Have you been worried about an older person’s memory or thinking abilities?
Maybe your parent has seemed more confused recently. Or you may have noticed that your aging spouse is repeating herself, or struggling to do things that didn’t use to pose much of a problem.
These are very common concerns, and they often lead to questions such as:
- Is this normal aging or something more significant?
- What is wrong?
- Could this be Alzheimer’s? Or some other form of dementia?
- Can this be treated or reversed?
- What should we do about this??
The answer to the last question is this: if you are worried about memory or thinking, then you should seek out some kind of medical evaluation.
That’s because when families worry about an older person’s cognitive abilities, there often are some underlying health issues affecting the mind’s function.
Those need to be detected, and treated if at all possible. So, you’ll need to request help from a health professional, and in this article, I’ll explain what that initial help should consist of. This way you’ll know what to expect, and what the doctor might ask you about.
Technically, these kinds of problems are called “cognitive impairment.” This is a broad term that means some kind of problem or difficulty with one’s memory, thinking, concentration, and other functions of the conscious brain, beyond what might be expected due to normal “cognitive aging.”
(For more on “cognitive aging” and what types of changes are considered normal aging, see this article: 6 Ways that Memory & Thinking Change with Normal Aging, & What to Do About This.)
Cognitive impairment — which is also called “cognitive decline” — can come on suddenly or gradually, and can be temporary or more permanent. It may or may not keep getting slowly worse; it all depends on the underlying cause or causes.
In this article, I’ll share with you the more common causes of cognitive impairment in older adults.
I’ll then share a list of 10 things that should generally be done, during a preliminary medical evaluation for cognitive decline in an older adult.
Common causes of cognitive impairment in older adults
Cognitive impairment, like many problems in older adults, is often “multifactorial.” This means that the difficulties with memory, thinking, or other brain processes are often due to more than one cause.
Common causes of cognitive impairment in older adults include:
- Medication side-effects. Many medications interfere with proper brain function.
- Sedatives, tranquilizers, and anticholinergic medications are the most common culprits. For more information, see 4 Types of Medication to Avoid if You’re Worried About Memory.
- “Metabolic imbalances.” This term refers to abnormalities in one’s blood chemistry.
- Examples include abnormal levels of blood sodium, calcium, or glucose.
- Kidney or liver dysfunction can also cause certain types of metabolic imbalances, and these sometimes affect brain function.
- Problems with hormones, such as thyroid hormones.
- Imbalances in estrogen and other sex hormones may also affect cognitive function.
- Deficiencies in vitamins and other key nutrients.
- Brain function is especially known to be affected by low levels of vitamin B12, other B vitamins, and folate.
- Delirium. This is a state of worse-than-usual mental function that can be brought on by just about any type of serious illness.
- Delirium is very common in hospitalized older adults, and can also occur due to infection or other health problems in older people who are not hospitalized.
- Psychiatric illness. Most psychiatric conditions can cause problems with memory, thinking, or concentration. Psychiatric illnesses can also cause paranoia and other forms of late-life psychosis.
- Depression and anxiety are probably the most common psychiatric conditions in older adults.
- It is also possible for older adults to have bipolar disorder, schizophrenia, or other forms of major mental illness; these have often been diagnosed earlier in life.
- Substance abuse and/or substance withdrawal.
- Both acute intoxication and chronic overuse of certain substances (such as alcohol, illicit drugs, or even prescription drugs) can impair brain function.
- Damage to brain neurons, due to an injury.
- “Vascular” damage to neurons means damage caused by problems with the blood vessels, such as strokes or some form of cerebral small vessel disease.
- Head injuries are also associated with temporary or longer-lasting cognitive impairment.
- Damage to brain neurons, due to a neurodegenerative condition.
- Neurodegenerative conditions tend to slowly damage and kill neurons. This can cause mild cognitive impairment, and then eventually dementia.
- The more common neurodegenerative conditions include Alzheimer’s disease, Lewy-Body disease, Parkinson’s disease, and frontotemporal degeneration.
- Infections.
- This is not as common in older adults as the other causes above, but certain chronic or acute infections can affect brain cells directly. (If cognitive impairment is caused by an infection outside the brain, such as pneumonia or a urinary tract infection, this would be considered delirium.)
Toxins are another potential cause of cognitive impairment. Research is ongoing as to the cognitive effects of toxins people may be exposed to, such as heavy metals, air pollutants, contaminants in our drinking water, pesticides, and others.
Now that I’ve covered the most common causes of cognitive impairment in older adults, here’s what an initial medical evaluation should generally cover.
10 Things the Doctor Should Do When Evaluating Cognitive Impairment in an Older Adult
Here are ten specific things the clinician should ask about, check on, or do, as part of an initial evaluation for cognitive impairment in an older adult.
The following list reflects my own practice and that of most geriatricians. It is in line with most syntheses of guidelines and best practices, including the UpToDate.com chapter on this subject.
Most experts agree that these steps can be done by primary care clinicians.
1. Ask about and document the patient’s concerns about memory and thinking.
At a minimum, the clinician should ask an older person something like “So, have you noticed any changes in your memory or thinking abilities?”
Now, many older adults will either have noticed nothing or won’t want to talk about it. This is in of itself worth noting, especially if family or others have voiced concerns.
If the older person does have concerns or observations, these should be explored. It’s especially important to ask when the problems started, whether they seem to be getting worse, and how quickly things seem to be changing.
2. Obtain or request information on memory or thinking difficulties from family members or other “informants.”
Older adults with cognitive impairment are often unaware of — or reluctant to reveal – the difficulties they are experiencing. For this reason, a health provider who has been alerted to the possibility of cognitive impairment should make an effort to get information from a family member or other knowledgeable informant.
The best is to ask a family member to complete a validated questionnaire, such as the AD-8 informant interview. (This questionnaire asks about 8 behaviors that may indicate a dementia such as Alzheimer’s disease.)
It’s sometimes necessary for the health provider to be diplomatic about requesting and getting information from family members, especially if the older person finds it upsetting. People may think that HIPAA doesn’t allow doctors to talk to family over an older person’s objections, but actually, clinicians do have some leeway in these situations. (See my HIPAA article here.)
Family members can facilitate this process by bringing in a written summary of what difficulties they’ve observed. Be sure to include information on when the problems started and whether they seem to be getting worse.
3. Ask about difficulties managing instrumental activities of daily living (IADLs) and activities of daily living (ADLs).
