Geriatric Evaluation and Treatment of Age-Related Cognitive Decline

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Continuing Education Activity

Cognitive decline affects many individuals above the age of 60. Mild cognitive impairment and dementia, commonly Alzheimer dementia, can affect many cognitive domains and negatively impact the quality of life. A geriatric evaluation can differentiate normal aging and age-related cognitive decline. This activity describes the assessment, treatment, and management of cognitive decline and highlights the role of the interprofessional team in evaluating, treating, and managing the patients with this condition.

Objectives:

  • Describe the steps in the geriatric evaluation.
  • Review the etiology of age-related cognitive decline.
  • Outline the examination findings in geriatric patients with age-related cognitive decline.
  • Summarize the management of age-related cognitive decline.

Introduction

With the increasing aging population in our communities, clinicians have to tackle the challenge of managing patients with multiple comorbidities and pay special attention to caring for the geriatric population. A decline in cognition occurs with increasing age. It is important to understand age-related changes in cognition to separate normal aging from mild cognitive impairment (MCI) and dementia. The expected changes in normal aging are a decline in processing speed and performance on complex tasks while maintaining simple attention tasks, a decline in auditory discrimination, and learning new information and prospective memory.[1]

In contrast, procedural memory stays intact with aging. There is also a decline in the executive cognition function, which involves problem-solving and decision-making. Lastly, there is a waning of visuospatial processing and judgment with aging. But, the recognition of objects and gestures stays intact.

MCI is a reduced function in either one or more areas of memory, attention, language, and judgment.[2] These patients retain good overall cognitive function with no disturbance in their activities of daily living, yet the deterioration is above what is expected for similarly aged individuals and educational levels.[3] 

The term dementia is used when the cognitive deficiencies become significantly greater and impact daily life. The possible triggers for initiating a geriatric assessment include age, cognitive changes, memory issues, increased frequency of falls, taking multiple medications, frailty, and concerns for safety at home.[4]

The assessment is not beneficial to certain patients with a terminal illness, lack of complete functional independence, severe dementia, and those requiring nursing home placement.[4] The geriatric assessment is more than just ruling out medical illnesses; it is an inquiry into the patient's psychological, functional, social, financial domains, and home environment.[5] Given the time limitations of office visits, multiple parts of the geriatric assessment can be undertaken at each visit.

Etiology

Understanding the etiology of cognitive decline is challenging and involves a deeper understanding of how medical and non-medical factors interact. Age itself is a risk factor that constantly increases to the age of 80.[3][6] 

Patients belonging to lower socioeconomic status and with a lower educational background have a high risk of cognitive decline.[2][6] Medical risk factors for cognitive decline include cardiovascular disease (particularly for vascular dementia and Alzheimer disease (AD)), high cholesterol, hypertension, diabetes mellitus, atrial fibrillation, stroke, and depression.[7][8] Smoking, heavy alcohol intake, and an inactive lifestyle are also associated with an increased risk.

Some biomarkers linked with progression to AD are apolipoprotein E4 genotype (ApoE4), positron emission tomography showing tau deposition in the lateral temporal lobe, and low plasma amyloid-beta levels.[7][9]

Epidemiology

The number of elderly patients will increase by 21% in the next 50 years. The prevalence of cognitive decline, especially dementia, increases exponentially with age. In adults greater than 60 years of age, the prevalence of mild cognitive impairment is roughly between 7 to 25%. MCI is 3 to 4 times more prevalent than dementia.[3] 

Cognitive decline is seen greater in aging women than men partly due to the difference in life expectancy between the sexes. The incidence of dementia exponentially rises to the age of 85 and continues to increase thereafter.[10] The incidence is similar between the sexes.

Pathophysiology

Many medical diseases share a positive association with MCI. Traumatic brain injury, stroke, Parkinson disease (PD), and Huntington disease are such examples.[11] In such cases, the diseases and events are followed by a decline in cognition years later, which can be determined from the patient’s history. Therefore, MCI can go undiagnosed in those instances. On the contrary, in Alzheimer disease, Lewy body dementia, frontotemporal dementia, and vascular dementia, the first symptom is usually a cognitive or behavior change.

