What is Geriatric Evaluation and Treatment of Age-Related Cognitive Decline?
As the number of senior citizens increases, more people might develop multiple health problems. This calls for specialized care for the elderly, especially with regards to their mental health. While some changes in thinking and memory are a normal part of getting older, the extent of these changes can dramatically differ from person to person. Health professionals need to understand these age-related changes to distinguish between normal aging, mild memory and thinking problems (known as mild cognitive impairment or MCI), and more significant brain disorders (referred to as major neurocognitive disorders or MND).
Loss of connections between brain cells is a typical part of aging. As we get older, attention span, memory, complex thinking, language skills, and spatial abilities all noticeably decrease. Studies show that as we age, our ability to process new information and make quick decisions can decline. However, skills and knowledge developed over a lifetime are usually preserved during normal aging. For instance, most people maintain their general knowledge and vocabulary as they age.
People with MCI experience a slight reduction in at least one cognitive function, like memory, compared to normal individuals of the same age and education level. Most of their cognitive function remains intact and they can carry out their daily tasks normally. On the other hand, people suffering from MND or dementia show a decrease in at least one cognitive area, such as memory or decision-making, and struggle to perform their day-to-day tasks.
A comprehensive geriatric assessment (CGA) helps assess an elderly patient’s functional, medical, financial, and psychological well-being. This enables early intervention and can prevent worsening of health conditions. It can also provide guidance on how to manage cognitive impairments if detected. Indicators for a CGA include: getting older, noticing cognitive changes, memory concerns, frequent falls, use of multiple medications, frailty, and safety issues at home. Due to the limitation of time during office visits, some aspects of the CGA can be conducted during follow-up visits or even at the patient’s home.
What Causes Geriatric Evaluation and Treatment of Age-Related Cognitive Decline?
While our genes play a role in about 60% of our mental abilities, aging is still the main reason why our cognitive functions decrease over time. Starting from the age of 20 and continuing until 80, people generally find it harder to use current situations and information to problem-solve and make decisions. After the age of 30, our hearing starts to decline, and this also affects our processing speed and perception of our surroundings.
Chronic diseases, losing our sight or hearing, lack or reduced blood flow to the brain, head injuries, toxins like alcohol, and too much stress hormones can all work together with aging, causing more damage to the brain and speeding up the natural decrease in cognitive functions.
A key sign in patients with Mild Cognitive Impairment (MCI), a condition that often leads to Alzheimer’s disease, is an increase in a protein called tau in a part of the brain called the temporal lobe. This protein can build up and block nutrients from getting to brain cells, eventually leading to cell death.
Risk Factors and Frequency for Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
As people get older, they are more likely to experience cognitive decline, including dementia. In fact, it’s projected that the older population will increase by 21% over the next 50 years. By the age of 70, about two-thirds of all Americans will experience some form of cognitive impairment. Meanwhile, worldwide, about 7% to 25% of people aged 60 and older have Mild Cognitive Impairment (MCI), which is three to four times more common than dementia.
The likelihood of developing dementia keeps escalating until the age of 90 and affects both men and women equally. While Alzheimer’s disease is somewhat more common in older women, usually due to their longer life expectancy, men tend to be diagnosed with vascular dementia at an earlier age.
The risk of cognitive decline is higher for people with lower incomes and education levels. Likewise, people with certain medical conditions like heart disease, high cholesterol, high blood pressure, diabetes, irregular heartbeat, stroke, and depression are more likely to suffer from cognitive problems.
- Getting older increases the risk of cognitive decline, including conditions like dementia.
- In the next 50 years, the number of older people is projected to grow by 21%.
- By age 70, around two-thirds of Americans will likely experience some cognitive impairment.
- About 7% to 25% of people 60 and older worldwide have Mild Cognitive Impairment, which is much more common than dementia.
- Both men and women are equally likely affected by dementia, which continues to increase until the age of 90.
- Alzheimer’s disease is more common in women due to their generally longer lives, while men often are diagnosed with vascular dementia earlier.
- People with lower incomes and education are at a higher risk of cognitive decline.
- A range of medical conditions can increase the risk of cognitive problems, including heart disease, high cholesterol, high blood pressure, diabetes, irregular heartbeat, stroke, and depression.