The ideal is to for the health provider to ask both the patient and the family about this. Older adults with cognitive impairment are often not reliable reporters of what difficulties they’re having.
Instrumental activities of daily living (IADLs), in particular, are often affected by cognitive impairment. So it’s important to ask if the older person is having difficulty with problems with tasks such as:
- Driving and other forms of transportation
- Management of finances
- Grocery shopping and meal preparation
- Home maintenance
- Managing the telephone, the mail, and other forms of communication
- Medication management
The provider should also ask about ADLs, which are the more fundamental self-care tasks such as walking around, feeding oneself, getting dressed, managing continence, and so forth.
You can learn more about ADLs and IADLs here: What are Activities of Daily Living (ADLs) & Instrumental Activities of Daily Living (IADLs)?
Difficulties with IADLs and ADLs (which geriatricians refer to as “functional impairment”) are important to document. They offer a practical lens on how “severe” an older person’s cognitive impairment might be, and on what steps could be taken to support an older person while these cognitive issues are getting evaluated.
Functional impairments may correspond with safety issues that need to be addressed; if an older person is having difficulty with finances, it may be a good idea to check for signs of financial exploitation, or otherwise take steps to protect the person financially.
Last but not least, impairment in daily functioning is also a criterion that separates mild cognitive impairment (MCI) from more significant impairment (including dementia). In MCI, a person may be experiencing some cognitive impairment, but it should not be bad enough to significantly interfere with performing their usual daily life tasks.
4. Check for the presence of other behavioral, mood, and thinking symptoms that may be related to certain causes of cognitive impairment.
These include:
- Hallucinations
- Delusions
- Personality changes
- Apathy (losing motivation)
- Depression symptoms
- Anxiety symptoms
- Getting lost
- Confusion about visual-spatial tasks (e.g. having difficulty figuring out how to put on one’s shirt)
5. Ask about any new symptoms or changes in physical health.
It’s especially important to ask about symptoms related to neurological function, such as new difficulties with walking, balance, speech, and coordination. Checking for tremor and stiffness (both of which are associated with Parkinsonism) is also recommended.
The exact questions the clinician asks will depend on the person’s particular medical history, and the other signs and symptoms that have been brought up.
6. Ask about substance use and consider the possibility of substance abuse and/or withdrawal.
Excessive use of alcohol, certain prescription drugs (such as tranquilizers), or of illicit drugs can affect cognitive function. Health providers should inquire about an older person’s use of these substances.
Suddenly stopping or reducing the use of alcohol or other substances can also occasionally cause or worsen cognitive function.
7. Review all medications, with a focus on identifying those known to worsen cognitive function.
Certain types of medications tend to dampen brain function, and may cause a noticeable worsening in cognitive abilities. The health provider should especially ask about use of:
- Benzodiazepines, which are often prescribed for either insomnia or anxiety
- Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
- Prescription sleeping pills, such as zolpidem (brand name Ambien)
- Anticholinergics, a broad category of medications which includes most over-the-counter sleeping aids, sedating antihistamines, drugs for overactive bladder, muscle relaxants, and others.
- For a list of commonly prescribed medications that are anticholinergic, see here.
For more on medications that affect brain function, see 4 Types of Medication to Avoid if You’re Worried About Memory.
8. Perform a physical examination.
At a minimum, the health provider should check vitals (blood pressure and pulse) and should also complete a basic neurological evaluation, including an observation of the person’s gait, balance, and coordination.
The purpose of the physical exam is to look for physical signs that may correspond to causes of cognitive impairment, or that may relate to other symptoms the patient or family brought up.
9. Assess the person’s orientation and perform some type of office-based cognitive test.
Assessing “orientation” means checking to see whether the patient knows things like the day, date, month, year, and where he or she is.
Some office-based testing should also be done, to check and document the older person’s memory and thinking abilities.
Probably the shortest well-validated test is the Mini-Cog, which involves a three-item recall and a clock draw.
A more detailed office-based cognitive test that can be done in primary care is the MOCA test (Montreal Cognitive Assessment Test). This takes 10-20 minutes to administer, so it often requires scheduling a separate visit.
There are some other “intermediate” length tests that can be done in the primary care office, such as the SLUMS (St. Louis University Mental Status Examination). The Mini-Mental State Exam is another option, although most experts (including myself) consider it less useful than the MOCA or SLUMS.
10. Order laboratory testing (unless recently done) and consider brain imaging.
In most cases, it will be appropriate for the health provider to order blood tests, to check for common health problems that can cause or worsen cognitive impairment.
Blood tests to consider include:
- A complete metabolic panel, which assesses electrolytes, kidney function, and liver function tests
- Vitamin B12
- Thyroid function tests
Additional tests, such as a complete blood count, may be ordered as well, depending on the person’s past medical history, current symptoms, and risk factors. For more on tests that are often ordered in older adults, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.
As for brain imaging, some expert guidelines recommend it for everyone and other guidelines suggest it be used “selectively.”
(In most cases, brain imaging reveals non-specific findings such as signs of cerebral small vessel disease and perhaps some mild atrophy of the brain. These are common findings in many older adults and tend to have a variable correlation with symptoms. Most causes of cognitive impairment cannot be definitely ruled in or ruled out by brain imaging.)
In Summary
Overall, an initial medical evaluation should result in these four key things happening:
- Documentation of the patient’s and family’s cognitive concerns.
- This means documenting what the patient and family have noticed, in terms of difficulties and changes in memory, thinking, behavior, or personality.
- Documentation of any functional impairment the older person is experiencing.
- This means documenting what the patient and family have noticed, in terms of difficulties managing life tasks (IADLs and ADLs).
- An objective assessment of the older person’s memory and thinking skills.
- This best done through some form of short standardized office-based test, such as the Mini-Cog.
- Clinicians can also document their impressions and observations based on talking to the older person. (Did the person seem confused? Paranoid? Repetitive? Tangential? Was the person able to answer detailed questions?)
- An evaluation for common medical causes and contributors of cognitive impairment.
- This means checking for those common problems that can cause or worsen cognitive impairment.
Generally, it will take at least two primary care visits to complete an evaluation for cognitive impairment.
The second visit is often used to do a cognitive test such as the MOCA, and can enable the clinician to follow up on laboratory tests that were initially ordered.
And then what?