Alzheimer disease results from years of amyloid-beta deposition, neuritic plaques, and neurofibrillary tangles.[12] Alpha-synuclein accumulation is seen in Lewy body dementia and Parkinson disease, whereas abnormal tau protein deposition is seen in frontotemporal lobar degeneration (also known as Pick disease) and progressive supranuclear palsy. Abnormal tau protein is also seen in Alzheimer disease. Ultimately, such changes in proteins lead to alteration of cellular function that leads to biochemical dysfunction, causing a decline in acetylcholine and dopamine, structural changes, and loss of synapses in some cases.[2][13]

History and Physical

The common complaints that bring attention to cognitive decline are memory loss, a decline in daily functioning, confusion, deteriorating language skills, and changes in behavior.[2] Clinicians need to understand age-related changes in the patient before considering cognitive decline. Normal age-related changes in the brain include a decrease in the number of neurons, an increase in cranial space from brain atrophy, decline in nerve fibers.[14]

As a result, the patient might have one or more of the following on physical examination: decreased hearing, decreased vision, psychomotor slowing, and decreased Achilles reflex. In normal aging, attention span, simple copy, procedural memory as well as remote memory stay intact while multitasking capability, learning of new information, time of reaction, cognitive processing speed, and language fluency decline.[2][14]

Patients with MCI tend to be aware of their impaired memory and are commonly troubled by it. This awareness is lost in patients with dementia, particularly in AD.[15][16] A good history is often important in gathering data about the patient focusing on reversible causes of their presentation. One such example is depression, where cognitive impairment is a presenting symptom along with personality changes.

Close friends and family members must be interviewed separately from the patient to gather collateral information. The progression from MCI to dementia is also considered when the number of family member and friend-reported symptoms is greater than the patient-reported symptoms.[17]

The patient or family members might explain that the patient quickly forgets things, has trouble putting objects in the correct places at home, repeats stories and questions, has wording finding difficulty, others fill in missing words while the patient is speaking, has difficulty learning new routines, hyperorality, behavioral changes, and may have some delusions.[16]

Evaluation

The evaluation of age-related cognitive decline is limited by the lack of specific diagnostic tests, non-pathological changes in the brain, and difficulty in differentiating signs and symptoms from normal aging.[2]

The diagnosis of MCI is based on subjective complaints, as mentioned earlier. At the initial visit, certain conditions must be investigated, such as polypharmacy, hypothyroidism, Vitamin B12 deficiency, hypo/hyperglycemia, sensory loss (hearing/vision), obstructive sleep apnea, and underlying infection.[11]

After common medical conditions that could alter the mentation are ruled out, the proceeding step is to interview the patient, followed by an interview of family members and, if possible close friends.

A comprehensive geriatric assessment (CGA) is a multidisciplinary and multimodal approach to evaluating a geriatric patient.[18] The initial evaluation should include the following:

  1. History of presenting illness
  2. Medical history
  3. Current and previous medications
  4. Family history with an emphasis on cognitive issues
  5. Social history, including occupation, education level, living situation, substance use, and advanced care planning
  6. Physical examination
  7. Cognitive assessment
  8. Laboratory studies
  9. Review of imaging
  10. Interview family members
  11. Identifying other professionals involved in the patient’s care

Subsequently, the following core components must be investigated:

Cognition - The United States Preventive Services Task Force (USPSTF) does not recommend screening for cognitive impairment in older patients due to a lack of evidence for harm and benefit.[19]

There are many screening tests available, and they generally test 1 or more domains of cognition. The most commonly used screening tests are the Mini-Mental State Examination (MMSE) and the Mini-Cognitive Assessment (Mini-Cog).[18][19]

Other tests are the Montreal Cognitive Assessment (MoCA), the clock drawing test (CDT), and the St. Louis University Mental Status Examination (SLUMS). One meta-analysis reveals that the sensitivity of MMSE, MoCA, and other screening tools is 75 to 92%, and the specificity is 81 to 91%.[20]

Depending on the screening test used, the domains tested are language, executive function, abstract reasoning, attention and concentration, memory, and visuospatial skills.

Office staff can also be trained to administer these screening tests. It is important to note that not one test can diagnose dementia or MCI. A positive screen must be followed by a thorough investigation that must include screening for mental health, especially depression.

Mood and altered thought content can also negatively impact cognitive and memory performance. These tests can also keep track of cognitive impairment over time. The caregiver completes certain screening tests, such as the Informant Questionnaire on Cognitive Decline in The Elderly (IQCODE) and Alzheimer Disease Caregiver Questionnaire (ADCQ).[21][22]

Interviewing family members and close friends also increase the amount of data that can be used to assess the patient’s cognitive abilities, especially memory and personality changes.

Functional ability - There are two key allotments of functional ability. The first is activities of daily living (ADL) which includes self-care activities, such as dressing, ambulation and transfers, bathing, toileting, feeding, grooming, and controlling bladder function. The second allotment is instrumental activities of daily living (IADL) which includes activities that a patient performs for independent living, such as managing finances, taking medication, driving, cooking, shopping, housework, and answering the phone.[18]

It is common to see dependency in IADLs than ADLs, and further loss of IADLs can impact independent living. However, impairment in ADLs can lead to a reduced quality of life and functional decline. It is no surprise that early intervention can reduce negative future outcomes. The standard screening tool for functional ability is the Katz ADL scale for ADLs and the Lawton IADL scale for IADLs.