- Other factors such as smoking, excessive drinking, and lack of physical activity can also increase the risk of cognitive decline.
Signs and Symptoms of Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
As people age, it’s normal to experience some degree of cognitive decline, such as slower learning and reduced multitasking abilities. This usually doesn’t impact daily activities, with the potential exception of driving. If significant functional difficulties start to appear, it’s wise to have an assessment. Warning signs of more serious cognitive impairment could include memory loss, confusion, decline in language skills, changes in behavior, and a decrease in day-to-day functioning.
- Reduced hearing
- Less visual sharpness
- Difficulty learning new information
- Challenges with multitasking
- Slower reaction times
- Reduced cognitive speed
- Decline in language fluency
However, tasks such as copying or recalling distant memories usually remain unaffected. People with Mild Cognitive Impairment (MCI – a condition between the expected cognitive decline of normal aging and the more serious decline of dementia) often recognize their memory issues and this can be distressing. On the other hand, those with dementia typically lose this self-awareness over time. To get a clearer picture of a patient’s cognitive health, healthcare providers may need to speak to close friends or family, who can often provide additional insights into the person’s daily experiences and any noticeable changes in behavior or abilities.
- Forgetting things quickly
- Struggling to put objects in their usual places
- Repeating stories or questions
- Becoming disoriented or lost
- Finding mysterious dents in the car
- Having trouble finding words
- Exhibiting unusual behaviors or delusions
- Difficulty learning new routines
Testing for Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
Assessing cognitive decline related to aging presents several challenges due to the absence of specific diagnostic tests and the difficulty in differentiating between normal aging and illness or brain changes. It’s very important early on to identify and treat any potential causes that might be reversed. For instance, mental health conditions like depression or anxiety may be causing the cognitive decline. By treating these conditions, cognitive function can significantly improve. Other potential causes that can be treated or reversed include thyroid issues, having too many medications (polypharmacy), sleep apnea, delirium, vitamin B12 deficiency, electrolyte imbalances, and sensory deficits. Information from family members, friends, or caregivers helps a lot alongside talking to the patient.
There’s an assessment known as a Comprehensive Geriatric Assessment (CGA) that’s useful for older patients experiencing cognitive decline. It’s a multi-level approach that can be conducted during a hospital stay, doctor’s appointment, or home visit. This assessment includes gathering information about the person’s health, medication, lifestyle, and family, as well as carrying out a physical examination, lab tests, and any necessary imaging. It’s also important to list all professionals involved in the patient’s care.
Frailty, which is a state of decreased physical resilience making a person more susceptible to stress, is also assessed. It looks at physical, social, and cognitive capabilities. Frailty is identified by weakness, unintentional weight loss, reports of poor energy, slow walking speed, and low physical activity. Having three or more of these are signs of frailty. Conversely, cognitive impairment may also predict frailty. Someone with poor balance, altered walking, frequent falls, and difficulty with physical tasks is at an increased risk for cognitive decline.
Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) provide a measure of a person’s functional abilities. IADLs are tasks we do to live independently, such as managing finances, taking medication, driving, cooking, shopping, housework, and answering the phone. Typically, individuals with cognitive decline have trouble with these tasks before ADLs. Loss in the ability to manage medication, finances, or drive can suggest increased vulnerabilities. Capacity to drive can be assessed with a performance-based road test. Early interventions can help avoid negative outcomes. Tools for assessing abilities include the Katz index for ADLs and the Lawton IADL scale.
Other factors that are explored include gait speed and falls, cognition, mood disorders, managing medications, diet and nutrition, social and financial support, hearing, vision, urinary incontinence, and advanced care planning. If you’ve fallen within the past year, for example, that’s associated with poorer outcomes and increased mortality rates, and often leads to hospitalization. Cognitive function can be assessed with a variety of tests, the most commonly used being the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Depression is also not a normal part of aging and is assessed as it can affect cognitive function and overall quality of life.