Well, what happens next depends on several things, such as:
- Whether the health provider was able to draw conclusions about what is likely causing the cognitive impairment
- Whether treatable conditions were identified
- How the patient and family feel about the evaluation
- Whether the older person is willing and able to cooperate
- Whether the clinician feels that referral to a specialist is necessary
- Whether the clinician is willing and able to help the older person and the family (or refer them for help) addressing any functional impairment or safety issues
You may be wondering: should you expect a diagnosis or “an answer” after this evaluation?
I’ll be honest here: probably not. Even with an adequate initial evaluation, cognitive impairment may take a few months (or even longer) to completely evaluate and diagnose. For instance, it’s often necessary to try treating one or more potential causes, to see if the cognitive problems improve or not.
Other causes of cognitive decline — notably neurodegenerative conditions such as Alzheimer’s and some of the other dementias — can take a while to diagnose because clinicians are first supposed to exclude the other potential causes, and that can take a while. (For more on the diagnosis of dementia, see “How We Diagnose Dementia: The Practical Basics to Know.)
What to expect from an initial evaluation for cognitive decline
It may not be realistic to expect definite answers. But that doesn’t mean you can’t expect some explanations.
Your health provider should be able to explain:
- How substantial the cognitive impairment appears to be, based on the office-based testing and the evaluation so far,
- What was checked for, and what has been ruled out (or deemed unlikely) as a cause for the problems you’ve been worried about,
- Whether any of the medications might be making memory or thinking worse, and what the options are for stopping or reducing those medications,
- What the healthcare team proposes to do next, to further evaluate the issues or follow up on the problems.
So if you’ve been worried about memory or thinking problems, ask for that medical evaluation. If your health provider skips any of the steps I listed, don’t be shy and ask about it. (Either it’s an oversight or they should be able to explain why it’s not necessary.)
You probably won’t get all the answers and certainty that you’re hoping for, but you’ll have gotten started and that’s vitally important.
Of course, you may well be facing the problem of not being able to get your older loved one to go to the doctor. That’s a very common issue, but almost too complicated to cover in an article. (We do guide people through this in the Helping Older Parents Membership.)
In the meantime, especially if it’s a challenge to see the doctor for some reason, then it’s all the more important to the most out of your medical evaluation when you do manage to get there.
This article was originally published in 2018, and reviewed by Dr. Kernisan in Dec 2019.
Thank you for the helpful and timely information. You are a blessing to many
Thank you, glad you found this helpful.
Found this article very helpful. How can I get a copy of the article? It is extremely important.
Thank you, I’m glad you found it helpful.
If you view my articles on a computer or laptop, at the end of the article (right before the comments section), you should see a little printer icon. If you click it, there should be an option to print the article easily, or to save it as a PDF.
Dear Dr
From the past few years, I have issues with thinking abilities.
It started from around 2009 when I observed these issues and now in 2020 I found this to be worsened. There is nothing in mind, no new idea, no visualizations, no attentiveness.
Can you suggest to me? Presence of gynecomastia and pan sinusitis
Vitamin B12: 275 Metabolic profile: Normal, Vitamin D: Normal, Thyroid profile.: normal
Prolactin 15
Clinician says nothing to worry about.
Please help
Hi Rahul. From your IP address, it looks like you’re in India, and I’m not sure what the medical resources are like there. It sounds like you’ve been noticing changes in your brain performance over a very long period of time, and that wouldn’t be typical of something like Alzheimer’s. I’m not aware of any causes of gynecomastia that would also cause dementia – except for alcohol abuse disorder… It’s reassuring that your physician is reassuring you and I wish you luck in sorting it out.
i love your articles and often share them with people who don’t have access to computers for online reading. Could you provide a pre-formated print option so we can share easily.
Thank you for your valuable work
Thank you for sharing the articles with others.
To create a print-friendly version, try clicking the little printer article visible at the end of the article. That should help.
Even if the physician has limitations as to what he can reveal to family members over the patient ‘s objection, there is no limitation on what family members can tell the physician. They are free to tell what they have observed.
Yes, absolutely true.
I do think the ideal is for the older person to be aware of and agreeable to a family member communicating with the doctor. If this seems upsetting to the older person, then family members can consider how to go about being more discreet. Options include contacting the doctor beforehand, or simply discreetly mentioning to the medical assistant in clinic that you have something to mention privately to the doctor. I do recommend putting concerns in writing, so that they can be added to the chart.
Now sometimes older adults will actually forbid their family to contact the doctor. This puts the family in a tough spot. It is still legal for them to contact the clinician, and if they are seriously concerned and there is no other way to alert the clinician, then the benefits of disregarding the older person’s preference might be worth it.
Perhaps the very best would be for every older person to talk to their family well ahead of time, about what to do if the older person ever becomes cognitively impaired and is refusing medical (or other) assistance.
All of these steps require competent physical and mental health professionals; the damage that can be done by the incompetent ones is unbelievable.
We could certainly question the “competence” of some health professionals, but I would say the bigger problem is that they are usually busy and distracted.
Doing the actual steps is not that difficult (with the possible exception of administering the MOCA), it’s thinking of them and following through on them which is the challenge. Everything other than an intermediate-length office-based cognitive test could be done in a single visit. Especially if the patient and/or family come prepared with all the medications (including over-the-counter ones) in a bag, plus a list of observations re cognitive difficulties and functional difficulties.
It also helps for the older person to be accompanied by a family member for the visit, if possible.
The risks of self diagnosis are much worse than the risks of being misdiagnosed by incompetent medical professionals….just my opinion, obviously….
Both approaches are risky! Since research shows that health providers often don’t provide a comprehensive evaluation or a diagnosis, when it comes to cognitive impairment, I recommend doing a little “homework” in advance and then coming in prepared to ask questions.
Good article…I shared with my adult children to help them from jumping to ill-founded conclusions…but also what to be aware of.
Article also reminded me of the difficulty I had in getting a ‘definitive’ diagnosis for my aging mother 8 years ago. For some legal and financial issues a diagnosis of ‘cognitive impairment’ is necessary.
Thank you…
Thanks for this feedback.
Yes, as you point out, a diagnosis often is necessary for legal and financial issues. A diagnosis — or even evidence of some cognitive impairment — should also prompt the medical team to reconsider some of what they are doing.
How to get a “definitive” diagnosis could be an article in of itself. The first step is to get the ball rolling with an initial eval and hopefully to not get too much of a run around.