Falls, gait, and mobility assessment - Falls are underreported to the clinicians by the elderly patients.[23] The assessment usually begins with a simple question of whether the patient had a fall in the last year. Falls are associated with worse functional outcomes and increased mortality and are a common cause of hospitalization.[18]

Gait should also be observed when the patient walks into the examination room by direct observation. The get-up and go-test evaluate a patient’s mobility and postural stability in addition to the gait. If the patient takes more than 12 seconds to complete the test, there is an increased risk of falls and functional decline. The office staff can also help the physician by administering this test. Direct observation is beneficial for identifying patients who might require assistive devices for ambulation and physical therapy for improving strength.

Polypharmacy - Certain medications can cause functional impairment in the elderly owing to their side effect profiles. The American Geriatrics Society (AGS) Beers Criteria lists certain medications that should be potentially avoided in older patients unless there is a specific indication for use.[24]

Physicians should take the time to review the medication list of their patients, especially when there are multiple specialists involved in medical management. The use of anticholinergic medications, opiates, benzodiazepines, muscle relaxants, sleep medications, and tricyclic anti-depressants must be reevaluated regularly to prevent polypharmacy and avoid adverse outcomes.

Antihypertensive medications can also cause hypotension leading to falls. Other tools to address the appropriateness of prescriptions are the Screening Tool To Alert Doctors To The Right Treatment (START) and Screening Tool of Older Persons' Prescriptions (STOPP). It is important to consider the time to achieve the medical benefit, the patient’s ability to manage and take the medication, and overall treatment goals when addressing the relevance of a medication.[4]

Diet and nutrition - It is vital to assess the patient's capacity to prepare their food, swallow, digest, and appetite level. Some objective measurements of nutrition include body mass index, height, and weight. Older individuals have reduced physiologic reserves, which puts them at increased risk for malnutrition, especially during an acute illness or hospitalization. One study showed that the body mass index under 23 kg/m² was associated with increased mortality.[25]

Cognition, social, and financial factors must be taken into account for a patient who reports significant weight loss. It is equally important to assess for underlying medical issues and psychological causes. After a thorough investigation, a plan of care can be devised for the patient to address their nutrition status, and if needed, appetite stimulants can be considered if appropriate.

Hearing - Age-related hearing loss, also called presbycusis, is an important consideration when assessing an elderly patient as it can lead to poor performance on cognitive assessments, social isolation, misunderstanding, anxiety or depression, and cognitive fatigue from an assessment, increased effort from listening, and frailty.[26] Common causes of hearing loss must also be investigated, such as cerumen impaction, head trauma, ototoxic medications, and any pathology involving inflammation of the auditory system, cranial nerves, or meninges.[26]

The finger rub test whispered voice test, or an audiometric test can be used to assess for hearing impairment.[27] Due to insufficient data regarding the benefits and harms of screening for hearing loss in adults greater than 50 years of age, the USPSTF and the American Academy of Family Physicians (AAFP) do not recommend its screening.[27]

Vision - Age-related visual changes are expected in the geriatric population. Reduced vision can impact the quality of life and activities of daily living, which can further reduce the chances of independent living. With aging, the visual acuity under low illumination is reduced, leading to low spatial contrast sensitivity, reduced color discrimination, and poor adaptation to the dark.[28][29] Common conditions for age-related visual impairment causes include macular degeneration, cataract, diabetic retinopathy, and glaucoma.[28]

Even though there is a lack of evidence for screening of vision loss by USPSTF and AAFP, vision testing can be done using a Snellen chart in the office. Some key aspects of visual assessment include testing the visual field, acuity, color and contrast discrimination, use of visual and non-visual cues, and patient’s assessment of lighting.[28]

It is also essential to observe the patient for their ability to perform the ADLs and IADLs for comfort level, stressors, and safety. Adverse consequences of visual deficits include increased risk of falls, reduced accessibility, postural instability, and increased risk of an automobile collision.[29]

Screening for depression - Normal aging does not include depression, and patients with depression have reduced function, poor appetite, sleep, and quality of life. They may also have multiple vague complaints, anxiety, preoccupation with finances, bodily function, and difficulty making decisions. Many studies have shown that depression affects cognitive impairment and memory, which is why any evaluation for them must have a screen for depression.[30]

Depression is seen in almost 40% of elderly patients residing in nursing home settings, whereas it is seen between 4% and 9% of elderly patients living in a community.[31][32] The geriatric depression scale (GDS) is a screening tool that is widely used. Patient Health Questionnaire-9 (PHQ-9) is another screening tool. The USPSTF recommends that all individuals over the age of 18 should be screened for depression if the screening tests are implemented with a system to support the diagnosis, treatment, and follow-up.

