Be Your Own Brain Advocate: Why Older People Should Request Routine Cognitive Testing

Introduction

On average, people are living longer lives, but as we naturally age, our brain function, or cognition, may decline. Older adults may worry about losing their memory and other cognitive abilities. The good news is that the normal age-related declines in cognition are subtle for the majority of older people and mostly include changes in speed of thinking or attention.

Signs that your cognitive changes might be worse than normal include forgetting something very soon after being told it, even while you were paying attention, or having trouble knowing where you are while walking or driving, even in a place you are quite familiar with. Other examples include trouble solving common problems or behaving or speaking in ways outside of your normal social behavior. If these occur, you may have mild cognitive impairment (MCI). Doctors can measure your MCI and determine if the rate of change over time is small, or if the MCI is a sign of a disease that could lead to dementia.

Dementia refers to a group of diseases that cause large changes in brain function (Alzheimer’s Association, 2022). Alzheimer’s disease is the most common kind of dementia. Other types of dementia stem from different diseases, and while other dementias may exhibit slightly different characteristics or symptoms, all dementias include significant loss of memory, language, and problem-solving skills.

Tracking Brain Changes – Why, Who, and How?

Why Track Cognitive Changes?

Testing brain function on a regular basis tells the medical team and the patient if brain function is healthy or if there are problems. Your doctor can give you a brief test to see how your brain can work through some memory and problem-solving tasks. You can get tested even if you don’t have any worrying symptoms. If you have Medicare Part B (medical insurance), these cognitive tests are covered by your insurance. If you want a longer assessment because you have noticed changes, Medicare Part B also covers a separate visit with a health care provider to review your symptoms fully, determine if you have Alzheimer's disease or another disease or if something else is causing the problem, and if needed, create a care plan.

Visit Cognitive Assessment and Care Plan Services to get more information about Medicare. For insurance plans other than Medicare, check with your provider for test coverage.

Who Can Track My Brain Changes?

Your primary care physician can conduct regular screenings and track cognitive changes. If there is noticeable loss in cognitive function, you may benefit from a more accurate diagnosis and a treatment plan or care plan from a medical specialist. A neurologist specializes in diagnosing and treating diseases of the nervous system. A geriatrician specializes in medical care of older adults, including the brain. A neuropsychologist conducts advanced cognitive testing and manages symptoms. All of these would be good specialists to consider as referrals if your primary care doctor identifies problems in cognition.

How Do They Test My Brain Function?

There are a lot of ways your doctor or a clinic can test cognitive function. Four of the most common tests that primary care physicians rely on to start are the Mini-Cog®, MoCA, MMSE, and RUDAS. You will likely only be given one of these tests, not all of them.

• The Mini‐Cog consists of two sections that take approximately 3 minutes to complete: a memory test, and a clock drawing exercise. The clock drawing task measures ways your brain processes things like following instructions, planning, and placing things in correct spaces (Seitz et al., 2018).
• The Montreal Cognitive Assessment (MoCA) is similar to the Mini-Cog, assessing many of the same domains, but takes around 10 minutes to complete. Compared to the Mini-Cog, it is slightly better in detecting mild cognitive problems and is less influenced by the patient’s language abilities and education (Nasreddine et al., 2005).
• The Mini-Mental State Examination (MMSE) has been in use longer than the tests above. It takes between 5–10 minutes to administer, and it is less effective at measuring MCI and better used in assessing and tracking dementia (Folstein et al., 1975).
• The Rowland Universal Dementia Assessment Scale (RUDAS) is a short cognitive screening test designed to minimize the effects of cultural learning and language differences, making it potentially more suitable for individuals with lower educational backgrounds or English as a second language. The RUDAS test takes less than 10 minutes to complete (Daniel et al., 2022).

If you are struggling with one of these tests, you will probably be referred to a specialist, such as a neurologist, geriatrician, or neuropsychologist, who may want to conduct more in-depth testing, like brain imaging.

Why You Need to Be Your Own Brain Advocate

To explain this point, we need to compare brain testing and other common medical tests. During your annual wellness visits, the doctor and staff take your blood pressure. They do not ask you if you want your blood pressure taken or if you need this done because you think you have problems with your heart or blood vessels. Testing blood pressure is a routine task, even if it is just to “see how things are going” in your heart and blood vessels. In other words, you don’t need to ask, or advocate for, getting your blood pressure tested.

Cognitive testing is very different. Medical staff often do not test your brain function “just to see how it’s going” or ask older patients if they want their cognition tested. Only 1 in 6 (16%) older adults report getting regular cognitive testing (Alzheimer’s Association, 2022). Physicians typically request that the patient take a cognitive test only if they suspect their patient exhibits clear signs of brain problems during the brief time they have been speaking with the patient in the visit, or if the patient volunteers that they have worrisome symptoms. Because physicians don’t routinely screen for cognitive problems, and patients don’t know that they should ask for this test, physicians miss nearly half (42%) of dementia cases simply by not testing for cognition (Lin et al., 2021). This is why older adults should ask and advocate for routine cognitive testing.