Two problems I have encountered are:
Finding a PCP willing to do a complete physical exam. I had one PCP who once didn’t look at my concern about my legs swelling. Too often they just refer a patient to a Specialist. Then they refer you to another one.
I live by myself, have no living or trusting relatives, and just a few friends. So, I don’t really have anyone
who a doctor can ask questions about my behavior. Please consider seniors who are aging alone.
This was a very informative article. Thank you.
Thank you for sharing these comments. Yes, PCP are often rushed or for other reasons, they are not as attentive to the patient’s concerns as we would like them to be.
Aging without the support of relatives certainly poses additional challenges…I’m still trying to determine what is useful advice to give, in terms of planning ahead to minimize problems and get help if cognitive impairment should become an issue. We want to hope for the best but it’s also a good idea to plan for things that well might happen.
There are some groups springing up online (and perhaps also in-person) of older people who are “solo agers”, in which people exchange ideas. You could see how others are tackling this type of issue. Good luck!
Some time ago, I wrote about a relative with memory problems. Twice now I have called and said that there are memory problems prior to scheduling checkup appointments. And twice my relative has proudly outwitted the doctor! Second visit doctor said that I had suggested there was a problem – I took some abuse without knowing the cause until just recently!! This third visit I said nothing, and my relative breezed through the exam and was declared perfectly healthy!!! Sheesh! I give up and I’m going to make an appointment with a counselor about all the problems my relative is causing in my life. I understand Harvard Medical has discovered that about 40% of potential dementia patients are smart enough to outwit these tests! I believe it! P.S. Thanks so much for the heads up on Smart Patients – their help and support got me through sarcoma cancer.
Unfortuantely, this kind of thing does happen. Sometimes the older person really does have minor deficits, but in other cases, the clinician is not being thorough enough or attentive enough.
I think it’s an excellent idea to get some support and counseling to help you cope with any caregiving stress. There are also online caregiving forums, such as the one at AgingCare.com, and those can be helpful for moral support. Good luck and take care!
My question is related to cognitive testing and the interpretation of results. At what point, is a senior considered unable to make medical decisions? At what point is a HCPOA activated? My father is living in a nursing home and the medical director deactivated his HCPOA. However, my loved one is testing as severely impaired with a score of 1.4 out of 4.0 on repeat Cognitive Linguistic Quick Test administered by the nursing home’s own Speech Therapist. However, the therapies cannot officially weigh-in on HCPOA status. The facility refuses to reactivate his HCPOA even when faced with the evidence. They are taking advantage of him by having him attend care meetings without family and signing paperwork without family present too. They say he is his own person, but my father doesn’t know where he is living, what he owns, or who in his life is dead or alive. It takes two doctors to activate a HCPOA but only one negligent doctor to deactivate it.
Interesting issue you are raising! Hm…well, a durable power of attorney for healthcare (DPOAH) often will specify whether the agent’s authority is effective immediately versus only when the principal (the person signing the form) is deemed incapacitated. Even if the agent has authority immediately, if the agent and principal disagree, the principal gets to decide, unless the principal is incapacitated.
Incapacity does sometimes reverse. Honestly, I don’t often hear about physicians “deactivating” an agent’s authority but it could be reasonable under certain circumstances. (Not at all clear it was reasonable for them to do so under the circumstances you describe.)
It sounds like the nursing home decided that your father currently has the capacity to make his medical decisions, and so they are relying on him to participate in care meetings rather than involving you, his healthcare proxy.
Capacity to make decisions is technically specific for the decision (some are much less complicated or high-stakes than others) and also can change depending on a person’s health and state of mind. That said, as dementia progresses, people lose their decision-making capacities and so we usually stop assessing it for every single decision at some point, when they’ve reached moderate stage or beyond.
If your father doesn’t know where he is living or what he owns, it would be unusual for him to still be able to comprehend and make medical decisions, so you’re probably right to be concerned.
The issue for you will be figuring out an effective way to intervene. Your options include:
– check your state’s laws (they are usually available and searchable online) regarding power of attorney and capacity, there may be something relevant to the situation you describe, in terms of who decides incapacity or under what conditions a previously authorized agent can be kept out of the proceedings.
– Write letters to the nursing home outlinining your concerns and the reasons why you believe he does not have the capacity to meaningfully participate in the care meetings. If you look like you understand what capacity involves, this might impress them. I have some information on capacity here: Incompetence & Losing Capacity: Answers to 7 FAQs
– Contact the long-term care ombudsman for your area. You can search for yours here: http://theconsumervoice.org/get_help
– Get another medical professional to assess your father’s capacity to participate in his decisions without you. A generalist physician should be able to do this, especially if you bring in enough information about your father’s past medical history and how long he has been impaired. You can also sometimes hire a clinician to go into the nursing home and see him. There are also some patient advocates who are doctors or other clinicians qualified to render an opinion on capacity.
– Talk to an elderlaw attorney. They will know the relevant laws and your options for challenging the nursing home’s decision.
In general, POA documents are regulated by state laws and I think most states don’t have very good provisions or guidance in place regarding assessing capacity and when an agent should and shouldn’t be involved.
Good luck!
Do you think it makes sense for doctors to conduct routine cognitive function screening of all patients at a certain age, e.g., 90? My dad’s physician saw him regularly but never checked how his brain was functioning. He checked his BP, blood work, an occasional viral illness or infection, and physical aches and pains, but that was it. My mom had been taking him there but was no help, since she was in denial that anything was wrong. When I finally took my dad (at age 93) to his doctor and provided a list of behaviors that had changed significantly over recent years, the doctor administered a mini-mental test. My dad scored 16 out of 30. I believe he had Alzheimer’s type dementia for at least a decade before this, but his doctor had no idea. Shouldn’t this have been detected earlier?
Yes, ideally his impairments would have been detected earlier. Unfortunately quite a lot of research indicates that older adults with impairment and even frank dementia are often not assessed or diagnosed by their usual physicians.
There are a lot of reasons for this which I won’t go into now, suffice to say that it’s not safe to assume that the doctor will notice or address cognitive impairment. This is one of many ongoing quality and safety issues relevant to the healthcare of older adults.