Urinary incontinence - The incidence of urinary incontinence increase with age, and it does not come without repercussions. Some of them are urinary tract infections, decubitus ulcers, sepsis, and increased mortality.[18] It also causes embarrassment and emotional stress to the patient that can lead to self-restriction of sexual and social activities and may also cause depression.[18]

A review of medications must also be performed to rule out any reversible causes. A screening questionnaire asking if the patient has lost control of their bladder in the last year and got wet, as well as asking if it has happened on more than six different days, is effective in identifying incontinence. It is also important to ask if the incontinence occurs with sneezing, coughing, or lifting. Other components of assessment include inquiry into previous urologic surgeries, fluid intake, and mobility.[18]

Socioenvironmental circumstances - Understanding the social health of elderly patients is tied to their overall well-being. Social history involves assessing the informal needs of the patient at their place of residence, eligibility of care resources, support structure, community involvement, caregiver needs, exercise, and financial assessment.[5][33]

Determining the most appropriate living arrangement is an important shared decision that usually occurs after home safety, injury risk, financial security, and caregiver support are well analyzed.[5]

Caregivers should be screened for burnout, and if needed, alternative living arrangements and support group referrals should be made. Sexually transmitted infections and sexual activity are commonly missed on CGA. Similarly, sexual dysfunction and impotence also need to be discussed for potential treatment options.[5]

Another important topic of inquiry is mistreatment. Elder abuse prevalence is about 10%, and women are more likely to be the victims of abuse than men. A shared living space with a spouse or adult children (the two most common abusers) is a risk factor, along with low income, isolation, and poor physical health.[34]

Types of abuse include financial exploitation, physical, verbal, sexual, and neglect. There are many manifestations of abuse, such as the presence of abrasions, lacerations, fractures, subtle signs of intimidation by the caregiver, frequent urinary tract infections while in a living facility, failure to pay for medications or renew prescriptions, worsening of chronic medical conditions, presence of decubitus ulcers, signs of malnutrition, dehydration, and poor hygiene.[34]

When abuse is suspected, the physician should seek support from law enforcement, social work, and protective services to report and intervene.

Frailty - Frailty is described as a state of reduced physiologic reserve that leads to a state of vulnerability to external stressors.[35] Frailty is a confounder in a patient who is extremely old (>90 years) and has a sudden near-complete loss of functionality in addition to a rapidly progressing dementia. This is rarely a presentation of MCI or Alzheimer disease alone.

Frailty encompasses the physical, social, and cognitive aspects of the patient. The two common measures of frailty include frailty index and frailty phenotype. The five areas of assessment for frailty phenotype are weakness (grip strength lower than 20% at baseline), unintentional weight loss (>10 pounds in the prior year), poor endurance and energy (self-reported), slowness, and low physical activity.[36] The combination of 3 or more characteristics constitutes frailty, whereas those with 1 or 2 characteristics are considered prefrail.

The frailty index, which is a continuous scale based on the effect of functional, psychosocial, medical, and age-related deficits, can predict mortality better than the frailty phenotype.[35] Evidence shows that there is a correlation between physical frailty and cognitive impairment.[37]

Frailty can predict cognitive decline, and conversely, cognitive impairment can predict frailty.[16] Patients with poor balance, altered gait, falls, and poor get up and go performance are at risk of cognitive impairment.[37] Treatment for frailty includes regular exercise, nutritional support, and avoidance of polypharmacy.[35]

Advanced care planning (ACP) - ACP is the process of identifying the patient’s goals and the extent of medical care in the future when the patient is unable to make a decision due to a serious illness. The key steps in the process are assessing the willingness of the patient, appointing surrogate decision-makers, articulating and documenting the patient’s values on medical care and quality of life, and translating those values and preferences into clinical management and treatment plans.[38]

Treatment / Management

Identifying and controlling the risk factors associated with cognitive impairment and dementia is key to planning a treatment plan for the patient.[11] There is no single pharmacologic agent that can reverse cognitive impairment and dementia. There is very limited evidence for nutritional intervention in patients with cognitive deficits for a statistically significant change in cognition.[39] Similarly, unless there is a clear deficiency, the use of antioxidants, vitamins, and herbal supplements has not shown a clear benefit.[11]

Lifestyle modification has been shown to positively impact the risk of cognitive decline. Regular physical activity, engaging in cognitively stimulating activities, social activity, cessation of smoking, and healthy dietary habits have been linked to a reduced risk.[8] The exact mechanism between physical activity and reduction of MCI risk is not well known.