Meds play a key role in cognitive and functional abilities in older people, and managing these properly is crucial. It’s important to regularly review and re-evaluate medications especially when various specialists are involved. Particular attention should be given to anticholinergic drugs, opiates, benzodiazepines, muscle relaxants, sleep medications, and tricyclic antidepressants to avoid polypharmacy and reduce the risk of adverse event. Antihypertensive medications, which can potentially cause hypotension, should also be assessed as they can increase the risk of falls.
Additionally, your doctor might assess your nutritional status, support network, and potential issues, and whether you’d benefit from adult protective services if abuse is suspected. Hearing and vision are also evaluated, as hearing loss and vision issues are associated with cognitive decline and can impact the quality of life and day-to-day activities significantly. An assessment for urinary incontinence is also carried out due to its links with increased mortality risk.
Lastly, advanced care planning helps determine your treatment preferences and the level of care you desire if you are too sick to make decisions. Once the initial assessment is complete, your doctor might suggest lab tests such as vitamin B12, complete blood count, and serum thyroid-stimulating hormone. Furthermore, some people might benefit from having a MRI or CT scan of the brain, especially if the cognitive changes are sudden or progressing rapidly, or if a structural brain lesion is suspected.
Treatment Options for Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
One of the most important parts of creating a care plan when dealing with cognitive problems and dementia is to identify and address the risks associated with these conditions. Unfortunately, there are no medicines that can reverse the natural cognitive decline linked to aging. Medical research does not strongly back the use of nutritional methods to help cognitive decline, unless there is a specific deficiency. Things like antioxidants, vitamins, and herbal supplements don’t seem to help if the patient doesn’t have a clear deficiency. However, improving cognitive function is possible when treating vitamin B12 deficiency and hypothyroidism, a condition that affects the thyroid gland.
Alterations in lifestyle can have a positive effect on reducing the risk of cognitive decline. These include regular physical exercise, cognitive stimulation like puzzles or games, maintaining an active social life, stopping smoking, and establishing healthy eating habits. Although the specifics are not entirely understood, physical activity is generally associated with a reduced risk of mild cognitive impairment. Managing frailty, which is a state of weakness increasing the risk of health issues, involves frequent exercise, nutritional support, and avoiding the use of multiple medications at once.
Stopping smoking has been shown to decrease oxidative stress and inflammation in the brain. Likewise, discontinuing alcohol consumption can reduce the risk of nutrient deficiencies and potential damage to brain cells related to alcohol. Treating hearing loss can involve avoiding medications that can harm the ear, cleaning the ear canal, using devices to assist with hearing, and promoting hearing health through rehabilitation efforts. For those with visual disturbances, using corrective glasses can significantly improve day-to-day functioning.
Treatment of depression can make a big difference in the quality of life and daily functioning among older individuals. Treatment options range from medicines to psychotherapy, cognitive behavioral therapy, and even electroconvulsive therapies which uses small electric currents to stimulate the brain. Depression can sometimes be resistant to treatment in some seniors. As a result, doctors must be cautious when determining medication levels and monitoring any negative side effects from antidepressant medications.
What else can Geriatric Evaluation and Treatment of Age-Related Cognitive Decline be?
As we age, our mental processes such as quick thinking, sensation, forming ideas, abstract thinking, and adaptability may slow down. A thorough assessment by healthcare professionals can help to differentiate between normal cognitive changes due to aging and symptoms that mimic or contribute to these changes. There are several common conditions that can cause or add to cognitive decline. These include:
- Infections like urinary tract infection, pneumonia, sepsis, and abscesses
- Vitamin B12 and folic acid deficiencies
- Issues with thyroid function (hypo- or hyperthyroidism)
- Low or high blood sugar (hypo- or hyperglycemia)
- Low oxygen level in the blood (hypoxemia)
- Low or high sodium level in the blood (hypo- or hypernatremia)
- Short-term confusion (delirium)
- Depression
- Extreme grief
- Side effects from certain medications, such as benzodiazepines, anticholinergics, and blood pressure medicines
- Mild cognitive impairment (MCI)
- Alzheimer’s disease
- Pick’s disease
- Lewy body disease
- Vascular and multi-infarct dementia
- Frontotemporal dementia
- Parkinson’s disease dementia
- Alcohol-related dementia
- Creutzfeldt-Jakob disease
It’s important for healthcare professionals to take these possibilities into account while assessing older patients and planning for their treatment and care.