In terms of whether doctors should screen: the US Preventive Services Task Force reviewed this question a few years ago and concluded that the evidence was insufficient to make a recommendation. Cognitive Impairment in Older Adults: Screening
Now that question was whether to screen all adults aged 65+ (i.e. Medicare beneficiaries). Technically screening means checking for disease or illness before symptoms become apparent, so evaluating someone who is having some difficulties is not the same thing, that’s doing an initial evaluation.
In geriatrics we believe it’s especially important to screen (meaning to ask everyone) about functional difficulties. If there are problems with IADLs then we are quick to consider cognitive impairment.
Cognitive screening IS supposed to be included as part of the Medicare annual wellness visit (AWV), but it’s not clear to me that most older adults are being offered the AWV, or that it’s being done thoroughly when it is done.
Generally a medical clinic that is specifically designed to care for older adults will do a better job of detecting these problems, compared to a general primary care office.
In short, much work remains to be done. Until the medical system is better at addressing this, we must keep encouraging family members to speak up and be proactive.
Your information is most helpful, clear and caring. As someone who has lost a parent, friends and other family members to various types of dementia, and now my husband has been diagnosed, I know how stressful and exhausting this disease can be for caregivers.
I live in a small town and the attitude of most GPs is that dementia can’t be “cured”, so there is not much they can do. However, they overlook the families and friends who are trying to help the patient. With all the information out there on the types of dementia, doctors need to make more effort to determine the type/cause of the dementias so caregivers can research what they will be dealing with as the disease progresses.
Your recommendation to find a support group is spot on! Talking with others who are going through the same thing, or have been there, will provide you with information you will not get from a doctor. Plus you will make friends who will understand, support and advise you through the various stages, and grieve with you as your loved one declines whether through dementia or a physical condition.
“I get by with a little help from my friends”
Glad you found the article helpful and thank you for sharing these insights.
Yes, dementia generally can’t be “cured” but there is always IS quite a lot that can be done, and it’s unfortunate that many GPs don’t realize this. It certainly is important to support and educate the person’s caregivers, and then often there are some things that can be done medically, to optimize person’s brain function and help them be at their best despite the underlying changes to the brain.
I do wish more people would find support groups, thank you for bringing this up!
Dr. Kernisan
Thank you for your article.
What do you suggest when your parent is in denial?
My heart is in pain and she lives where Dr. Pickings are poor. Terrible options available and she just refuses to believe that there is a problem.
The Dr.gave MCI DC but no information.
I just don’t know what to do and is causing me stress and worry so losing sleep.
Thank you sincerely
Mary Ann
Ah, denial…well, I will say that it’s extremely common in people who are cognitively impaired. And it’s also extremely difficult to deal with. There’s basically no good easy answer.
I have some specific suggestions on trying to help a resistant parent in the last part of this article: 6 Causes of Paranoia in Aging & What to Do.
I do recommend connecting with others facing similar challenges; the online caregiving forum at AgingCare.com is quite active and you can get support and ideas there. Good luck!
thank you i found this very helpful.
Am finding your articles very helpfull, thanks. I am a recently retired 66 year old relief worker who was beginning to struggle with memory loss, so that’s why I quit. I did a cognitive assessment test last year and was diagnosed with good scores in all cognitive fields but 20-30% below standards scores on memory and was given the diagnosis of Mild Amnestic Cognitive Impairment.
I was using low dose (2-3mg) of Diazepam per night for several years to help me fall asleep again half way the night. Was told low dosage like that would be OK, but am now beginning to wonder if there possibly is a relation with my memory loss?
Glad you are finding the articles helpful. Many people with MCI do remain stable or even improve, but for this diagnosis and especially at your age, I think it’s good to be proactive about optimizing one’s brain health and brain function.
Diazepam and other benzodiazepines have actually been associated with an increased risk of later dementia, but there has been some debate about whether this is really a causational relationship versus an association. (For example, brain changes related to Alzheimer’s occur 10-15 years before obvious symptoms emerge, and could potentially cause sleep disturbances that are then treated with benzodiazepines.)
I have suggestions on optimizing brain function in this article: How to Promote Brain Health
Good luck!
So glad I’ve found your website and this article in particular.
My mom now 92 has memory/cognitive issues along with mildly high blood pressure but otherwise is in excellent physical health. She lives alone in a house and needs help with financial stuff, keeping track of medications, making appointments and wouldn’t be able to follow a recipe etc. She usually would be stumped if asked what day/month/year it is unless she could look at her calendar and I don’t think she does a great job shopping for her groceries but doesn’t want my help with that. However, her house is reasonably clean, she’s well kept personally, has no problems physically with anything at all. She’s still driving and has never gotten lost. It’s like she has no cognitive problems at all when in her car which is so weird to me.
When we go to the Dr. office they do the one page cognitive test and can see that she has some pretty significant problems but they see that I’m with her and what great shape she’s in physically and she jokes around with everyone and makes everyone laugh and I feel like that part takes over and they aren’t concerned with the findings of the test they gave her. They spend most of the visit telling her how great she’s doing for her age which is true and makes her think she has no problems at all.
In reality, she spends many days in front of her TV with the volume turned way up.
As her primary caregiver, I’m just wondering if I should be expecting more advice at the Dr. office or some sort of talk about the future as far as should she be thinking about giving up driving, living alone etc.
A lawyer told us that if she can understand a situation and make decisions in the moment then she’s considered legally able to make financial/medical decisions even if five minutes later she has no memory of what she’s done. This got her in reversible financial trouble twice last summer that would have cost her thousands of dollars had I not caught them.
I guess I’m just looking for some advice on what to ask the Dr. at her upcoming Dr appt in June and are there any other doctors or resources I should be looking into as she ages.
Thanks so much.
I agree that the changes you’re noticing sound quite concerning. Given her age, if this has been going on for a while, it’s unlikely completely reversible and so you are right to think about next steps, and also how to protect her from financial problems and other safety issues right now.
Ideally, the doctors would come to some conclusions and give you more advice. But in reality, they often don’t, for various reasons.
If you have documented that she made significant financial errors of consequence twice, then it may be worth revising the lawyer’s advice to you. You may want to get a second opinion, especially from an attorney with particular experience in elderlaw.
These articles may be helpful to you:
Incompetence & Losing Capacity: Answers to 7 FAQs
Financial Exploitation in Aging: What to Know & What to Do
Good luck!