The Lifestyle Interventions and Independence for Elders (LIFE) study showed no significant difference in cognitive outcomes in the moderate-intensity exercise group and the health education control group. However, patients over 80 years and those with poor baseline physical activity had better cognition scores.[40]

The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study revealed no difference in the incidence of dementia with the training of memory, reasoning, and speed of processing compared to the control group.[41] But there was a retention of the speed of processing and reasoning after ten years, but no such effect was seen for memory training.[42] Since the etiology of MCI and dementia is multifactorial, the interventions must also be aimed at multiple domains of cognition for effective prevention.

Cholinesterase inhibitors (AChEIs), such as donepezil, galantamine, and rivastigmine, are approved by the Food and Drug Administration (FDA) to treat mild to severe AD.[43] These drugs increase the amount of acetylcholine (a neurotransmitter) at the synapse and aid in improving memory, mood, attention, and behavior. Significant side effects include loss of appetite, loose stools, weight loss, vivid dreams, increased salivation, bradycardia, and muscle cramps.[44]

These medications should be cautiously used in patients with peptic ulcer disease, cardiac conduction disorders, and seizures. The risk of heart block must be assessed in all patients before initiating AChEIs with an electrocardiogram. Setting expectations with the patient at the beginning of the treatment prevents disappointment and establish realistic goals. The efficacy of the medication is determined 2 to 3 months after starting the medication with a reevaluation of cognition and function. These medications are not shown to delay the onset of dementia in patients with MCI.

Antagonists to N-methyl d-aspartate (NMDA), such as memantine, are another class of FDA-approved medication to treat moderate to severe AD. These medications prevent activation of the NMDAR (NMDA receptor) glutamate receptor to prevent cell death from calcium influx. The most common side effect of memantine is confusion and drowsiness.

It is important to note that even though AChEIs and NMDAs have therapeutic effects, they only help treat the symptoms and do not prevent or cure AD.[44]

Disease-modifying therapies (DMTs) target underlying mechanisms that damage a nerve cell. There are a few ongoing clinical trials that allow DMT (aducanumab, gantenerumab, and solanezumab) to be add-on therapies to either cholinesterase inhibitors or memantine.[44][45]

Despite innovation, many new drugs fail phase III trials upon failure to meet the endpoint targets. Continued investigations into combination therapies, repurposing existing drugs, and DMTs add-on to standard-of-care are needed to meet the challenge of treating AD.

Modifying other risk factors - On cessation of smoking, oxidative stress and neuroinflammation are reduced. Similarly, on stopping alcohol, there is a reduced risk of nutritional deficiency and alcohol-related neuron damage. Avoid ototoxic medications, clear out tympanic canal sediment in the clinic, assistive hearing devices, and audit rehabilitation can address hearing loss.[27] Corrective lenses for visual disturbance can increase performance functionally.

Treatment of depression can significantly improve the quality of life and function in the elderly population. Treatment options for depression are multimodal and not limited to psychosocial therapy, cognitive behavioral therapy, medications, and electroconvulsive therapy.[30] It is important to note that depression can be resistant in some elderly patients despite treatment. Extra caution must be used for dozing and monitoring of side effects of antidepressant medications.

Reducing the risk factors of MCI can slow the progression of AD-related dementia and delay mortality.[46] Periodic physician follow-up (3 to 6 months) is encouraged to monitor and delay the progression of cognitive impairment to dementia.

Differential Diagnosis

As previously discussed, certain common clinical conditions can present in an uncommon manner that can be confused with primary cognitive impairment or functional change. An infection, whether urinary, respiratory, or from a wound, can cause functional change, altered mental status, or worsening falls.

Similarly, hypothyroidism, depression, vitamin B12, frailty, and electrolyte abnormalities combined with existing comorbidities can complicate the presentation of a new problem. Thus, a careful clinical assessment, close management of existing medical problems, and identification of reversible causes are important.

Prognosis

It is important to note that not all patients with MCI will progress to dementia. According to some estimates, about 30 to 50% of patients with MCI return to normal cognitive function within one year from the initial presentation.[3][11]

A study using data from the National Alzheimer Coordinating Center showed that the annual progression probability from normal cognition to MCI varied from 4 to 10% from underlying AD.[46] That study also revealed a 92% likelihood of maintaining normal cognition at age 66, and the risk of developing MCI increased with age.[46]

Another study investigated individuals with positive amyloid pathology and showed that there was about a 40.8% probability of transitioning from asymptomatic to MCI-AD stage with a 5.3% probability of annual reversion back to the asymptomatic stage.[47] The annual transition probability from MCI-AD to mild and severe AD dementia ranged from 21.8 to 36%, with a 1.8 to 3% reversion rate.[47]

Some favorable factors encouraging the possible return to normal cognition include successful treatment of depression, lack of ApoE4, higher scores on cognitive testing, and greater hippocampal volume seen on imaging.[11]

Complications

Complications of cognitive impairment include the inability to perform daily tasks of living, increased risk for infection, behavioral disturbances (hallucinations and psychosis with severe dementia), frequent falls, increased mortality, and personality changes.[48]

As dementia progresses, individuals with cognitive impairment experience difficulties eating and swallowing and are at risk for aspiration. Functional disability can also restrict the patient from using utensils correctly, and likewise, depression can limit food intake.[49] Dietary modifications are needed to adjust fluid consistency and texture. Nutritional deficiencies are also commonly seen.

