Repeating questions as though they’re being asked for the first time. Forgetting conversations. Misplacing items more frequently than usual. Difficulty finding just the right word or remembering a person’s name. Getting turned around or lost in a familiar place. Losing your train of thought or the thread of conversations. Changes in mood and emotions and an increase in impulsivity, irritability or poor judgment. Any and all of these could be signs of being tired, stressed or overwhelmed. But especially in older adults, they could also be signs of cognitive decline or dementia.
Cognitive decline refers to a reduction in mental capabilities. This can occur with age or can result from a brain injury or stroke, another disease or even a vitamin deficiency. Cognitive decline can sometimes lead to dementia, a condition the Alzheimer’s Association defines as “a decline in mental ability severe enough to interfere with daily life.” Dementia isn’t a single disease; rather it’s a term describing a group of symptoms that are associated with a decline in cognitive function.
[See: 9 Strategies to Help People With Dementia Avoid Falls.]
Alzheimer’s is the most common form of dementia. According to the World Health Organization, about 50 million people worldwide have dementia and Alzheimer’s disease accounts for about 60 to 70 percent of these cases. “Although dementia mainly affects older people, it is not a normal part of aging,” the WHO reports.
Dr. Mark W. Albers, assistant professor of neurology at the Harvard Medical School, says the symptoms of cognitive decline may start out subtly and only be noticeable to the patient. This is a stage called “subjective cognitive decline, where the person senses that they’re having some cognitive issues with short-term memory and word finding, particularly with proper names.” He says visual perception problems may also emerge but many people can still work around these problems and carry on almost normally.
But these conditions typically progress, and as they do, symptoms may become more problematic. “Once the patient can no longer compensate and they’re having difficulty performing their daily functions either at work or at home, that’s where you’d cross over into what’s considered dementia,” Albers says. But this tipping point is highly subjective and often dependent on the type of work a person does. Albers gives the example of a courtroom lawyer who has to have the right word at just the right time and be able to pivot arguments in an instant based on evidence that’s just been presented. This all requires a fully functioning short term memory, and so for individuals with these sorts of highly articulate and time-sensitive jobs, changes in cognition may interfere with work much faster than for someone who is under less time pressure or who can work from notes or employ other strategies to compensate for any loss of memory or other changes in cognitive function.
No matter which type of job you have, if you notice changes in cognition, it’s important to see a doctor before your symptoms begin interfering with your life. But who’s the right person to see for such complaints? “Like in all diseases, the front line is the primary care physician,” Albers says.
Dr. Douglas Scharre at the Ohio State University Wexner Medical Center agrees, saying the PCP should be your first stop in dealing with cognitive issues. “The PCP needs to get a complete medical history, family history, social history, current medication list and a review of any loss of abilities to perform day-to-day activities,” he says.
During this initial visit, the PCP will likely perform a physical exam and administer a cognitive assessment. Scharre has developed a self-administered gerocognitive exam, called SAGE, that patients can take at home and bring in to the office for scoring. MoCA — the Montreal Cognitive Assessment — is another common test your doctor may use. “If there is evidence of cognitive impairment or cognitive decline by history and/or cognitive assessment, then the physician should order lab tests” to look at the levels of various compounds in your blood such as cholesterol and B12 and markers that indicate how well your liver and thyroid are functioning, Scharre says. Beyond those blood tests, your doctor may also order a CT scan or an MRI, two imaging tests that offer a view of structures inside the brain.
“These evaluations should result in a diagnosis,” Scharre says, but sometimes it’s not clear cut. Your doctor may refer you to a neurologist or cognitive specialist for further testing and for care after a diagnosis has been made.
[See: 11 Things Seniors Should Look for in a Health Provider.]
In addition to a neurologist, depending on your exact diagnosis and the symptoms you’re experiencing, you may also work with a few other health care providers. Albers says a social worker or a psychologist is often called on to “provide counseling and support” to patients having behavioral issues. Some patients also struggle with the changes they’re going through and a mental health professional may be able to help you learn new coping strategies or come to terms with the changes you’re experiencing. A psychiatrist may be able to offer medications that further bolster mental health.
Albers also notes that because lifestyle factors have been shown to be effective in slowing the progression of cognitive decline and dementia, you may want to seek out a nutritionist or a physical therapist to help you make the right changes. “The physician can cover [nutrition and dietary changes] at a high level, but to sit down and go through what you eat in a week and make concrete suggestions about helpful substitutions — that’s a nutritionist.”
Likewise, you might need some help in becoming more active. “Often among people who don’t exercise, there’s a barrier and trying to identify what the barrier is and then addressing that barrier can be enabling,” Albers says. For example, a person experiencing cognitive decline or dementia might be experiencing balance issues or a loss of confidence in their physical abilities, which leads to an avoidance of exercise. “So I end up having some people see a physical therapist to try to help them with their walking so they feel more confident.”
For any and all of these needs, Scharre says providers with a special interest in cognitive disorders will likely be able to offer you the best care. “The key to finding the best doctor is to find one who has a special interest in cognitive disorders. If the doctor does not seem to feel that an evaluation for diagnoses and treatment of the cognitive problem is that important, then it’s time to get a second opinion.”
You may have more luck finding a cognitive specialist and have more options if you visit a larger or university-based hospital, Sharre says. This is often where you can find clinical trials that may offer more or newer treatment options than smaller facilities, which may lead to better outcomes for some patients. “Physicians involved in clinical trials for cognitive disorders are often at the cutting edge for diagnosis and treatment,” Scharre says. The National Institutes of Health provides a searchable list of all ongoing clinical trials. Searching on the condition you or a loved one is dealing with — cognitive disorders, dementia or Alzheimer’s disease — may give you some additional options for treatment.
When you do visit with a doctor, make sure that you come prepared with a list of all your medications and their dosages and frequency. Another important thing to bring to a doctor’s visit for cognitive issues is a loved one. “In our clinic we require patients bring a caregiver or somebody. The other word we use, which is kind of an awkward word, is an ‘informant.’ Often it’s the spouse and/or kids, but somebody else who can provide an outside, independent perspective on what they’ve noticed over time,” Albers says. “I think that’s the No. 1 requirement because in this field, the story, the history is so important and the patient is doing their best to give you the best history they can. But particularly among people with memory problems it’s inherently going to be problematic.” The patient may not even realize the full extent of the problem or may not be willing to admit it out loud.
[See: Emerging Treatments for Alzheimer’s Disease.]
Although many people assume that dementia or a steep reduction in cognitive function is simply part of getting older, Albers says it doesn’t have to be. “Increasingly with more and more research on aging, we are learning that successful aging really doesn’t involve this degree of decline.” He says that while some changes in cognitive function are normal, “I think we’re redefining what is considered normal aging and what our aspirational goal ought to be.” He says it’s not inevitable that you’ll end up with dementia and intervening early can make a big difference on your quality of life. “I think there is evidence that lifestyle modifications can slow that decline.” The four main areas of lifestyle intervention are diet, exercise, socialization and keeping your mind engaged in subjects that interest you.
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Which Doctor Should I See for Dementia and Cognitive Decline? originally appeared on usnews.com
