Cognitive Impairment Concerns: ‘Worried Well’ or Early Alzheimer Disease?

By Lauren LeBano

Marc Agronin, MD, faced a clinical challenge familiar to physicians who treat older patients. Two individuals, both in their early sixties, reported short-term memory problems, occasional difficulty with reading and concentration, and considerable frustration with these limitations. The patients were worried and wanted to know whether their memory problems were a symptom of Alzheimer disease or part of the typical aging process.

History and physical examination results for both patients were unremarkable, but Dr. Agronin, who serves as the Vice President for Behavioral Health and Clinical Research at Miami Jewish Health (MJH), reserved judgment until cognitive evaluation was completed.

Neuropsychological testing for one patient revealed short-term memory impairment and changes across multiple domains, which pointed to Alzheimer disease. An amyloid-based positron emission tomography (PET) scan later confirmed the diagnosis. However, neuropsychological test results for the other patient showed normal short-term memory, though the patient’s attention and concentration were poor. After obtaining additional history, Dr. Agronin suspected a diagnosis that did not seem obvious at first—adult attention deficit disorder (ADD). The patient was reassured that she did not have Alzheimer disease, and she improved on a stimulant medication.  

THE IMPORTANCE OF PATIENT HISTORY 

These cases with similar presentations and very different outcomes illustrate the importance of a thorough evaluation of individuals with cognitive complaints. Dr. Agronin recommends that clinicians approach each cognitive evaluation by considering 2 components: the context of the complaint, and the objective data.

The context involves a comprehensive history detailing factors that may explain the memory changes, such as the patient’s age, medical or psychiatric problems, substance use, over-the-counter (OTC) and prescription medication use, and the presence of major life stressors.¹ “The more factors presenting in younger people, the more likely the memory problems are due to normal transient changes or some reversible cause. However, if someone is older or has fewer or less influential contextual factors at play, we have a greater concern about having an actual neurocognitive disorder,” said Dr. Agronin. 

Details about the memory lapse provide additional context: 

·      Does the memory complaint involve long-term or short-term memory? Long-term memory problems are less suggestive of a neurocognitive disorder than short-term memory problems. 

·      Does the patient have insight? Some patients have insight into their memory problems and report them of their own accord, whereas other patients may be unaware of the changes and are brought in by family members. “When a patient comes in and tells me everything they forgot, I’m less concerned,” said Dr. Agronin. 

·      Is the memory problem occurring intermittently, or constantly? The frequency of the memory complaints is important.

·      What is the extent of the memory problem? Is the patient not only having short-term memory issues, but is also struggling to find words or navigate to familiar locations? A broader spectrum of issues that occurs frequently is concerning.

The Perils of a Deficit Model

A focus on the patient’s strengths, rather than deficits, may lead to a better sense of the patient’s history and better management, Dr. Agronin explained. “I like to start by having a conversation with the patient about who they are and where they’re from. I prefer a free-flowing discussion because I can see how they talk and whether they’re aware of the cognitive issue that brought them to my office. This approach relaxes patients, builds rapport, and shows me the patient’s strengths, which is important because if we’re not focusing on strengths, we’re handicapping our approach to management,” he said.

Emphasizing deficits demoralizes patients and can lead to patients seeing themselves as more impaired. As a result of this negative self-image, patients may perform as more impaired, and they may have poorer scores on cognitive tests. 

Additionally, a person who sees himself as impaired may be less motivated to improve and make changes, and clinicians may view the individual as a disease and not as a person. “If you get to know the patient as a person before exploring their cognitive complaints, you understand their strengths and their background.” If a patient does have Alzheimer disease or a condition that will involve caregivers, “this allows you to care for them and to help caregivers appreciate them, too,” said Dr. Agronin.

Medications and Other Conditions

A thorough medication history is part of the process for evaluating cognitive impairment.² Certain medication combinations are particularly likely to indicate that the effects of medication rather than Alzheimer disease could explain the impairment. Dr. Agronin is most concerned with 1) opioids, 2) sleeping medications, including OTC varieties, and benzodiazepines, 3) statin medications, though only for a small percentage of people, and 4) corticosteroids, especially when individuals have started and stopped the corticosteroids.

Other causes of cognitive impairment¹ may include:

·      Depression

·      Postoperative cognitive dysfunction

·      Recent infection

·      Hypothyroidism

·      B12 or folate deficiency

·      Toxic exposure (eg, heavy metals)

·      Benign meningioma

·      Normal pressure hydrocephalus

·      Menopause

·      Sleep apnea or other sleep disorder

·      Alcoholism

·      Hyponatremia

·      Severe anemia

According to Dr. Agronin, if an overt medical issue is identified, then it should be treated and the patient observed for some time to evaluate whether the memory complaint has resolved. 

He emphasizes that a workup should be shaped by the context and history, but should also include some form of objective data. “Many people have subjective complaints,” he said. “They’re seeing and hearing more about Alzheimer disease and are worried about it. That worry can often lead them to unintentionally exaggerate symptoms. When we look at the complaint objectively, we may or may not see any corroborating information.” 

ADDING OBJECTIVE DATA TO THE EVALUATION

Cognitive Screening Tips

Gathering data may first take the form of an in-office screening test. Cognitive screening tests help to objectively assess a person’s memory status, though they are not diagnostic tools and offer only a general sense of whether impairments exist. They are a “thermometer for the brain,” said Dr. Agronin, who suggests that clinicians choose from commonly administered tests such as the Mini-Mental State Exam, the Montreal Cognitive Assessment (MoCA), the Saint Louis University Mental Status Exam (SLUMS), and the Mini-Cog test.