Worsening agitation can be problematic to the patient as well as the caregivers. The possibility of environmental factors must be investigated first before any intervention. Excessive noise, uncomfortable temperature, and restraints can escalate behavioral disturbance.[49]

Another common factor is unrecognized pain, as individuals with advanced cognitive impairment or dementia may not be able to verbally express discomfort. Addressing any potentiating factor is the key treatment.

Constant supervision and frequent assistance with activities and dealing with hallucinations, paranoia, and anger from the patient can contribute to caregiver burnout.[49] Attention should also be paid to caregivers who exhibit denial, anger, grief, and depression. Social support and ways to increase help from friends and other family members should be addressed to establish trust and open communication to aid everybody involved in patient care.[49]

Deterrence and Patient Education

As the population ages, physicians should pay careful attention to their elderly patient panel. Avoidance of polypharmacy, assessment of falls, frailty, mood, and function are some of the key topics to address at each clinic visit. A comprehensive geriatrics assessment can be broken down into multiple visits to account for time constraints.

Early detection of cognitive impairment opens the opportunity to initiate investigation and interventions to prevent progression to dementia. A holistic overview of the patient’s care and treatment goals will prevent unnecessary medical interventions. Conservative measures such as restricted diets and screening procedures with frequent blood draws can often precipitate behavioral disturbances in the elderly population and are inappropriate for patients with advanced dementia.[49]

Frequent counseling, access to community resources, and social support groups must be offered to the patient and the caregiver.

Enhancing Healthcare Team Outcomes

Geriatric care and management of a patient with cognitive impairment is an interprofessional effort. While it is essential to recognize that different specialties focus on different problems, maximum benefit is achieved when multiple assessments are synthesized into a coherent plan.

Coordination and clear communication must be established with physicians, nurses, healthcare agencies, pharmacists, and others who are involved in the patient care. Safety planning and assessment of the living situation can be performed by involving a social worker.

Using a common centralized electronic record system between specialties to organize appointments and medications is important to prevent adverse outcomes and helps maintain adherence.


Article Details

Article Author

Samender S. Randhawa

Article Editor:

Dona Varghese

Updated:

5/10/2022 8:57:03 AM

References

[1]

Murman DL, The Impact of Age on Cognition. Seminars in hearing. 2015 Aug;     [PubMed PMID: 27516712]

[2]

Jongsiriyanyong S,Limpawattana P, Mild Cognitive Impairment in Clinical Practice: A Review Article. American journal of Alzheimer's disease and other dementias. 2018 Dec;     [PubMed PMID: 30068225]

[3]

Eshkoor SA,Hamid TA,Mun CY,Ng CK, Mild cognitive impairment and its management in older people. Clinical interventions in aging. 2015;     [PubMed PMID: 25914527]

[4]

Tatum Iii PE,Talebreza S,Ross JS, Geriatric Assessment: An Office-Based Approach. American family physician. 2018 Jun 15;     [PubMed PMID: 30216018]

[5]

Tran HT,Leonard SD, Geriatric Assessment for Primary Care Providers. Primary care. 2017 Sep;     [PubMed PMID: 28797368]

[6]

Hugo J,Ganguli M, Dementia and cognitive impairment: epidemiology, diagnosis, and treatment. Clinics in geriatric medicine. 2014 Aug;     [PubMed PMID: 25037289]

[7]

Langa KM,Levine DA, The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014 Dec 17;     [PubMed PMID: 25514304]

[8]

Kivipelto M,Mangialasche F,Ngandu T, Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease. Nature reviews. Neurology. 2018 Nov;     [PubMed PMID: 30291317]

[9]

Doecke JD,Pérez-Grijalba V,Fandos N,Fowler C,Villemagne VL,Masters CL,Pesini P,Sarasa M,AIBL Research Group., Total Aβ{sub}42{/sub}/Aβ{sub}40{/sub} ratio in plasma predicts amyloid-PET status, independent of clinical AD diagnosis. Neurology. 2020 Apr 14;     [PubMed PMID: 32179698]

[10]

Jorm AF,Jolley D, The incidence of dementia: a meta-analysis. Neurology. 1998 Sep;     [PubMed PMID: 9748017]

[11]

Sanford AM, Mild Cognitive Impairment. Clinics in geriatric medicine. 2017 Aug;     [PubMed PMID: 28689566]