What If There Are Problems? Knowing Early Is Better Than Knowing Too Late

Identifying cognitive changes early (changes that are age-related or indicate mild cognitive impairment) has important benefits compared to waiting until symptoms are significant enough for a dementia diagnosis. Early detection allows for:

• Making lifestyle changes. By taking care of your physical health, managing high blood pressure, eating healthy foods, being physically active, keeping your mind active, staying connected in social activities, and managing your stress, you may be able to slow the rate at which your brain is changing.
• Seeking a more in-depth assessment. A specialist may determine that your changes are not dementia-related, but instead something else that is treatable.
• Using certain new drugs for Alzheimer’s disease when eligible (for example, Leqembi or Lecanemab). Many drugs and experimental drug trials for dementia require that patients have milder dementia-related impairment to be eligible for treatment. Getting tested early is important for people who want to seek existing treatment options.
• Planning time. You can make decisions about future care needs or living options if these needs arise. You can ensure your financial and legal matters are addressed while you have the competence to make important decisions.
• Living life well! Knowing that there may be a time in the future when you are less able to travel or do more complex hobbies can really help you prioritize doing what’s important to you now.

Resources

Preventing Cognitive Decline

• Contact your Department of Health and Human Services or Area Agencies on Aging for classes in brain health or exercise opportunities.
• Read about the importance of brain activities in preventing decline in this USU Extension fact sheet: A Healthy Brain: Use It or Lose It!
• Learn how stress contributes to brain-related problems in this USU Extension fact sheet: Psychological Stress Among Risks for Alzheimer’s Disease.

Brain Changes and Measuring Brain Function

• Read about the underlying biological processes of brain function in this University of California at Los Angeles, David Geffen School of Medicine article: Alzheimer’s Vs Dementia - What Is the Difference?
• Learn about memory changes in this USU Extension fact sheet: Are My Memory Changes Normal?

References

• Alzheimer’s Association (2022). Alzheimer's disease facts and figures. Alzheimer's & Dementia, 18(4), 700–789.
• Chodosh, J., Petitti, D. B., Elliott, M., Hays, R. D., Crooks, V. C., Reuben, D. B., Galen Buckwalter, J., & Wenger, N. (2004). Physician recognition of cognitive impairment: evaluating the need for improvement. Journal of the American Geriatrics Society, 52(7), 1051–1059. https://doi.org/10.1111/j.1532-5415.2004.52301.x
• Daniel, B., Agenagnew, L., Workicho, A., & Abera, M. (2022). Validation of the Rowlands Universal Dementia Assessment Scale (RUDAS) to detect major neurocognitive disorder among elderly people in Ethiopia, 2020. PloS one, 17(1), e0262483. https://doi.org/10.1371/journal.pone.0262483
• Fauth, E. B., & Norton, M. C. (n.d.). A healthy brain: Use it or lose it! [Fact sheet]. Utah State University Extension. https://extension.usu.edu/aging/research/a-healthy-brain-use-it-or-lose-it
• Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6
• Lin, P. J., Daly, A. T., Olchanski, N., Cohen, J. T., Neumann, P. J., Faul, J. D., Fillit, H. M., & Freund, K. M. (2021). Dementia diagnosis disparities by race and ethnicity. Medical Care, 59(8), 679–686. https://doi.org/10.1097/MLR.0000000000001577
• Mitchell, A. J., Meader, N., & Pentzek, M. (2011). Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta psychiatrica Scandinavica, 124(3), 165–183. https://doi.org/10.1111/j.1600-0447.2011.01730.x
• Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x
• Norton, M. C., & Fauth, E. B. (n.d.-a). Psychological stress among risks for Alzheimer’s disease [Fact sheet]. Utah State University Extension. https://extension.usu.edu/aging/research/pyschological-stress-among-risks-for-alzheimers-disease
• Norton, M. C., & Fauth, E. B. (n.d.-b). Are my memory changes normal? [Fact sheet]. Utah State University Extension. https://extension.usu.edu/aging/research/are-my-memory-changes-normal
• Seitz, D. P., Chan, C. C., Newton, H. T., Gill, S. S., Herrmann, N., Smailagic, N., Nikolaou, V., & Fage, B. A. (2018). Mini-Cog for the diagnosis of Alzheimer’s disease dementia and other dementias within a primary care setting. The Cochrane Database of Systematic Reviews, 2(2), CD011415. https://doi.org/10.1002/14651858.CD011415.pub2
• Sievert, D. (2023). Alzheimer’s vs dementia – what is the difference [Fact sheet]. David Geffen School of Medicine, University of California - Los Angeles. https://medschool.ucla.edu/news-article/alzheimers-vs-dementia-what-is-the-difference#:~:text=In%20summary%2C%20dementia%20is%20an,own%20distinct%20causes%20and%20characteristics

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Authors

Josey M. Batura and Elizabeth B. Fauth

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