Hello Dr. Kernisan,
My mom is 67, she has been taking 300 mg of wellbutrin and 150 mg of Venlafaxine for maybe 25 years. Her psychiatrist has retired so we can’t get her past records unfortunately because the practice closed and we don’t know how to find her. But she believes she has been taking these same two for a very long time. She said that sometimes the amount has changed at times if she was not doing well, but it seems she has been taking these for a long time. Just in the last year she has started having symptoms such as short term memory loss, having trouble putting a key in the door sometimes but other times not having as much of an issue. One day she forgot how to put her car in reverse. The shifter is down in the middle like most new vehicles but she was looking for it on the steering wheel column. Some days she seems better. The medicines really do help her to feel good. She is almost always in a good mood. About a year ago my brother had taken a bunch of her medicine so she ran out and it really affected her mood. She did not feel well until we were able to get another prescription filled. We have a new MD for her and they did a lot of blood work and an MRI. Both looked good and they said nothing acute appeared on the MRI. I asked the doctor if the medications she has been taking for a long time could be a cause and if cutting the size of the doses in half (Under the care of a psychiatrist) would possible be helpful. She said no, she does not think moms symptoms are coming from the medications and that we need to continue trying to find what is the cause. Any advice would be very much appreciated. We are located in St. Louis, Missouri. Also if you know of a practitioner here in the area that is along your lines of thinking, that would be great as well. Thank you for listening! Kirby
Sorry to hear that your mother has been experiencing symptoms, I can see why you’d be concerned. In general, we would not expect bupropion (brand name Wellbutrin) or venlafaxine to cause the kinds of symptoms you describe.
Venlafaxine, in particular, is associated with significant symptoms when it’s suddenly stopped, so I’m not surprised that your mother felt unwell when she ran out of medications. If your mother decides she wants to reduce the dose, she should work closely with a healthcare provider. Cutting the dose in half may be too big a jump, some people need more gradual tapers.
Re what’s causing her symptoms, I agree with your doctor, those two medications are unlikely to be the main cause of her symptoms, and so it would indeed be appropriate to continue evaluation and continue looking for a cause. For challenging cases related to memory and thinking problems, it can be helpful to look for a specialized memory clinic. There may be one at the major academic medical centers in the St. Louis area. Good luck!
It seems as though every health related writer feels the need to include smoking as one of the causes of whatever problem is being discussed. To the extent that “smoking” means, inter alia, inhalation of smoke, I agree that there is substantial evidence that it causes problems. Inhalation of any kind of smoke causes problems. But some people assume that the problem is nicotine, even though several scholarly articles exonerate it. In particular, with respect to mild cognitive impairment, a 2012 study showed benefits from using a nicotine patch” Nicotine treatment of mild cognitive impairment
P. Newhouse, K. Kellar, P. Aisen, H. White, K. Wesnes, E. Coderre, A. Pfaff, H. Wilkins, D. Howard, E.D. LevinNeurology Jan 2012, 78 (2) 91-101; DOI: 10.1212/WNL.0b013e31823efcbb
I have been trying this on my wife for almost 1 year. The results are not conclusive. But it has been an uncontrolled test. I plan to start monitoring her cotinine level. Perhaps more important is REM sleep and its effect on the Glial cells and clearance of waste products. There was a good article in Science within the last 2 years or sobut I don’t have it at hand. I myself have “smoked” cigars regularly since1964 (no inhalation) and am in good health- no disease, no medicines.
I welcome your comments.
Sleep is indeed important to brain health (although the problems is that many problems affecting the brain also tend to disrupt sleep, and sleeping pills make brain function worse). I cover the treatment of mild cognitive impairment here: Q&A: How to Diagnose & Treat Mild Cognitive Impairment
Hello Dr. Kernisan,
I am a 34 years old woman based out of Delhi, India. Around 3 years ago, I took 2 different medications ( Lamotrigine for anxiety and Ginette/ ethinylestradiol for PCOS). There after I developed multiple symptoms, most of which got alright. However, my memory/ brain is not the same since then. I have mild issues with remembering tasks to be done, recalling names and tasks.
Consulted neurologists, physicians,psychiatrists, no one seems to have heard of this problem at my age. Tried homeopathy, ayurvedic herbs like Bacopa, others like Ginko biloba, Dr. Amen’s Brain and Memory boost and Neuro PS, nothing worked. Recently heard of HBOT tretament, do you feel it could help with my kind of an issue?
Looking forward to hearing from you.
Warm regards
As far as I know, hyperbaric oxygen therapy is not a proven treatment for memory problems.
Given your age of 34, I am not sure how much of what is in this article can be applied to you. I would recommend you try to get help from a health provider with experience addressing cognitive issues in people of your age. Good luck!
Dear Dr Kernisan
I am most grateful for your reply. Would you know of any other treatment or a Practitioner who could help with cognitive issues at my age. It affects my functioning and efficiency. I haven’t been able to find anyone who could possibly help me.
With gratitude
I had a 4-hour memory test in Psychiatry. Results were 97% right hemisphere working. Left hemisphere working only 67%. Dr. was very concerned saying the result numbers are usually around the same. He thought I had brain CA. But did not. They cannot figure out what is going on. However test results were consistent with “memory problems.” Was diagnosed with amnestic MCI with multidomain. Can you explain why the big difference with the hemispheres? They are telling me it is due to major depression and anxiety from starting my new 1st-shift job. I couldn’t learn it but I tried my best every day. I didn’t realize “gee… something must be wrong!” My boss said I didn’t appear depressed. Dr. put me up to 120mg duloxetine. Now I don’t want to be around a crowd of people I even know. I’m not hungry and am able to sleep 12-18 hours at a time, and still tired. I am on FMLA for now, but he won’t back the duloxetine back down to 30mg. Lots of tests done… labs, MS, etc. They can’t find any underlying problem. I’ve had fibromyalgia since 1991 and am 57 years old. Former 1st-shift certified pharmacy technician for 29 years. Was also 2nd and 3rd shift worker for 4 years. I hope you can shed any light on my situation. I surely would appreciate it. Thank you in advance!!
Sorry to hear of your symptoms. Hm, I don’t particularly know why one hemisphere would work less well, short of there being some kind of injury or disorder that is more present on one side of the brain.
You are younger and your condition sounds a bit unusual. You may want to try getting a second opinion, either from a large academic medical center (they will sometimes do them remotely) or consider a good functional medicine doctor, as they sometimes take a more holistic approach that can yield results where “traditional” medicine has failed. Good luck!
