Incompetence & Losing Capacity:
Answers to 8 FAQs

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Have you ever been concerned about an older relative who seems to be making bad decisions?

Perhaps your elderly father insists he has no difficulties driving, even though he’s gotten into some fender benders and you find yourself a bit uncomfortable when you ride in the car with him.

Or you’ve worried about your aging aunt giving an alarming amount of money to people who call her on the phone.

Or maybe it’s your older spouse, who has started refusing to take his medication, claiming that it’s poisoned because the neighbor is out to get him.

These situations are certainly concerning, and they often prompt families to ask me if they should be worried about an older adult becoming “incompetent.”

In response, I usually answer that we need to do at least two things:

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Financial Exploitation in Aging: What to Know & What to Do

by Leslie Kernisan, MD MPH

Here’s an upsetting situation that comes up a lot, and may have come up for you: is someone financially taking advantage of Mom or Dad?

It’s a pretty legitimate concern to have. To begin with, most people know that there are plenty of “scammers” out there, phoning or mailing older adults with deceptive information designed to hoodwink them out of some of their savings.

But there’s actually another form of exploitation that may be more common, and is often harder for families to address.

That would be exploitation perpetrated by a someone the older person knows and has a personal relationship with.

Sometimes the person suspected of exploitation is relatively new to the older person’s life, such as a new romantic interest, friend, or paid caregiver.

In other cases, family members become concerned that someone in the family – such as one of the older person’s children – is beginning to take financial advantage of things.

Exploitation in the context of personal relationships is often especially tricky for families to address. The older person may be quite attached to – or otherwise feel dependent on – the person that others perceive as suspicious or problematic. Or there may be concerns about stirring up family dramas and conflicts, by voicing concerns about a sibling or another relative.

People are often unsure of what exactly constitutes illegal activity, and what can be done if they are concerned about financial exploitation.

So in this article, I’ll cover the key things you should know, so that you can better evaluate and address a worrisome situation, should one arise.

Specifically, in this article I’ll explain:

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4 Medications FDA-Approved to Treat Alzheimer’s & Other Dementias:
How They Work & FAQs

by Leslie Kernisan, MD MPH

If someone in your family has been diagnosed with Alzheimer’s or another dementia, chances are that they’ve been prescribed one of the “memory medications,” such as donepezil (brand name Aricept) or memantine (brand name Namenda).

But were they told what to expect, and how to judge if the medication is worth continuing?

I’ve noticed that patients and families often aren’t told much about how well these medications generally work, their side effects, and how to determine if it’s likely to help in their situation.

So in this post, I’ll explain how the four Alzheimer’s medications in wide use work. I’ll also address some of the frequently asked questions that I hear from older adults and families.

If someone in your family is taking one of these medications or considering them, this will help you better understand the medication and what questions you might want to ask the doctors. It’s especially important to understand the pros and cons if finances or medication costs are a concern.

I also have a video discussing this topic, along with newer discoveries in Alzheimer’s care and non-drug related approaches:

Note: This article is about those drugs that have been studied and approved to treat the cognitive decline related to dementia. This is not the same as treating behavioral symptoms (technically called “neuropsychiatric” symptoms) related to dementia, such as paranoia, agitation, hallucinations, aggression, sleep disturbances, wandering, and so forth. Until 2023, there were no drugs FDA-approved to treat the behavioral problems of dementia. The use of psychiatric medications, such as quetiapine and brexpiprazole (Seroquel and Rexulti, respectively), in dementia and is covered here: 5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors.)

Worried about the health & safety of an aging loved one? I explain how to address driving and other safety issues here: How to Help Your Parent with Memory Loss Be Safer (Even if They’re Resisting).

4 Oral Medications FDA-Approved to Treat Dementia

FDA-approved medications to treat Alzheimer’s and related types of dementia basically fall into two categories:

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4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory

by Leslie Kernisan, MD MPH

A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the short-term memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory loss or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.

And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”

Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimer’s dementia.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory loss.

Featured Download: Get my free list of medications that can affect memory and thinking in aging adults. This handy PDF includes all the medications I usually check for. Click here to download.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

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Cerebral Small Vessel Disease:
What to Know & What to Do

by Leslie Kernisan, MD MPH

Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults. (This is also called “white matter disease.”)

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? Is this the same as vascular dementia? And how they can best help their parents with cognitive decline?

Well, these types of brain lesions don’t happen to every older person, but they do happen to the vast majority of them. In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

Cognitive decline,
Problems with walking or balance,
Strokes,
Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

White matter disease
Small vessel ischemic disease
Brain lesions
Periventricular white matter changes
Perivascular chronic ischemic white matter disease of aging
Chronic microvascular changes, chronic microvascular ischemic changes
Chronic microvascular ischemia
White matter hyperintensities
Age-related white matter changes
Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

What is cerebral small vessel disease (SVD)?
What are the symptoms of cerebral SVD?
How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?
What causes cerebral SVD?
How can cerebral SVD be treated or prevented?
Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

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6 Ways that Memory & Thinking Change with Normal Aging (& What to Do About This)

by Leslie Kernisan, MD MPH

It’s annoying but unfortunately true: most parts of the body work less well as one gets older and older.

