PET) or cerebrospinal fluid biomarker analysis.