A 74-Year-Old Man with a History of Hypertension Comes to the Clinic

A 74-year-old man with a history of hypertension comes to the clinic asking advice about his recent memory problems.  He is accompanied by his wife.  The patient says, "I have always been very sharp but over the last year I have had difficulty remembering things.  I missed a number of appointments and sometimes I feel embarrassed because I forget names of the people I meet."  His wife says he has been moody and irritable and that he complains of headaches; "He doesn't sleep well at nights and we rarely have sex now.  I don't know if it's old age or what."  The patient reports no nausea, vomiting, falls, weakness, weight loss, fevers, chills, vision changes, or incontinence.  Other issues include obesity, diet-controlled type 2 diabetes mellitus, and coronary artery disease.  Current medications include lisinopril, atorvastatin, aspirin, and carvedilol.  He does not use alcohol, tobacco, or recreational drugs.  Family history is unremarkable.  Temperature is 36.7 C (98 F), blood pressure is 155/95 mm Hg, pulse is 62/min, and respirations are 14/min.  BMI is 34 kg/m² and neck circumference is 45.7 cm (18 in).  Examination shows normal jugular venous pressure and no lymphadenopathy.  Lung fields are clear, and S1 and S2 are normal.  The abdomen is soft and nontender.  Examination shows no edema.  Mental status examination shows poor concentration and 3-object recall, while other aspects are normal.  Cranial nerves are within normal limits.  Muscle strength is 5/5 in both upper and lower extremities, and upper and lower limb deep tendon reflexes are 2+.  Gait is normal.  The patient's complete blood count and metabolic panel are normal.  Other laboratory results are as follows: Which of the following is the best response to this patient's concerns?

A)"I understand this is frustrating for you, but what you are experiencing may be a part of normal aging."
B)"Unfortunately, these are the symptoms of early dementia and treatment is warranted."
C)"We need to look at your medications and see if some of them should be stopped."
D)"We will obtain a brain MRI to rule out an unexpected brain lesion."
E)"Your symptoms may be caused by a sleep abnormality and we will obtain a sleep study."

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