Continuing Education Activity

Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. It encompasses various aspects of high-level intellectual functions and processes such as attention, memory, knowledge, decision making, planning, reasoning, judgment, perception, comprehension, language, and visuospatial function, among others. "cognitive deficit" is an inclusive term used to describe the impairment of different domains of cognition. This activity reviews the evaluation and management of cognitive deficits and highlights the role of the interprofessional team in evaluating and improving care for patients with this condition.

Objectives:

• Summarize the risk factors for developing cognitive deficits.
• Outline the typical presentation of a patient with cognitive deficits.
• Review the management options available for cognitive deficits.
• Describe the importance of coordination and communication among the interprofessional team in the evaluation and management of patients with cognitive deficits.

Introduction

Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. It encompasses various aspects of high-level intellectual functions and processes such as attention, memory, knowledge, decision-making, planning, reasoning, judgment, perception comprehension, language, and visuospatial function. Cognitive processes use existing knowledge and generate new knowledge.

"Cognitive deficit" is an inclusive term used to describe the impairment of different domains of cognition. Cognitive deficit is not limited to any particular disease or condition but may be one of the manifestations of someone's underlying condition. It is also used interchangeably with "cognitive impairment." It might be a short-term condition or a progressive and permanent entity.

On the other hand, cognitive disorders are a bigger entity that is a part of neurocognitive disorders (DSM-5). Cognitive disorders are defined as any disorder that significantly impairs the cognitive functions of an individual to the point where normal functioning in society is impossible without treatment. Alzheimer disease is the most well-known condition associated with cognitive impairment.

Etiology

Cognitive deficits may be from birth or caused later by environmental factors such as brain injury, mental illness, neurological disorders. Not every elderly will have a cognitive deficit, but the cognitive deficit is more common in the elderly. 

Some of the early causes of cognitive deficit include chromosome abnormalities/genetic syndromes, prenatal drug exposure, malnutrition, poisoning due to lead or other heavy metals,  neonatal jaundice, hypoglycemia, hypothyroidism, prematurity, hypoxia, trauma, or child abuse.

In childhood or adolescence, Cognitive deficit may develop as a result of many conditions. Some examples include side effects of cancer therapy, heavy metal poisoning, malnutrition, metabolic conditions, autism, and immune conditions like systemic lupus erythematosus.

With increasing age, conditions such as stroke, delirium, dementia, depression, schizophrenia, chronic alcohol use, substance abuse, brain tumors, vitamin deficiencies, hormonal imbalances, and some chronic diseases may cause a cognitive deficit. Brain pathologies like Alzheimer disease, Parkinson disease, Lewy body dementia, Huntington disease, HIV dementia, prion disease manifest with cognitive deficits. Drugs like sedatives, tranquilizers, anticholinergic, glucocorticoids are also associated with cognitive deficits. Head injury and infection of the brain or meninges can cause cognitive deficits at any age.[1][2]

Epidemiology

The frequency of cognitive deficit due to various causes is difficult to predict and is not well established. However, increasing age is the most important factor for cognitive impairment. Alzheimer disease is the most well-known condition associated with cognitive impairment. Approximately 5.5 million people are affected by Alzheimer disease in the US, and the worldwide prevalence is estimated to be more than 24 million.

The prevalence and incidence of Alzheimer among African American populations were approximately twice those among European Americans. The incidence of dementia is predicted to double every 10 years after 60 years of age. Age-specific incidence of Alzheimer disease increases significantly from less than 1% per year before the age of 65 years to 6% per year after the age of 85 years.[3][4]

Pathophysiology

The general pathology of cognitive decline/deficits is damage to neuronal tissue.  This includes damage to the grey matter, which comprises the cortex and the thalamus, basal ganglia, and the white matter, which comprises the coverings of the axons of the connections between grey matter areas. The damage to certain areas is responsible for certain deficits. For instance, damage to the parietal lobe can cause the inability to dress or visuospatial function.  Damage to the frontal lobe systems can cause deficits in planning and abstract understanding, and damage to the temporal lobes causes deficits in language and memory.

The causes of this damage are due to toxicity to neurons from metabolic disorders or heavy metals or other toxins such as toluene or infection or due to ischemic damage due to stroke or hemorrhage or direct injuries such as head injury or cancer, or surgery. Damage can also be caused by neurodegenerative processes such as Alzheimer, Parkinson, multiple sclerosis, or Huntington disease.  These illnesses appear to directly damage neuronal tissue through immunologic interaction with abnormal proteins.

