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.
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.
- Historically, this has not been 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.) More recently, the COVID virus has become fairly prevalent; it does affect brain cells in some cases, and research is ongoing to learn more about this.
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.
Poor sleep and/or high levels of stress are two additional factors to consider, as the brain works less well under these conditions. (For more on sleep problems in aging, see here.)
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.
(Wondering how to talk to an older person about their memory loss? I explain how to do this here.)
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 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 more information on the most common anticholinergics, see 7 Common Brain-Slowing Anticholinergic Drugs Older Adults Should Use With Caution.
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 it’s too complicated to cover in an article. (So I’ve written a book! You can find it here.)
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 was last reviewed by Dr. Kernisan in Dec 2023.
Carol says
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”
Leslie Kernisan, MD MPH says
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!
Ruth Obadal says
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?
Leslie Kernisan, MD MPH says
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.
Sue Smith says
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.
Leslie Kernisan, MD MPH says
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!
Trisha says
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.
Leslie Kernisan, MD MPH says
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!
HP says
I was noticing severe mood swings in my Mom, and it became more obvious after a fall that resulted in a broken wrist. At first I heard that it was sprained so I went to see her because I also know she has osteoporosis. Sure enough, it was purple and swollen and I told her it should be x-rayed to determine how extensive the damage was. Although I shared this information in writing to her PCP, he ignored me. I continued to observe problems and reported them to this doctor, thinking he would eventually evaluate her, especially given her treatment of my Dad after he suffered a stroke. He would not address my concerns. My brother, a state licensed teacher enabled Mom and our relationship has been damaged. Ultimately I have had to step back. I have a sense of peace in knowing that I did my best for both parents. I appreciate the recommendations here for support groups and counseling. Even when you do the right thing, it can be painful.
JL Adams says
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.
Leslie Kernisan, MD MPH says
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!
SweetSioux says
Primary Care Physicians are unsung heroes. They carry out the lion’s share of medical care. God bless them!
Nicole Didyk, MD says
I agree with you that Primary Care providers are key players in healthcare. As a specialist, I collaborate with family doctors and primary care nurse practitioners daily.
Joe Messina says
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…
Leslie Kernisan, MD MPH says
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.
joanna thomas says
this article is very helpful my older brother is in hospital being asseded for these issues of delirium and dementia it will help when asking for imformation
Nicole Didyk, MD says
I’m sorry to hear that your brother is in hospital and I’m so glad that you found the article helpful. Here’s a link to a video I made about delirium for more info: https://www.thewrinkle.ca/site/blog/2019/09/19/delirium-prevention. There’s more about delirium on this website as well, which you can find here.
Alicia Butcher Ehrhardt says
All of these steps require competent physical and mental health professionals; the damage that can be done by the incompetent ones is unbelievable.
Leslie Kernisan, MD MPH says
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.
Jeffrey A Glenn says
The risks of self diagnosis are much worse than the risks of being misdiagnosed by incompetent medical professionals….just my opinion, obviously….
Leslie Kernisan, MD MPH says
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.
Laura Effel says
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.
Leslie Kernisan, MD MPH says
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.
mike says
Dr Kernisan, you are a decent and helpful MD, but you are probably not aware that MDs only take 3 minutes to diagnose or see a patient. They do not bother to analyze our diseases as patients. They won’t take any notes from relatives or parents concerning their concern.
Nicole Didyk, MD says
I can understand feeling rushed or not heard during a medical encounter. Geriatricians are fortunate to be able to take the time for a thorough and detailed assessment. My assessments are usually 90 minutes or longer.
A Geriatrician is a specialist, and a primary care provider rarely has time in their office schedule to look at every aspect of an older adult at every encounter.
The National Institute for Aging has some good advice about how to enhance communication with your medical provider, which you can read here: https://www.nia.nih.gov/health/how-prepare-doctors-appointment
Terryk says
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
Leslie Kernisan, MD MPH says
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.
Sue Denosowicz says
There is no printer to click on to print the article.
Nicole Didyk, MD says
Hi Sue. The printer icon is pretty small, and it’s at the very bottom of the article on the left. I hope that helps!
Melodee MacKinnon says
Thank you for the helpful and timely information. You are a blessing to many
Leslie Kernisan, MD MPH says
Thank you, glad you found this helpful.
Lois Joseph says
Found this article very helpful. How can I get a copy of the article? It is extremely important.
Leslie Kernisan, MD MPH says
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.
Nadia Sainato says
On older adults: Hair loss, can you address that. What can be done naturally to help the problem. I don’t want to go complete bald.
Thank you.
Nicole Didyk, MD says
Hair loss isn’t an issue that I treat very often. There are many causes of hair loss associated with aging, as described in this article: https://www.jle.com/fr/revues/ejd/e-docs/hair_loss_in_elderly_women_284060/article.phtml. It can also be related to family history.
In addition, some medications can make hair loss worse such as lithium, spironolactone, propranolol, hormones and some anticonvulsants. A good start would be to review your medications and ask your doctor if you need to see a dermatologist.
I’m not sure if there are any natural remedies but many people take biotin supplements for thicker hair and stronger nails.
Rahul Tyagi says
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
Nicole Didyk, MD says
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.
Adria E. Navarro. PhD, LCSW says
Thank you for this vital and comprehensive article, yes I will share this as well! I hear from folks just after the MD says yes you have AD, no need to come back to see me (okay, what?). Capacity assessments around specific decision making is critical and hard to find… decreasing risks (physical, financial, emotional) can be a tough road for families. I worry most about folks that live alone with cognitive impairment and ask, who makes decisions when the person lacks insight? Social workers in various roles/settings often assist.
Nicole Didyk, MD says
I’m so glad you found the article shareable! In my work as a Geriatrician, I refer many individuals to a Social Worker to help sift through these complex issues.
Angelina says
Dr Leslie –
Can you email me at ***@yahoo.com I need some help. I have been on a roller coaster with my doctors and symptoms. Please I’m a mom and need some guidance
Thanks Angelina
Nicole Didyk, MD says
Hi Angelina. I’m sorry to hear about your difficulties – you’re not alone in trying to find good medical advice. Unfortunately, we can’t provide specific advice for medical concerns by email. I hope you get some traction on your search for help.