AGING
December 30, 2014

Are You Losing Your Mind?

You're over 60 and are starting to find it hard to remember things. Are you on the road to senility?

As we age we stop discounting symptoms as minor annoyances and begin to wonder if they are harbingers of bad things to come. Is that ache arthritis? Is that twinge angina? And perhaps most alarming: Are we losing our minds?

When we misplace our keys, can’t locate our glasses, forget words and names, we begin to worry we have the kind of memory problem that puts us on the slippery slope to Alzheimer’s disease.

What distinguishes “senior moments” from serious dementia? What can we do to prevent or slow the loss of our mental functions? How can we and our friends and families tell if we are in need of medical evaluation and care?

A recent study looked at these and other questions related to cognitive impairments related to age and revealed some useful guidelines and recommendations.

What Qualifies As Mild Cognitive Impairment (MCI)?

If you — or knowledgeable observers (such as a spouse, children or siblings) — begin to feel you or your loved one are having trouble recalling basic information and feel as though a change in thinking processes has occurred, the suspected diagnosis is often mild cognitive impairment. If that person is formally tested and found to have some changes in either memory, organizational skills, attention, or language, it's natural to worry it might be dementia.

But if that person is able to independently perform self care tasks such as feeding, grooming, toileting and activities of daily living — like shopping, managing money, and taking medications — and if he or she is still functioning well in social or occupational settings in spite of these signs and symptoms, then the diagnosis is mild cognitive impairment (MCI).

Nine percent of all mild cognitive impairments are thought to be caused by potentially reversible medical causes.

Mild cognitive impairment is different from the more severe dementia caused by Alzheimer’s disease, which is characterized by memory impairment, progressive decline of thinking skills over months to years, and lack of evidence for other medical causes for cognitive decline.

Minor cognitive impairment is diagnosed in about 10 to 20 percent of people 65 years and older. Its prevalence goes up with age, and men are at higher risk. Statistically, the risk for developing MCI also increases among those who have less education, have diseases that effect blood vessels such as diabetes and hypertension, or vitamin D deficiency, and sleep-disordered breathing.

MCI and Dementia
Patients with MCI do have an increased risk of developing dementia. However, the data varies from less than 5%, to a 12-20% conversion rate depending on the country and the population studied. Other studies show that from 40-70% of patients with MCI will not progress to dementia even after ten years.

Fifteen to twenty percent of people diagnosed with an MCI will actually experience improvement one to two years after diagnosis.

If you suspect that you or a loved one may have a mild cognitive impairment, the first step is to have a comprehensive evaluation designed to distinguish MCI from normal aging or other types of dementia and to identify potential reversible forms of MCI. Nine percent of all mild cognitive impairments are thought to be caused by potentially reversible medical causes.

Diagnosing Mild Cognitive Impairment

Precise information about the nature, earliest symptoms, and trajectory of the cognitive decline is important. For example, very rapid changes in cognition, appearing over weeks to months, may signify tumors, metabolic disorders, or a group of very rare diseases like Mad Cow disease, caused by prions, abnormal proteins that can neurological deterioration.

In addition to a complete medical history, an evaluation needs to include a physical and neurological exam and targeted laboratory tests to check for reversible medical problems like abnormal levels of calcium, magnesium, thyroid, B12/folate levels, as well as the presence of infection or kidney failure.

Standardized tests of thinking and reasoning skills should also be performed as part of a neuropsychiatric assessment.

Medications That Can Affect Thinking
Medications should also be reviewed, since many have side effects that can cause or contribute to changes in cognitive skills. Drugs used to treat pain, anxiety, depression, seizures, muscle spasms, allergies, sleep disorders, urinary and bowel problems, and heart conditions can cloud memory and thinking.

Aggressive treatment of high blood pressure and elevated blood sugar may also lead to abnormally low values that may contribute to cognitive decline. Patients should also undergo a psychiatric assessment, as depression can both cause and result from cognitive decline .

Tests and Treatments

There are no routine neuroimaging studies such as MRI and CT or PET scans that are currently recommended for evaluation of MCI although some are used for research purposes. Similarly, spinal taps are not recommended at this time.

Clinical trials have not revealed any drugs that are proven effective in the treatment of MCI or the prevention of its progression to dementia. Therefore, drugs such as Aricept, Exelon, and Namenda are not currently FDA-approved for treatment of MCI. Ginkgo biloba and testosterone supplementation have also not been shown to be effective.

Research suggests that the prevention of stroke and attention to vascular risk factors such as hypertension and diabetes may reduce the risk of progression of MCI to dementia. It is well known that acute stroke and unnoticed silent strokes can hasten cognitive decline and lead to dementia in MCI patients. Blood pressure control, smoking cessation, statin therapy, antiplatelet therapy, and anticoagulation medications used for atrial fibrillation can all help reduce the risk of developing MCI.

Untreated hearing and vision loss can contribute to cognitive decline so these skills should be assessed and referrals should be made for glasses or hearing aids when needed.

There is a good deal of evidence that blood pressure control can reduce dementia risk independently from its role in stroke prevention. The recommendation is that adults, ages 60 and older, have a blood pressure goal of less than 150/90.

A thorough assessment of the patient’s functional status, including her ability to care for herself, and her ability to live independently in her community will help inform treatment and referrals. When a person has had recent accidents or near misses, or when he has developing problems driving, such as maintaining speed, staying in the lane, or an increased tendency to get lost, giving up driving should be considered.

Untreated hearing and vision loss can contribute to cognitive decline, so these skills should be assessed and referrals should be made for glasses or hearing aids when needed.

Although the research data are not definitive, it is suspected that patients with MCI and sleep-disordered breathing would benefit from treatment of their breathing condition with CPAP machines.

When depression is identified, care must be taken in medication selection to avoid medications that are known to worsen cognition. These include amitriptyline (Elavil), nortriptyline, (Pamelor) and paroxetine (Paxil).

Studies have shown that there are several behavioral interventions that can benefit patients with MCI. Home-based or professionally-supervised programs of aerobic exercise or resistance training have produced modest improvement in cognition over an 18-month period of follow up.

A combination of aerobic exercise and mental activity has been similarly successful following a 12-week intervention period. Patients who follow the Mediterranean diet had reduced risk of converting from MCI to dementia. Other studies have shown that social engagement is effective in reducing the risk of cognitive decline and in preserving memory.

For Seniors and Families

If you are an aging adult or the family member of one and have the sense that you or your family member are not as sharp as they used to be, do not panic. Make an appointment for a comprehensive evaluation to establish a definitive diagnosis and reveal any possible reversible causes of the cognitive changes you are seeing. That's the first step.

You will also want your healthcare provider to look for any risk factors that can be modified — like smoking, diabetes or hypertension or the use of multiple medications with cumulative side effects. Changing your diet and exercise patterns, or helping your loved one do so can also have a positive impact on cognitive decline.

If MCI is the diagnosis, you'll want an assessment of functional status and help figuring out whether there are any changes that can be made to promote safety and independence.

The study is published in JAMA, the Journal of the American Medical Association.

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