My Dad was showing signs of dementia at age 76. He started talking funny, just didn’t make sense. It seemed like he was sundowing at dusk. Took him to his PCP. PCP said it’s nothing he is getting old. I demanded an MRI of head.
To my surprise, his brain was filled with fluid and lesions. My next step was to demand an immediate brain biopsy. Biopsy showed lymphoma brain cancer.
His Medicare advantage plan did not cover the cancer center I wanted him to be treated at. I had to make a decision on where to bring him for treatment. So I changed his health insurance, fired his PCP, and brought him to MSK in NYC.
They immediately accepted him and he started chemotherapy. Thank God for MSK. With their help, he beat brain cancer and is still in remission.
If your older parent is showing signs of dementia, take them for a head MRI to rule out brain cancer first. From what I’ve seen, this cancer spreads like wild fire, and symptoms get worse with each passing day.
I’m 47, male, and shocked I didn’t die of a stress related heart attack. I snapped into action, my gut told me to take him to MSK for treatment and I am so glad I did.
Life is so unpredictable from one day to the next. I’m glad he is well, but he does need me by his side from day to day. I had to quit my 15 yr career to become his caregiver. My Dad hasn’t left my side since Jan 2018. I take care of him daily, I am his health care proxy, power of attorney, etc.
My concern now is my health. I’m affraid I may eventually get sick and not be able to be his caregiver. I worry about that every day. He is divorced, and I’m his only child.
Hello Nick and thanks for sharing your story. It sounds like you have been a powerful advocate for your Dad and have done a lot of work to get clarity and get the right treatment plan.
I just want to take a moment to reply to your comment about getting an MRI when there is a suspected dementia. Currently, there are guidelines to help decide if imaging (CT or MRI) is necessary. If someone has a change in their speech or a sudden onset of cognitive difficulty, as you describe in your Dad’s case, these could be reasons for imaging, but not everyone does need imaging right away.
You shared that your journey with your Dad was stressful – I can’t imagine the complexity of organizing all of the care and the logistical manoeuvres they entailed. You are right to be concerned about your own health, caregivers have a higher risk of health problems than others in the same age group. Better Health While Aging has a special section for caregivers like you and there is also a program, The Helping Older Parents Membership which is currently closed, but opens periodically to add members, and it has invaluable information for caregivers like you, as well as opportunities to interact with professionals and peers.
I would also encourage you to consider getting help from professionals in your area, such as a geriatric care manager, or in-home help. It’s important to build your team so you have the time to do the things you need to do to stay well, and to have the energy to do the things only a son can do.
Another practical, user-friendly article, Dr. Kernisan. I’m an RN specializing in dementia caregiver support. I recommend your site to caregivers often.
One consideration I would add to your discussion is hearing. While hearing deficits don’t cause cognitive impairment, it can contribute to worsening symptoms. Difficulty hearing only adds to the trouble of receiving and processing sounds and verbal messages. Given how insidious hearing loss can be, I encourage testing as a routine matter.
Hi Gail, and thank you for the work you do with older adults and their families! I agree that hearing screening can be very important in sorting out a diagnosis of dementia.
I am a retired veteran who is 100% service related disability, I was diagnosed 2 years ago with TBI (5 concussions in the USCG) and cognitive disorder. I also have Chronic Migraines with aura ( I get Botox every 3 months by the VA), PTSD, Anxiety, major depression, and frontal lobe dementia. My question is can some of these symptoms be related to chemicals or toxins, (I was on board a USCG Ship during 911 and also around ground zero and also another USCG Ship that had asbestos everywhere ) we were there for almost 4 months. (I cannot work anymore due to these issues. I also see a neurologist (but I don’t seem he gives me any information on my issues or what are my future issues will be) and also a physiologist.
Hi Dan and I am sorry to hear about your many challenges.
There has recently been some study of the long-term effects of being a responder at 9/11, and there may be some association with that and mild cognitive impairment (which can be a precursor to dementia), at least in this study.
It’s a complicated question though, as we know that dementia risk is related to many things, including head injury (concussion), depression, genetic factors, and emotional trauma.
Some toxins, like lead, manganese and other heavy metals are definitely related to cognitive impairment,but again it is often very difficult to prove a causative relationship between those exposures and a neurological condition.
Given the complexity of your situation it’s also probably difficult to predict how things will go in the future but it sounds like you do have some medical professionals to work with. Best of luck.
Dr. Kernisan,
I enjoyed your article. While not exclusive to aging, CSF Leak with SIH can cause significant cognitive impairment. What is your opinion on this?
Thanks, Dennis
Hi Dennis, and thanks for your question. Leakage of the CSF (cerebrospinal fluid) can cause symptoms that can resemble cognitive impairment. It’s usually associated with headaches, tiredness and an improvement in symptoms when one has been lying down for an extensive period of time. It can occur in any age group as you mention, most commonly in the 40’s and 50’s. Most of the symptoms are related to the spontaneous intracranial hypotension that you mention. This is sort of a loss of the pressure in the brain and causes the brain to sag a little bit inside of the skull.
Having done a quick review of the literature there is not much known about the association of CSF leak with SIH and dementia. I would say that this is a pretty rare cause and can also be difficult to diagnose so unless somebody is having very unusual symptoms it is pretty low down on our list of potential causes of cognitive impairment.
In the last 3 months I’ve seen a noticeable mental decline in my mother. About 3 months ago the doctor diagnosed her with pre-diabetes which seemed to send her into a mild state of depression (She is prescribed Metformin and already takes pills for hypertension and high cholesterol. She also takes a daily multivitamin and calcium pill). Within 2-3 weeks she withdrew from all outside activities and refuses to drive or cook. Simple math was really hard for her to do. She seemed to improve, her math skills are back but In recent weeks she is exhibiting other signs. She doesn’t sleep through the night. She wants to lay around all day, but won’t watch tv or even listen to the radio. She doesn’t want to leave the house because she feels unsafe. She thinks someone is coming to get her and insists ‘she has lost it’. She doesn’t want to be alone and wakes nearly every hour anxious about some new subject. She is forgetting thinks like taking pills and paying bills. She can’t make a decision on what to eat – she literally gets stressed out trying to make a decision on what to eat at every meal. But then complains about whatever gets given to her. She will not take any sleep aids the doctor has prescribed. I’ve talked with her primary care physician several times about the issues I’m seeing. I was able to convince him to give a referral for a diabetes doctor and a psychiatrist about 6 weeks ago. However I’m being told by the respective offices that the earliest they can even review the referral to schedule an appointment is in Feb. For the past month I take her walking each morning for 2 miles. She seems much better immediately after, but it doesn’t last the whole day. I’ve also noticed she ‘perks up’ for a bit when she gets calls from my siblings. What can I do to get more help now. I am in desperate need to figure out how to help my mom. My mom is on Medicare and I don’t have a lot of money for private programs. I really need to know should I be a bigger ‘nag’ with her primary care office or just continue to check biweekly for any new movement for the doctors to see her? What else can I do to help I the meantime.