Clinicians may consider themselves already familiar with these instruments, but there are pitfalls that can lead to inaccurate results in clinical practice, he cautioned. It is important that the person administering the cognitive screen be properly trained and, if possible, be the “go-to” person who administers the test to all patients in that practice. “Different approaches can bump scores up or down, which can give misleading or distorted results,” said Dr. Agronin. 

For example, tests dealing with orientation to time should be administered with consistency in language and cutoff dates referring to seasons. “Otherwise, one person might call a season ‘spring’ and another ‘summer,’ but there are certain cutoff dates that determine which is which. Differences in those dates could significantly change a patient’s score,” said Dr. Agronin.

To prevent inconsistencies, the person administering the test should review online instructions and practice the administration and scoring several times. If other people in the office will be administering, they should make an effort to conduct the examination and scoring as similarly as possible. If a screening test indicates a decline in cognitive function, clinicians may refer the patient for relevant brain scans such as magnetic resonance imaging or PET scan and for more comprehensive neuropsychological testing.

RECOMMENDATIONS FOR PATIENTS

A Brain-Healthy Lifestyle

For “worried well” patients who do not receive an Alzheimer disease diagnosis, Dr. Agronin recommends a brain-healthy lifestyle that involves moderate exercise and awareness of vascular risk factors. Recent reports have indicated that rates of dementia are decreasing, which may reflect improved vascular health in the general population.³ Patients with poor control of their vascular health are at greater risk of dementia. “What’s bad for the heart is bad for the brain,” he said.

Diet is one modifiable risk factor that benefits the heart and brain. Dr. Agronin recommends the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, which emphasizes fruits, vegetables, healthy oils such as olive oil, and a daily glass of wine.⁴

Patients should strive to be physically active, as exercise helps to improve blood flow to the brain and release neural growth factors.⁵ Mental activity is also important, particularly if the activities are varied. “Computer programs are great, but there’s no need to spend money to achieve these goals,” said Dr. Agronin. Instead, he might suggest that patients play bridge, learn a new language,⁶ or volunteer, which is beneficial because it is both socially and mentally stimulating.

“I tell patients to take care of the brain, and don’t take risks with it,” he said. “Get enough sleep and don’t overdo wine or spirits. That’s really the best you can do.”

Dr. Agronin has seen both patients and health care professionals make claims about untested herbs, supplements, and even cannabis use for ameliorating and preventing cognitive problems. However, he emphasizes that they do not have FDA approval, that there is no evidence for these claims, and that a brain-healthy lifestyle is the best approach at this point in time. “No data at this point suggest any meaningful role of cannabis for Alzheimer disease, and in my own clinical experience it has not been helpful,” he said. He added that more research is needed.

Different Outcomes, Different Treatment

For many patients, Alzheimer disease is the cause of memory complaints, and “the bottom line is there is no cure and people do decline,” Dr. Agronin said. He recommends referring individuals with Alzheimer disease to a clinical trial⁷ because trials offer some hope and are controlled, vetted, and ethically conducted. In the case of Dr. Agronin’s patient with short-term memory complaints that indicated Alzheimer disease, she was started on a cognitive-enhancing medication, which can help to modestly improve or stabilize symptoms. She was also enrolled in a clinical trial in hopes of actually modifying the course of the disease itself.

However, for some patients, cognitive difficulties can point to a completely different condition that may sometimes resolve with the correct treatment. Dr. Agronin’s patient with memory complaints that indicated adult ADD was not started on a cognitive enhancer, or alternatively, reassured and sent on her way. After a thorough examination that included history and objective data, she began taking a stimulant medication, and “she could read and concentrate better,” said Dr. Agronin. “Her symptoms really improved.”

Marc Agronin, MD, is a board-certified adult and geriatric psychiatrist. Since 1999, he has worked at Miami Jewish Health and currently serves as the Vice President for Behavioral Health and Clinical Research. He is also an Affiliate Associate Professor of Psychiatry and Neurology at the University of Miami Miller School of Medicine. Dr. Agronin is a prolific author of books and articles on caring for older individuals, including the acclaimed How We Age: A Doctor’s Journey into the Heart of Growing Old. His most recent book is The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer’s Disease and Other Neurocognitive Disorders.

References

1. Wilcox JA, Duffy PR. Is it a ‘senior moment’ or early dementia? Addressing memory concerns in older patients. Current Psychiatry. 2016;15(5):28-30.

2. Rogers J, Wiese BS,  Rabheru K. The older brain on drugs: substances that may cause cognitive impairment. Geriatrics and Aging. 2008;11(5):284-289.

3. Langa KM, Larson EB, Crimmins EM, et al. A comparison of the prevalence of dementia in the United States in 2000 and 2012.  JAMA Intern Med. 2017;177(1):51-58.

4. Morris MC, Tangney CC, Wang Y, Sacks FM, Bennett DA, Aggarwal NT. MIND diet associated with reduced incidence of Alzheimer disease. Alzheimers Dement. 2015;11(9):1007-1014.

5. Duzel E, van Praaq H, Sendtner M. Can physical exercise in old age improve memory and hippocampal function? Brain. 2016;139(3):662-673.

6. Antoniou M, Gunasekera GM, Wong PC. Foreign language training as cognitive therapy for age-related cognitive decline: a hypothesis for future research. Neurosci Biobehav Rev. 2013;37(10 Pt 2):2689-2698.

7. National Institute on Aging. Clinical Trials. https://www.nia.nih.gov/alzheimers/clinical-trials. Accessed on January 16, 2017.