Histopathology

Most dementias are confirmed by finding abnormal proteins in brain sectioning. Alzheimer is defined by amyloid and Tau inclusions in the brain tissue, Parkinson and Lewy body dementia are supported by Lewy bodies and frontal dementias by Tau inclusions. Parkinson-like illness is also associated with synuclein inclusions. Prion diseases have abnormally folded proteins called prions in the brain tissue.

History and Physical

Cognitive deficit is not an illness in itself but a manifestation of an underlying condition. The patient may notice these changes themselves, or most of the time, it is noticed by the caretakers and friends of the patient. The patients usually have the following:

• Trouble remembering things (frequently asking the same question or repeating the same story again and again )
• Difficulty in learning new things and concentrating
• Vision problems and trouble speaking
• Difficulty recognizing people and places. They often find new places or situations overwhelming.
• Confusion or agitation.
• Mood changes
• Change in their behavior, speech,
• Difficulty even with their usual daily tasks

Cognitive impairment can come and go or wax and wane. Cognitive impairment can be mild, severe, or anything in between. With mild impairment, there are changes in cognitive functions, but the individual can still do his/her everyday activities. Severe levels of impairment (dementia) can lead to a point where the individual is incapable of living independently because of the inability to plan and carry out regular tasks (Activities of daily living/instrumental activities of daily living) and apply judgment.

Cognitive impairment may accompany different other symptoms, depending on the underlying disorder or condition. Sometimes they may present as emergency cases and may require acute life-saving interventions.

Infective causes may present with fever, rashes, headache, nausea, vomiting, neck stiffness, malaise, seizures, and others.

It may accompany metabolic disorders and present with abdominal pain, nausea, vomiting, tachycardia, bradycardia, fatigue, muscle weakness, shortness of breath, excess thirst, urinary problems, and even loss of consciousness. 

Cognitive deficits may accompany symptoms of other problems, such as head injury, stroke, or dementia. The patient might present with behavioral or personality changes, loss of consciousness, vision changes, imbalance, severe headaches, seizures, sleep pattern changes, numbness, weakness, and paralysis. 

Cognitive disorder includes delirium and mild and major neurocognitive disorder, which may present as follows:

• Delirium develops very rapidly and over a short period of time. It is mainly characterized by disturbances in cognition. Other manifestations are confusion, disorientation, excitement, and also a change in consciousness. Hallucinations and illusions may be common. It also makes processing new information and situational awareness very difficult. Its onset ranges from minutes to hours and sometimes days. However, it only lasts a few hours to weeks. It can also be accompanied by inattention, mood swings, or abnormal behaviors. There is usually an underlying medical or surgical condition causing it. Delirium during a hospital stay can result in complications and long terms stay.

• Mild and major neurocognitive disorders are commonly associated with the elderly. These disorders develop slowly and are mainly characterized by memory loss in addition to cognitive impairments. There may also be psychosis, agitation, and mood changes. The difference between mild and major neurocognitive disorders is mainly based on the severity of the symptoms. Major neurocognitive disorder(previously known as dementia) is characterized by significant cognitive decline and the development of dependence. The mild neurocognitive disorder is characterized by moderate cognitive decline, and the patient is still independent. To be diagnosed, delirium and other mental disorder should be ruled out. For causes of dementia, such as age, which is irreversible, the decline of cognition and memory is lifelong.[5][6][7][8]

Evaluation

The evaluation consists of detailed history from the patient and family members (including the onset, duration, symptoms, impact, impact on activities of daily living, and changes from the patient's previous level of execution and functioning) and clinical assessment of the patient that encompasses a wide range of information collected from physical, neurological, and mental status examinations.

The history gathered from the patient and the accompanying family/friends should be focused on the following:

• Changes in cognitive functions (onset, course, and examples)
• Change in functional status-Selfcare (cooking, testing, hygiene, finances)
• Physical symptoms (nausea, vomiting, vision, hearing, speech, balance, gait, balance, sensation, and motor functions)
• Psychiatric symptoms (mood changes, behavioral and personality changes) 
• Current medication, if any

There are various screening tools used by patients, families, and physicians to assess the patient's cognitive abilities. Screening is to identify those patients who deserve a complete diagnostic assessment. Physicians often assess the patient's mental status with a brief test, such as the mini-mental state examination (MMSE). However, the experts have identified several new and improved instruments suited for use in primary care settings. Popular tools used by primary care physicians are:

• General practitioner assessment of cognition (GPCOG)
• Memory impairment screen (MIS)
• Montreal cognitive assessment (MoCA)
• Mini-Cog
• Memory and executive screening (MES), etc. 

Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Dementia Severity Rating Scale (DSRS), AD-8, and General Practitioner Assessment of Cognition (GPCOG) can be used to gather information from caretaker/ family members. Individuals who fail these tests need further diagnostic evaluation or a referral to a specialist. In addition, more detailed neuropsychological testing may help determine the type and degree of impairment and what mental skills are impaired.

Different tools have different applications according to the presenting case. For example, Montreal Cognitive Assessment (MOCA) is mostly used for general screening because of its coverage of a broad array of cognitive functions. Mini-mental state examination (MMSE) is used for the evaluation of patients with Alzheimer disease because of its main focus on testing memory.

As part of the physical exam, the physician should perform a detailed neurological examination to determine the involvement of the brain and nervous system. These tests can help detect neurological signs of different brain pathologies like stroke, Parkinson disease, brain tumors, or other medical conditions.  The neurological exam includes the basement of mental status, cranial nerves, motor and sensory functions, reflexes, coordination, balance, and gait.

Other tests depend upon the accompanying physical signs and symptoms. It may include complete blood count, thyroid tests, vitamin B12 levels, basic metabolic panel, urine analysis, liver function tests, and renal function tests, which may help find out different Infectious causes and metabolic disorders. Also, brain imaging like CT-scan and MRI may be useful to delineate brain pathologies like a brain tumors, bleeding, or stroke.[5][6][9][10]

Treatment / Management

Treatment of cognitive deficits depends on what actually is causing impairment. If it is caused by an illness or a condition, then it is likely to recover after the treatment. Infections and metabolic syndromes, depression, thyroid disorders, and medication effects are some curable causes of cognitive decline. For cognitive disorders, a detailed assessment and management are required, and the interventions focus mainly on the improvement of quality of life and the limitation of residual defects.

There is no pharmacological treatment for mild cognitive impairment. The management is focused on promoting functional status. Counseling is a very important component of patient management. These individuals are at increased risk for trouble with mobility and recurrent falls. Problems with vision and hearing need to be addressed and corrected. People with sleep apnea may be benefited from continuous positive airway pressure (CPAP). There is no established evidence to conclude that the treatment of depression improves cognitive impairment. There are negative impacts of the use of anticholinergic medications on cognitive function in the elderly. Treatment with antidepressants should be avoided, especially the ones with amitriptyline, nortriptyline, and paroxetine (ones with significant anticholinergic properties). A trial of withdrawing, managing, and simplifying medications in older adults may lead to an effective improvement in cognitive function.

For the treatment of delirium, the cause must be established first. Medication such as antipsychotics or benzodiazepines (BZDs) can help reduce the symptoms in some cases. For alcohol abuse or malnourished cases, vitamin B supplements are recommended. Some extreme cases also require life support. Ginkgo biloba is a popular herbal supplement that is thought to improve cognition and memory. However, it has failed to prevent cognitive decline in those with mild cognitive impairment or normal cognition in randomized control trials.[11][12][10]

Physical activity, cognitive training and exercises, proper sleep, and relaxation techniques can help cognitive health. Mediterranean diet may help people with cognitive impairment. Occupational therapy focuses on teaching different patient strategies to minimize the effect of cognitive impairment on daily life. Environmental approaches, such as reducing noise around the patient, help the patient focus on tasks and reduce distraction, confusion, and frustration. They are making sure that the patient is around familiar objects and surrounding help. Psychotherapy and psychosocial support for patients and families have evidence of better outcomes in clear understanding and proper management of the disorder and therefore maintaining a better quality of life for everyone involved.

Alzheimer disease has no cure, but available medications slow the worsening of dementia symptoms and help improve cognition and behavioral problems that appear during the disease course. The standard medical treatment for Alzheimer disease includes cholinesterase inhibitors and a partial N -methyl-d-aspartate antagonist. Behavioral symptoms are common and can exacerbate cognitive and functional impairment in patients. Secondary symptoms of Alzheimer disease-like depression, delusion, agitation, aggression, sleep disorders, and hallucinations, also need treatment. Psychotropic medications like antidepressants, anxiolytics, neuroleptics, beta-blockers, antiparkinsonian agents, and antiepileptic drugs (for their effects on behavior) are regularly used. Cognitive decline in normal aging is usually mild and requires behavioral and supportive interventions only.[6][8][10][13][14]

Differential Diagnosis

Cognitive deficit is not an illness in itself but a manifestation of an underlying condition. Some disease conditions associated with cognitive deficits are:

• Delerium
• Alzheimer disease
• Huntington disease
• Stroke
• Developmental disorders (Down syndrome)
• Head injury
• Multiple sclerosis
• Parkinson disease
• Lewy body dementia
• Meningitis
• Acquired immune deficiency syndrome
• Alcohol, drugs, toxins
• Wernicke Korsakoff syndrome