[12]

Honig LS, Translational research in neurology: dementia. Archives of neurology. 2012 Aug;     [PubMed PMID: 22473767]

[13]

Mesulam M,Shaw P,Mash D,Weintraub S, Cholinergic nucleus basalis tauopathy emerges early in the aging-MCI-AD continuum. Annals of neurology. 2004 Jun;     [PubMed PMID: 15174015]

[14]

da Costa JP,Vitorino R,Silva GM,Vogel C,Duarte AC,Rocha-Santos T, A synopsis on aging-Theories, mechanisms and future prospects. Ageing research reviews. 2016 Aug;     [PubMed PMID: 27353257]

[15]

Petersen RC,Doody R,Kurz A,Mohs RC,Morris JC,Rabins PV,Ritchie K,Rossor M,Thal L,Winblad B, Current concepts in mild cognitive impairment. Archives of neurology. 2001 Dec;     [PubMed PMID: 11735772]

[16]

Tangalos EG,Petersen RC, Mild Cognitive Impairment in Geriatrics. Clinics in geriatric medicine. 2018 Nov;     [PubMed PMID: 30336988]

[17]

Tabert MH,Albert SM,Borukhova-Milov L,Camacho Y,Pelton G,Liu X,Stern Y,Devanand DP, Functional deficits in patients with mild cognitive impairment: prediction of AD. Neurology. 2002 Mar 12;     [PubMed PMID: 11889240]

[18]

Elsawy B,Higgins KE, The geriatric assessment. American family physician. 2011 Jan 1;     [PubMed PMID: 21888128]

[19]

US Preventive Services Task Force.,Owens DK,Davidson KW,Krist AH,Barry MJ,Cabana M,Caughey AB,Doubeni CA,Epling JW Jr,Kubik M,Landefeld CS,Mangione CM,Pbert L,Silverstein M,Simon MA,Tseng CW,Wong JB, Screening for Cognitive Impairment in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Feb 25;     [PubMed PMID: 32096858]

[20]

Tsoi KK,Chan JY,Hirai HW,Wong SY,Kwok TC, Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA internal medicine. 2015 Sep;     [PubMed PMID: 26052687]

[21]

Cole JC,Ito D,Chen YJ,Cheng R,Bolognese J,Li-McLeod J, Impact of Alzheimer's Disease on Caregiver Questionnaire: internal consistency, convergent validity, and test-retest reliability of a new measure for assessing caregiver burden. Health and quality of life outcomes. 2014 Sep 4;     [PubMed PMID: 25186634]

[22]

Burton JK,Stott DJ,McShane R,Noel-Storr AH,Swann-Price RS,Quinn TJ, Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early detection of dementia across a variety of healthcare settings. The Cochrane database of systematic reviews. 2021 Jul 18;     [PubMed PMID: 34275145]

[23]

Bergen G,Stevens MR,Burns ER, Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014. MMWR. Morbidity and mortality weekly report. 2016 Sep 23;     [PubMed PMID: 27656914]

[24]

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel., American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2019 Apr;     [PubMed PMID: 30693946]

[25]

Winter JE,MacInnis RJ,Wattanapenpaiboon N,Nowson CA, BMI and all-cause mortality in older adults: a meta-analysis. The American journal of clinical nutrition. 2014 Apr     [PubMed PMID: 24452240]

[26]

Völter C,Götze L,Dazert S,Wirth R,Thomas JP, Impact of Hearing Loss on Geriatric Assessment. Clinical interventions in aging. 2020;     [PubMed PMID: 33408469]

[27]

Michels TC,Duffy MT,Rogers DJ, Hearing Loss in Adults: Differential Diagnosis and Treatment. American family physician. 2019 Jul 15;     [PubMed PMID: 31305044]

[28]

Watson GR, Low vision in the geriatric population: rehabilitation and management. Journal of the American Geriatrics Society. 2001 Mar;     [PubMed PMID: 11300245]

[29]

Owsley C, Vision and Aging. Annual review of vision science. 2016 Oct 14;     [PubMed PMID: 28532355]

[30]

Casey DA, Depression in Older Adults: A Treatable Medical Condition. Primary care. 2017 Sep;     [PubMed PMID: 28797375]

[31]

Hu SH,Chuang YH,Ting YF,Lin KY,Hsieh CJ, Prevalence of depressive symptoms in older nursing home residents with intact cognitive function in Taiwan. Research in nursing     [PubMed PMID: 29574780]

[32]

Luppa M,Sikorski C,Luck T,Ehreke L,Konnopka A,Wiese B,Weyerer S,König HH,Riedel-Heller SG, Age- and gender-specific prevalence of depression in latest-life--systematic review and meta-analysis. Journal of affective disorders. 2012 Feb;     [PubMed PMID: 21194754]