Hi NJ, and thanks for your detailed information! You sound like a wonderful advocate and support to your mother, and that is commendable. Your description of the changes you’re seeing are suggestive of depression but could be due to other medical issues, or could be related to a cognitive impairment, like dementia. Sometimes it’s hard to tell these two conditions apart, and sometimes they are both present.
It’s understandable that you’re worried and want to have your mom assessed as soon as possible, and waiting is very frustrating. I practice in Canada, where “nagging” doesn’t necessarily help to speed things up, but does take a lot of energy on your part. I advise people to seek urgent attention if there is a sudden, alarming change in the person’s condition, or if they start to talk about harming themselves or others, which you don’t describe, thankfully.
In the meantime, I think your idea about exercise is excellent, and looking online for support is also a good idea. You might also consider Dr. Kernisan’s Helping Older Parents Course.
I am 66 and have a full time job in corporate finance, rather stressful. I have high blood pressure and take 10mg of Amlodipine in the morning. I have three areas of concern, getting a good nights sleep, occasional anxiety in social situations, and short term memory issues. For years I took 1.5mg of Lunesta for sleep most nights. I have tried to eliminate this altogether. For anxiety, I will take a dose of Inderal which helps keep me calm but it makes my heart rate go too low. Years ago I used to take Lexapro for depression/anxiety and it definitely helped with anxiety, but I am reluctant to take it now because I think it may affect my short term memory. Mainly, I’m asking for advice on meds to help anxiety (which I feel most days) that will not take a toll on my short term memory loss. Thank you.
Hi Robert and thanks for sharing your story. I’m glad you’re working on eliminating the lunesta (eszopiclone), as we generally discourage the use of sleeping pills on a long-term basis. They tend to stop working, which often leads to a person taking higher and higher doses over time, with more side effects.
You’re correct in noting that medications that we use for anxiety or depression (they often treat both) can interfere with cognition. This is thought to be related to their anti-cholinergic properties, and we even have a rating scale to help us determine how anti-cholinergic a medication is.
Escitalopram (aka Lexapro or Cipralex) does have some anticholinergic properties, but not as much as some other anti anxiety drugs (like amitryptiline, fluoxetine or many benzodiazepines). There isn’t a medication for anxiety or depression that doesn’t have some potential to affect brain function – that’s kind of what makes them work in the first place!
If a person is experiencing daily anxiety symptoms and wants to avoid medication, there are other strategies that might help, such as exercise, meditation and cognitive behavioural therapy.
Hope this information is helpful!
Your articles are excellent, as well as to all the responses you take the time to write. Thank you. We live with my mom and haven’t noticed any real issues other than she is unaware of the fact that she is becoming incontinent of urine and that her clothes smell terribly. I’ve discussed it with her 6 times, and she still doesn’t seem to be doing anything about it. I’ve tried to encourage her to see her doctor, but she rarely goes and is resisting. She seems totally oblivious to it.
Could it be denial?
Hi Cathie and thanks for your positive feedback. With aging, there can be changes to a person’s sense of smell, and loss of olfactory abilities can be an early sign of Alzheimer’s. It may be that your mom doesn’t notice the odour as much as you do.
In terms of why she isn’t seeking help, it may be that she thinks incontinence is just a normal part of aging, or she could be embarrassed. Many causes of incontinence are treatable, as I discuss in my YouTube video.
I’m sure it’s not pleasant reminding your mom of this so often, so maybe suggesting she go see the doctor for another reason, and trying to accompany her to a visit could be helpful. It could be a sign of dementia if she isn’t remembering the conversations that you’re having, so an assessment would be a good next step.
I noticed the odd memory problem starting for myself in November 2020. At the time I was tappering off klonopin and also suffer Bipolar disorder, Ocd, and anxiety problems. So im not sure one or all these issues are to blame. Just wondering if these other disorders are to blame.
Assuming you mean November 2019, so about 6 months ago? Mental health issues can definitely affect memory performance. When a person is anxious or depressed, it can affect concentration, memory and more. I made a YouTube video that discusses these issues, and you can watch it here.
My mother is 82 and has always been very independent. Her very best friend was diagnosed with Alzheimer’s several years ago and it broke mom’s heart. She was in denial for a while and then seemed to begin to accept. The end of 2018, mom became depressed and it seemed to the family, that she had decided to give up on living. She has continued to decline cognitively and physically. Her Doctor has run every test imaginable, and all come out normal. She has had CT scans also. They ruled out thyroid dysfunction, diabetes/hypoglycemia, brain tumors, strokes, sepsis, dementia, dehydration, electrolyte abnormalities, kidney failure, liver failure, b12 deficiency. Doctor is thinking it looks more psychological, because she can randomly make cognitive comments. Have you ever seen this behavior? If so, do you have a suggestion for what we should do next? She is taking 20mg of Paroxetine (Paxil). She had been on Prozac but did not seem to help.
Thank you for any guidance you can give us.
It must be so hard to see your mom suffer and feel like you don’t have all the answers. You mention depression and dementia, and it can be hard to distinguish those conditions from each other, and sometimes they are both present. A thorough search for other medical issues that could be contributing to mood changes is vital for an older patient, as you mention.
Depression in later life can be complex to diagnose and treat, and a person usually has to be on a good dose of the right medication for several weeks to se if there’s going to be an effect. The medications that you mention are not the typical “first-line” choices in older adults, although the family that they belong to, selective serotonin reuptake inhibitors (SSRI’s) are used very commonly in Geriatrics.
In all individuals with depression, adding in psychotherapy (talking to a counselor) and exercise is likely to help, especially when used together with antidepressant drugs. Primary care providers have a lot of expertise when it comes to managing depression, but I often refer my patients to a Geriatric psychiatrist for additional guidance.