What to expect with Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
Around 67% of people aged 70 or older will experience some form of mental decline. Each year worldwide, 15% of this group will develop Mild Cognitive Impairment (MCI), which is a slight but noticeable decrease in cognitive abilities.
On average, each year, 12% of the general population transitions from having MCI to some form of dementia, which is a more severe mental decline. This rate rises to 20% for those at a higher risk. Particularly, patients with late-life onset of persistent neuropsychiatric symptoms are more likely to develop dementia. According to some estimates, 12% of patients with MCI can see an improvement in their cognitive function within three years of their initial diagnosis.
The APOE ε4 allele, a specific type of gene, is often associated with an increased risk of MCI developing into Alzheimer’s, a type of dementia. Those individuals with the presence of amyloid plaques in their brain, which are abnormal clumps often found in Alzheimer’s patients, have a 40.8% chance of their condition progressing from having no symptoms to MCI due to Alzheimer’s. Their chances of their condition improving back to no symptoms stand at 5.3% each year.
The risk of Alzheimer’s disease can increase with many factors like the presence of deep white matter lesions (damages in the nerve fibers in the brain) coupled with a Hachinski ischemic score greater than 4, the APOE ε4 allele, the clusterin (CLU) risk variant genotype (another type of gene variant), and having more than six genetic markers linked with Alzheimer-type dementia. Additional risk factors include the amnestic subtype of MCI, mental conditions such as anxiety, depression, or apathy, and health conditions like diabetes or prediabetes.
However, some positive factors can encourage a possible return to normal mental function. These include controlling for vascular risk factors with medicines, successful treatment of depression, not having the APOE ε4 allele, higher scores on cognitive testing, and observing larger hippocampal volume on brain imaging tests. The hippocampus is a part of the brain that’s important for memory and learning.
Possible Complications When Diagnosed with Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
As people grow older, they may find that their ability to make decisions, solve problems, plan, sequence responses, and multitask diminishes. This is a normal part of aging and usually doesn’t affect their ability to carry out most daily activities. However, if an elderly person is having trouble driving, it might be beneficial for them to take a road test to assess their driving abilities.
Mild cognitive impairment (MCI) is a condition that can develop in older adults. People with MCI usually can still perform their daily activities independently, but they run the risk of eventually developing dementia. The complications that can arise from cognitive decline and dementia include:
- Struggling with daily activities
- Increased risk of infections
- Behavioral issues
- Hallucinations and psychosis
- Increased risk of falls
- Higher risk of death
- Changes in personality and agitation
- Poor eating habits
- Depression
- Unidentified pain
- Fatigue and frustration for caregivers
- Increased risk of abuse
- Injuries from falls
- Death
- Issues with bladder control
- Difficulty swallowing
- Decreased inhibition
Preventing Geriatric Evaluation and Treatment of Age-Related Cognitive Decline
As our population ages, it’s increasingly important for healthcare workers to evaluate the overall wellbeing of their elderly patients. Despite the normal mental changes that come with aging, most older adults should still be able to take care of themselves. A Comprehensive Geriatric Assessment (CGA) is a thorough check-up that evaluates an older adult’s physical, functional, emotional, and financial health. This process is carried out by a team of experts from different fields, such as primary care doctors, specialists, nurses, pharmacists, therapists, psychologists, dentists, hearing specialists, foot health experts, dieticians, and eye doctors. Completing a CGA might take more than one appointment or home visit.
The main goal of a CGA is to make sure that the older adults stay as healthy as possible. This process will help to reduce unnecessary medication usage, evaluate patient’s risk of falling and frailty, monitor their mood, and check their ability to perform tasks of day-to-day living. Detecting cognitive issues (problems with thinking, learning, and memory) early on can help identify their causes and start treatments that could prevent or slow down the progression into dementia. This also helps avoid unwanted medical interventions and procedures, and restrictions on diet and tests requiring frequent blood draw.
Regular counseling sessions, resources in the community, and participating in social support groups can greatly benefiet patients and their caregivers. This has the potential to connect them with others facing similar challenges, reducing feelings of fear, isolation, and caregiver burnout.