This is even true of the brain, which is part of why it becomes more common to experience a “tip of the tongue” moment as one gets older.

Such age-related changes in how the brain manages memory, thinking, and other mental processes are called “cognitive aging.”

Understanding how aging changes cognitive function is important. It can help you understand what to anticipate when it comes to your own aging. It can also help families better understand the changes they’re noticing in an older person, and whether those are out of the ordinary or not.

Since I’ve often written about changes in thinking that are abnormal and concerning in older adults, I thought it might be helpful for me to write an article outlining what is normal and to be expected.

Specifically, I’ll cover:

How cognitive aging differs from other diseases and conditions that affect memory and thinking
6 ways that memory and thinking change with aging
The difference between crystallized and fluid intelligence
How to tell cognitive aging apart from more worrisome changes, such as mild cognitive impairment and signs of Alzheimer’s and related dementia
Practical takeaways and what you can do

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Q&A: How to Diagnose & Treat Mild Cognitive Impairment?

by Leslie Kernisan, MD MPH

Q: I realize that I sometimes have difficulty connecting a name and a face. I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it. These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation.

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

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Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check

by Leslie Kernisan, MD MPH

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.

Or you may have noticed false accusations, or irrational worries getting out of control.

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 these memory problems 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.

You can also watch a subtitled video version of this information below.

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7 Commonly Neglected Problems to Address for Healthier Aging:
The Healthy Aging Checklist Part 3

by Leslie Kernisan, MD MPH

This is the third in a series of posts covering the Healthy Aging Checklist.

Again, the Healthy Aging Checklist summarizes the six fundamental activities I recommend when asked what to do to maintain the best possible health while aging. They are:

Promote brain health and emotional well-being.
Promote physical health.
Check for and address common aging health problems (such as falls, memory concerns, depression, incontinence, pain, isolation, polypharmacy).
Learn to optimize the management of any chronic conditions.
Get recommended preventive health services for older adults.
Address medical, legal, and financial advance care planning.

In this post, I’ll cover the third item: addressing commonly neglected aging health problems that routinely sabotage healthy aging.

These issues are sometimes referred to as geriatric syndromes. They affect health and quality of life, and although they happen more in people who are older or frailer, they affect countless people in their 60s and 70s as well.

Virtually all of these issues affect a older adults’s ability to socialize, be physically active, and take good care of himself or herself. So addressing these is key to enabling healthier aging.

Unfortunately, these issues routinely fall through the cracks of usual medical care. People often suffer from these problems for years without anyone taking effective action.

This may be because many people — doctors, older adults themselves, or family members — assume nothing can be done about these, and that they are just “part of getting old.”

Don’t believe that. We have studied these problems in geriatrics and most of the time, correctly evaluating and then managing these problems helps older adults and their families feel better, live better, and sometimes even live longer.

Remember, healthy aging is not just about preventing problems. It’s also about spotting them and addressing them before they get worse, or drag down the rest of your health and independence.

So for healthier aging, be proactive in checking for these oft-neglected problems.

And then remember: sub-optimal treatment of these problems is all too common. So you’ll need to be proactive about getting them correctly managed — which might mean either seeing a geriatrician (here’s how to find a geriatrician) or making sure your usual doctor is thinking like one.

Here’s what to look for, and how to learn more:

7 Common Problems to Check for and Address for Healthier Aging

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How to Promote Brain Health:
The Healthy Aging Checklist, Part 1

by Leslie Kernisan, MD MPH

“Doctor, what do you recommend for healthy aging?”

“My mom is getting older and I want to help her stay healthy. What should we be doing?”

On this site, I usually write about how to manage or avoid specific aging health challenges. But in real life, I often get asked the questions above. After all, many people want advice on how to be healthier, or stay healthy.

That’s because we all intuitively know that maintaining good health (including cognitive function) is key to maintaining what is most important to us as we age: our ability to be physically and mentally capable, so that we can remain active, engaged in our lives, and as independent as possible.

We also know that poor health can bring on pain and other symptoms, as well as disabilities that can jeopardize how we live our usual lives. In fact, most “aging” problems that older adtuls and families struggle with — like difficulties with mobility, memory, or independence — track back to underlying health problems.

So it’s good to know how to maintain one’s health as one ages, in order to keep our minds and bodies working well for as long as possible.

Furthermore, healthy aging isn’t just about forestalling aging or disability. It’s also about knowing how to make the best of things even once you do have chronic diseases or chronic disabilities of the mind or body. I call this optimizing health, for better health while aging.

It means optimizing one’s health — and health care — so that the brain and body work at their best for now and for the future. And the beauty of this is that the same key things work, whether you are a “healthy” older person with no particular health problems versus someone who has chronic conditions or even an “uncurable” disabling disease such as Alzheimer’s.

In this series of posts, I’m going to tell you how to do this.

The Healthy Aging Checklist

For the healthiest aging, do this:

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4 Oral Medications FDA-Approved to Treat Dementia

The Four Most Commonly Used Types of Medications That Dampen Brain Function

What is Mild Cognitive Impairment?

7 Common Problems to Check for and Address for Healthier Aging

The Healthy Aging Checklist

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