Prognosis

The prognosis of cognitive deficits depends upon the underlying cause. There are many causes, like medication, depression, thyroid disorders, and infections, which are correctable. Whereas conditions like Alzheimer disease cannot be reversed, and only the progression can be slowed. Many causes of cognitive deficits are acute life-threatening conditions, and without proper medical or surgical management, can result in a great deal of morbidity and mortality. For patients diagnosed with Alzheimer disease, the average life expectancy for a person aged 65 years or older is about 4 to 8 years. Some individuals with Alzheimer disease even may live up to 20 years after the first signs of disease.

In some instances, cognitive deficits may be a symptom of an underlying serious or life-threatening condition that can be life-threatening. These include:

• Brain tumor
• Stroke
• Encephalitis
• Meningitis
• Traumatic head injury 
• Heatstroke or profound dehydration
• Kidney failure
• Sepsis
• Spinal cord injury or tumor

So the prognosis depends on various factors.[15]

Complications

A cognitive deficit can be coexisting with a variety of serious diseases and conditions. Therefore the failure to timely seek treatment can result in serious complications and even permanent damage. Once the underlying condition is diagnosed, it is important to follow a proper treatment plan to reduce the risk of potential complications, which may include:

• Developmental delays and failure to thrive
• Learning disabilities
• Speech and hearing defects
• Paresis/paralysis
• Permanent cognitive impairment
• Permanent sensory loss
• Physical disabilities
• Personality changes
• Permanent loss of memory
• Loss of independence
• Falls/injuries
• Coma

Deterrence and Patient Education

Age is the primary cause of cognitive impairment. Other risk factors include family history, physical inactivity, and disease/conditions such as Parkinson’s disease, heart disease, stroke, brain injury, brain cancers, drugs, toxins, and diabetes. Individuals may reduce the risk of cognitive impairment by keeping physically active, eating a healthy diet, and maintaining healthy blood pressure, blood sugar, and cholesterol levels. Some causes of cognitive impairment are treatable, like infections, medication side effects, depression, and vitamin B12 deficiency. It is important to identify people who are showing signs of cognitive impairment to ensure that they are evaluated by a healthcare professional and receive appropriate care or treatment.

Apart from increasing age, hypertension, diabetes, hypercholesterolemia, smoking, and obesity are thought to be responsible for the clearance of amyloid (protein) from the brain, which in turn increases the risk of developing Alzheimer disease. A higher risk of Alzheimer disease, in particular, is associated with the presence of a number of these risk factors at the same time and while the person is in his or her 50s. So it is essential to maintain healthy blood pressure, blood sugar, and blood cholesterol.

Environmental and behavioral interventions are beneficial, especially in managing behavioral problems. Simple approaches such as noise cancellations and redirecting attention, maintaining a familiar environment, providing security objects, monitoring personal comfort, and avoiding confrontation can help in managing behavioral issues. Regular aerobic exercise and the Mediterranean diet have been shown to slow the progression of Alzheimer disease. 

There are various memory and cognitive function tests available online. It is important to understand that these tests only give you a general idea about cognitive deficits in someone. However, consultation with a physician and a full medical checkup is always necessary before coming to any diagnosis and starting management options. Alzheimer disease and dementia can create havoc not only in the patient but also in the family, friends, and the community. So the management encompasses the role of the physicians, patients themselves, family and friends, and also policymakers. Healthcare policymakers must explore policy changes and initiatives that will increase support, expand research, and, ultimately, improve the quality of life for people living with cognitive impairment and also their families.

Enhancing Healthcare Team Outcomes

Cognitive deficits may be a manifestation of a variety of systemic conditions. So it requires an interprofessional team to act via a comprehensive and coordinated approach to carefully come to a particular diagnosis and start necessary interventions. Many healthcare professionals, including primary care physicians and nurses, psychiatrists, physiotherapists, dieticians, caregivers, and also social workers, work together to ensure that the patient with cognitive deficits remains safe and leads a proper quality of life. [Level-5]

Because these patients suffer from sensory and sensory processing deficits, the team can be helpful in directing the patient and family on how to overcome these issues.  For instance, an Alzheimer patient will often have dressing apraxia, so clothing with Velcro or lacking sleeves is easier for the patient to don those buttons and things that tie.

Patients with dementia often cannot chew and have a coordinated swallow and so dietary and speech consults can be useful in helping the patient enjoy eating and drinking without the risk of aspiration pneumonia.