Q&A: Signs that cognitive changes are worrisome — and what you can do about it

Amid ongoing conversations about the United States presidential race, a recurring topic has been the cognitive capacity of candidates and some speculation about "cognitive decline"—but what does this mean in terms of a person's health?

As a geriatrician and palliative medicine physician, Hillary Lum, MD, Ph.D., has spent her career working to better the lives of older adults and their families, often raising awareness about what cognitive decline can look like and when it is concerning. She is currently involved in the Colorado Alzheimer's Disease and Related Dementias State Plan, a state initiative to improve awareness and actions to address dementia in Colorado, specifically looking at how to build a competent workforce related to Alzheimer's disease and related dementias.

Lum, an associate professor in the Division of Geriatric Medicine at the University of Colorado Department of Medicine, talks about what cognitive decline is, symptoms to look out for, and how people can best protect their brain health.

Q: How do you define cognitive decline?

Cognitive decline is not a medical term. It is a broader, subjective experience where individuals notice changes in their life from what they are used to. This may look like struggling to remember the names of things, new problems with speaking or writing, or issues with processing and understanding information.

In the medical field, we have a diagnosis of mild cognitive impairment, and that's when there are objective differences in a person's current cognition compared to before, but they're still able to manage their life and the things they need to do.

About 10% to 15% of cases of diagnosed mild cognitive impairment will resolve over time. Roughly 50% will progress and, at some point, individuals will be diagnosed with dementia related to an underlying brain disease.

Q: What leads to cognitive decline? Should most people expect to experience cognitive decline at some point in their life?

There can be many reasons for cognitive decline, and individuals can experience cognitive decline at any age.

In younger individuals, cognitive decline—or a subjective feeling that may be described as brain fog and not being able to function in the way a person would like to—could be related to different causes such as sleep issues, mood disorders, anxiety, medications, or substance use.

As we get older, there can be cognitive changes that are expected as part of aging. For example, it becomes harder to multitask as we age. That is a normal, age-related change that is not due to dementia.

Memory issues are another topic that can come up. When individuals say that they're having more difficulty with names, or they will come into a room and forget what they came in for—that is a type of change that can be common, and it is not a symptom of dementia.

However, changes in memory or thinking that disrupt daily life could be symptoms of underlying brain disease, such as Alzheimer's disease, that is causing dementia.

For example, if a person is having trouble remembering the name of something they interact with every day, like a spoon in their kitchen drawer, that might raise some concerns about a potential underlying issue that may be affecting their memory. Common early changes could be difficulty managing finances, traveling to known places, or using technology that was previously possible.

Q: What is the association between cognitive decline and dementia?

When people talk about cognitive decline, the diagnosis that most people and health care teams are trying to distinguish is whether someone has dementia or not.

Dementia is an umbrella term for when a person experiences cognitive decline that causes them to need assistance with daily life. There are several brain diseases that cause progressive neurodegenerative disease, which then look like signs and symptoms of dementia.

The number one risk factor for dementia is age. That's why it is important to think about what the cause of cognitive decline is, and whether it might be due to an underlying brain disease.

Some have the misconception that everyone who is older will develop dementia at some point, and that is not true. Not everyone will get dementia.

Q: In general, what are signs of cognitive decline, and which signs are red flags that there may be an underlying health issue?

A great resource is from the Alzheimer's Association, which put together a list of 10 early signs and symptoms of Alzheimer's and dementia. This resource also mentions typical age-related changes a person should not be alarmed by.

For example, a typical age-related change is forgetting names or appointments and remembering them later. However, if a person's memory loss is disrupting their daily life and they are doing things like asking the same questions over and over, that may be a sign of dementia.

Other signs to look out for are challenges in planning or solving problems, difficulty completing familiar tasks, confusion with time, and trouble understanding visual images and spatial relationships. Concerning signs may come up when a person is driving, for instance. Other worrisome signs may be if someone is not able to distinguish a financial scam.

Q: How quickly can cognitive decline occur in a person?

It is highly variable. Some individuals have a rapidly progressive underlying brain disease that is causing dementia, whereas others may be experiencing more subtle changes over several years. I think that long timeline, in some people, contributes to the false perception that dementia happens just because of aging, and that everyone will develop dementia.

Sometimes, individuals will not bring up their perceived cognitive decline to their clinicians. As a society, there is a lot of stigma related to dementia. Therefore, it's difficult for individuals to bring it up to their health care team, and it's scary for individuals who are experiencing changes in their cognition.

Q: What should a person do if they suspect they are experiencing cognitive decline?

I encourage them to bring it up with their health care team. The Alzheimer's Association has a guide on what to do if you notice changes in yourself and steps you can take.

Additionally, the Medicare Annual Wellness Visit is an opportunity for health care teams to do a brief cognitive assessment, and it is another opportunity for people to share if they are noticing changes so that a more detailed evaluation can occur.

It's important to know there can be many different factors causing memory changes, including medications that are over the counter. For instance, in caring for older adults, we want people to avoid anything that has a nighttime aspect to it—so any medication that has "PM" in its name—because that has an anticholinergic medication that increases the risk for cognitive decline.

Q: Why is it important for a person to tell their doctor early on if they are experiencing cognitive decline?

Having an accurate diagnosis allows individuals to take proactive next steps to reduce their risk of worsening cognitive impairment and optimize brain health through a careful review of medications, good sleep, a healthy exercise routine, social engagement, and evaluating for hearing loss, which is a known risk factor for dementia.

In addition to optimizing brain health, having a diagnosis provides an opportunity to plan for the future. By voicing concerns early on, people will hopefully be able to get a diagnosis while they still have the ability to talk about advance care planning and decisions like who should be a trusted decision maker and serve as a medical durable power of attorney.

Having a diagnosis is also a chance for ongoing conversations about living arrangements, support as needs change, and other preferences to focus on quality of life.

We know that when someone has dementia, if they have to go to the emergency room or hospital, that can be difficult. There is a higher risk of delirium and confusion. It's important to know early on if dementia is present, because it influences so many different aspects of quality of life, decision making, and care and caregiving.

Also, cognitive changes related to an underlying brain disease can be quite insidious, and it can take time to make an accurate diagnosis. It often requires assessment over time. That's another reason why it's valuable for individuals to bring up their concerns early on with a trusted health care professional.

If you are concerned that a loved one is experiencing cognitive decline, I encourage you to have an honest and supportive conversation with them.

Q: What are steps people can take to help preserve their brain health?

There are many risk factors for dementia that can be modified and improved. In fact, about 40% of the risk can be modified. I encourage individuals to focus on lifestyle changes that help with heart health. What's good for your heart is good for your brain.

Secondly, we are increasingly recognizing that hearing loss is a risk factor for dementia. Early screening for hearing changes and modifying the risk with the use of amplification devices like hearing aids is important for reducing the risk of developing dementia.

There is also increasing knowledge about the value of social engagement. Social "exercise" helps our brains remain engaged. I don't want individuals to stop meeting and conversing with people because the conversation is harder to follow or it's harder to say what they want to say. I encourage people to continue to work at it, because getting your brain engaged is important for brain health.