[33]

Wieland D,Hirth V, Comprehensive geriatric assessment. Cancer control : journal of the Moffitt Cancer Center. 2003 Nov-Dec;     [PubMed PMID: 14652521]

[34]

Lachs MS,Pillemer KA, Elder Abuse. The New England journal of medicine. 2015 Nov 12;     [PubMed PMID: 26559573]

[35]

Lee H,Lee E,Jang IY, Frailty and Comprehensive Geriatric Assessment. Journal of Korean medical science. 2020 Jan 20;     [PubMed PMID: 31950775]

[36]

Fried LP,Tangen CM,Walston J,Newman AB,Hirsch C,Gottdiener J,Seeman T,Tracy R,Kop WJ,Burke G,McBurnie MA,Cardiovascular Health Study Collaborative Research Group., Frailty in older adults: evidence for a phenotype. The journals of gerontology. Series A, Biological sciences and medical sciences. 2001 Mar;     [PubMed PMID: 11253156]

[37]

Arai H,Satake S,Kozaki K, Cognitive Frailty in Geriatrics. Clinics in geriatric medicine. 2018 Nov;     [PubMed PMID: 30336994]

[38]

Lum HD,Sudore RL,Bekelman DB, Advance care planning in the elderly. The Medical clinics of North America. 2015 Mar;     [PubMed PMID: 25700590]

[39]

Coley N,Vaurs C,Andrieu S, Nutrition and Cognition in Aging Adults. Clinics in geriatric medicine. 2015 Aug;     [PubMed PMID: 26195103]

[40]

Sink KM,Espeland MA,Castro CM,Church T,Cohen R,Dodson JA,Guralnik J,Hendrie HC,Jennings J,Katula J,Lopez OL,McDermott MM,Pahor M,Reid KF,Rushing J,Verghese J,Rapp S,Williamson JD,LIFE Study Investigators., Effect of a 24-Month Physical Activity Intervention vs Health Education on Cognitive Outcomes in Sedentary Older Adults: The LIFE Randomized Trial. JAMA. 2015 Aug 25;     [PubMed PMID: 26305648]

[41]

Unverzagt FW,Guey LT,Jones RN,Marsiske M,King JW,Wadley VG,Crowe M,Rebok GW,Tennstedt SL, ACTIVE cognitive training and rates of incident dementia. Journal of the International Neuropsychological Society : JINS. 2012 Jul;     [PubMed PMID: 22400989]

[42]

Rebok GW,Ball K,Guey LT,Jones RN,Kim HY,King JW,Marsiske M,Morris JN,Tennstedt SL,Unverzagt FW,Willis SL,ACTIVE Study Group., Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. Journal of the American Geriatrics Society. 2014 Jan;     [PubMed PMID: 24417410]

[43]

Yiannopoulou KG,Papageorgiou SG, Current and Future Treatments in Alzheimer Disease: An Update. Journal of central nervous system disease. 2020;     [PubMed PMID: 32165850]

[44]

Breijyeh Z,Karaman R, Comprehensive Review on Alzheimer's Disease: Causes and Treatment. Molecules (Basel, Switzerland). 2020 Dec 8;     [PubMed PMID: 33302541]

[45]

Cummings JL,Tong G,Ballard C, Treatment Combinations for Alzheimer's Disease: Current and Future Pharmacotherapy Options. Journal of Alzheimer's disease : JAD. 2019;     [PubMed PMID: 30689575]

[46]

Davis M,O Connell T,Johnson S,Cline S,Merikle E,Martenyi F,Simpson K, Estimating Alzheimer's Disease Progression Rates from Normal Cognition Through Mild Cognitive Impairment and Stages of Dementia. Current Alzheimer research. 2018;     [PubMed PMID: 29357799]

[47]

Potashman M,Buessing M,Levitchi Benea M,Cummings J,Borson S,Pemberton-Ross P,Epstein AJ, Estimating Progression Rates Across the Spectrum of Alzheimer's Disease for Amyloid-Positive Individuals Using National Alzheimer's Coordinating Center Data. Neurology and therapy. 2021 Dec;     [PubMed PMID: 34431074]

[48]

Vogelgsang J,Wolff-Menzler C,Kis B,Abdel-Hamid M,Wiltfang J,Hessmann P, Cardiovascular and metabolic comorbidities in patients with Alzheimer's disease and vascular dementia compared to a psychiatric control cohort. Psychogeriatrics : the official journal of the Japanese Psychogeriatric Society. 2018 Sep;     [PubMed PMID: 29993172]

[49]

Volicer L,McKee A,Hewitt S, Dementia. Neurologic clinics. 2001 Nov;     [PubMed PMID: 11854104]