Cognitive health is a major concern for older Americans but it’s important to recognize that no single test can definitively diagnose cognitive impairment. Instead, a diagnosis is based on a combination of the patient’s history and the results of multiple cognitive assessments.
Input from family members or close friends is often invaluable, as they can provide insight into changes in a person’s memory, ability to plan, follow instructions and make decisions.
While symptoms of cognitive decline naturally cause concerns, most individuals are still able to manage their daily lives as usual.
“Cognitive function does change as you get older,” said neurologist Dr. James Shafer. “There are different parts of the brain that have different levels of difficulties at certain ages, and they manifest certain types of symptoms that are specific to those parts of the brain.
“The frontal lobes of the brain are what we call our executive part of the brain. It’s where we do a lot of cognitive planning. Those are the parts of the brain that allow us to remember things, like when you enter a room and wonder why you went in there and then think, ‘Oh, I came in to get a pencil.’ I like to call this remembering to remember,” said Dr. Shafer.
“Then there’s the temporal lobes of the brain, which control immediate, short- and long-term memory” he continued. “What you remember depends on their relevance, their intensity, their environment and their purpose. Language is also embedded in the temporal lobes, mostly on the left side. This is where the order and meaning of our words reside.
“The parietal lobe brings meaning to our environment, meaning how we navigate our environments and how we constructively do things. Simple things like putting on a coat or grabbing a fork are controlled in the parietal lobes.
“There’s actually a lot of thought that goes into using a fork. You need to have the dexterity and motor function to use the fork, and you need to know what to do with it. You have to pick up the fork and know it’s used for eating and that it goes into your mouth.
“Finally, there’s the occipital lobes, which is the primary visual center of the cortex. It has to do with what you see and assists in bringing meaning and emotion to what you see by connecting with multiple other areas of the brain. All of these primary senses come together to create a memory or the ability to carry out an action to respond to a memory.
“All that being said, there are standardized tests that we use to access all those areas of the brain.”
According to Mayo Clinic, the most common tests are the short test of mental status, the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE).
These tests may reveal the types of memory most affected and whether other mental skills are impaired. More detailed testing can help determine if the degree of memory is impairment.
The MoCA test, for example, has been translated into 36 languages and accepted worldwide as a valid screening tool for detecting MCI (Mild Cognitive Impairment). The brief 30-point assessment takes approximately 10 minutes to complete and assesses multiple cognitive domains including executive function, memory, visuospatial ability, language and attention.
The patient may be asked to recall certain words, draw a clock, and associate numbers and letters.
While this assessment is superior to other cognitive tests such as the MMSE, there has been some debate as to whether the original cutoff score suggested for MCI (26/30) leads to a higher rate of false MCI diagnoses. On the other hand, with the development of new therapies targeted to treat Alzheimer’s Disease, diagnosis of early cognitive dysfunction (MCI) is increasingly important.
Longer forms of testing attempt to compare someone’s mental function with others of similar age and education. They may also help identify patterns of change that offer clues about the cause of the symptoms.
“These tests are screening tools that are used in conjunction with much larger data to assess someone’s cognitive function,” Dr. Shafer explained. “We assess what the patient is doing, how they perceive what they are doing and what others around them see.”
A thorough neurological exam may reveal how well the brain and nervous system are working. By testing reflexes, eye movements, walking and balance, early signs of Parkinson’s disease, strokes, tumors and other conditions that may impair memory may be revealed.
Physical problems can also affect memory loss. Something as simple as not enough vitamin B-12 or thyroid hormone can result in cognitive impairment. More serious conditions like brain tumors, stroke or bleeding can be checked with an MRI or CT scan.
“In this practice we look at the structural component of the brain through an MRI and we look at the cortical function of the brain with an EEG,” Dr. Shafer continued. “We use the MMSE cognitive test and also a test called Cognivue, which is a computerized test that assesses the executive function. We also do the Boston Naming Test because naming is one of the most sensitive indicators of early temporal dysfunction that could be related to short-term memory loss.
“A baseline assessment is established by assessing all the scores and then re-evaluated again in three to six months. The scores should be staying pretty level over time, but if patients start declining and display certain other predictors of organic cognitive dysfunction it’s generally a sign that we’ve got to jump in a little harder.”
So how valid are these tests?
“They are valid in the context of being interpreted and used by a professional that understands memory disorders and in the context of a positive history and other positive data that would help corroborate the finding of the cognitive testing,” Dr. Shafer said. “The only limitation is using the data in the wrong hands. That’s why it’s very important to see a memory specialist because the entire field has become highly specialized. And it’s equally important to see that specialist as soon as any symptoms arise because the earlier a memory disorder is diagnosed the more likely we can treat it.”
Dr. James Shafer has practiced Adult Neurology in Vero Beach and the surrounding area since 1997. He received his medical degree from the University of Miami at Jackson Memorial Hospital, followed by an internship in Internal Medicine at Jackson Memorial Hospital. He completed his residency in Adult Neurology at the University of Florida at Shands Teaching Hospital. He can be reached at his solo practice, Vero Beach Neurology and Research Institute and the Memory and Cognitive Disorder Center of Vero Beach, located at 1040 37th Place #201 in Vero Beach. Call 772-492-7051 or visit verobeachneurology.com.
