PUT YOUR BRAIN TO THE TEST
How useful are cognitive assessment tools? The answer might surprise you
Twenty years ago, at a particularly stressful time in my mid-40s, I thought I was losing my mind — or at least my memory. I sometimes had trouble coming up with words — initially names, then simple phrases (like referring to the proverbial “night owl” as a “night bird”). Each flub made me anxious, which then worsened my memory issues. Listening to my inner hypochondriac, I became convinced I had a brain tumour. I went to see my primary care doctor.
She asked me a series of questions. “What year is it?” “What's today's date?” “Who's the president?” I was batting 1.000 until she asked me to spell “w-o-r-l-d” backward, when I faltered. My pulse began to race. “Can you count backward from 100 by sevens?” she queried me. I got to 93 but could go no further, which is when I broke down sobbing, convinced I'd been right about my diagnosis.
“You don't have a brain tumour or a cognitive deficit,” she told me. “But you do have an anxiety disorder,” she said abruptly, knowing the stress I'd been under. She prescribed medication for the anxiety and suggested I begin a meditation practice.
I'm not the only one I know to worry about my cognition or brain health. According to a 2020 study, two-thirds of Americans experience some level of cognitive decline by age 70. The lifetime risk for dementia for women is 37 per cent (24 per cent for men). These are stats that will make you pay attention.
Notably, there are key differences among populations. Higher education and continued learning appear to build up a “cognitive reserve” that can help stave off symptoms. Disadvantaged groups experience a younger age of onset, higher lifetime risk and more years of cognitive impairment than their more advantaged counterparts. Race and ethnicity seem to count, too: White women average six years of cognitively impaired life compared with 12 and 13 years among Black women and Latinas.
Unbeknownst to me, my doctor had used one of the most commonly used cognitive assessment tools (also known as memory tests), the Mini-Mental State Exam (MMSE). It's considered highly effective in recognizing cognitive impairment and revealing changes that may benefit from intervention.
But if you're considering getting tested to assuage anxiety or to learn more, know that cognitive assessments don't tell the whole story. Ronald Petersen, a neurologist at the Mayo Clinic who specializes in the cognitive changes associated with aging, notes that “they give us an approximate idea of how someone is doing cognitively, but they're not diagnostic.”
He won't tell a patient to stop driving based on the results, for example, and he can't use them to make a diagnosis of Alzheimer's disease. Screening tests don't reveal why there may be cognitive impairment, where in the brain there's a problem or what condition might be causing it.
Petersen explained that these screenings are like blood pressure readings, providing “a metric, a number that we can put on cognitive function that helps us assess where the person is now and, most importantly, where they may be going if, in fact, we do this (testing) on a regular basis.”
This is why psychologist Stephen Rao, who heads the cognitive neuroimaging centre at Cleveland Clinic, recommends annual assessments for those 65 plus. All patients in his facility are given a battery of tests during their yearly wellness appointments to measure and track cognitive function (orientation, registration, attention/calculation, recall and language).
If the findings suggest a noticeable change or an abnormality, Rao can recommend more sophisticated testing, including an MRI or PET scan, a lumbar puncture to look at cerebrospinal fluid (which can help diagnose Alzheimer's) and blood biomarker tests, seen as an emerging option for detecting the abnormal buildup of proteins that could be an early sign of Alzheimer's disease.
Medicare covers cognitive assessments during an annual wellness visit, but Petersen says many primary care doctors are uncomfortable administering them. They don't know which tests to use — some are as simple as the one my doctor used, but others can take up to 25 minutes to administer — how to interpret the results and what to do with abnormal findings.
A recent poll showed that 80 per cent of older adults see the benefit of these assessments, with 60 per cent saying they'd like their health-care providers to offer them. At the same time, 80 per cent haven't been tested in the past year and 59 per cent report never having had one.
It's important to differentiate the changes to be expected during aging from actual cognitive impairment. “It's not black and white,” says Petersen, adding that normal aging includes occasionally forgetting the names of acquaintances, missing a monthly payment, having trouble finding the right word, and losing things.
More troubling signs might be forgetting names of close family members, often being unable to find things, ongoing problems managing bills, or difficulty maintaining a conversation. It may be time for a cognitive test if you are asking the same question repeatedly, getting lost in places you know well, or having trouble following recipes.
Some people are hesitant to take a cognitive assessment due to privacy concerns or because they incorrectly assume that nothing could be done with the results or are worried what they might find out. But Rao said that about 40 per cent of dementia cases “can either be reversed or slowed down if detected early.”
He also emphasized that screening can alert doctors to look for other, treatable issues that may cause cognitive decline. For instance, doctors say, blood clots may cause memory issues, as can some medications, a head injury, alcohol or drug misuse, too little sleep and low levels of crucial nutrients (such as vitamin B12). Depression and stress can also affect memory. The good news, says Petersen, is that memory problems may go away once the underlying condition is treated.
That's why, when I go in for my next annual wellness visit, I'm going to ask my doctor for a cognitive assessment.
I've learned a trick or two since my last test: It's much easier to do the countdown exercise (repeatedly subtract seven from 100) if you subtract 10 and then add three back. Also, it's not hard to memorize how to spell “w-o-r-l-d” backward. As long as my doctor doesn't give me a different word, I should do fine.
Some people are hesitant to take a cognitive assessment due to privacy concerns or because they incorrectly assume that nothing could be done with the results or are worried what they might find out. Steven Petrow