Recognizing cognitive impairment is not often easy in the clinical setting. Patients typically do not come into the office with cognitive complaints. Often, it is the recognition of unusual symptoms by a caregiver or a loved one that prompts an evaluation. Once a problem with cognition is established, proper treatment can begin.

There is a lot of stigma and fear surrounding Alzheimer’s disease, and patients may hide their symptoms and may not necessarily bring up issues with their memory during their clinic visits. Often, it is someone from their family, a caregiver, or a close friend who voices concern and wants the patient evaluated for their memory problem. Having informants with the patient is important when considering and evaluating for cognitive disorders. In my experience, cases in which a support person voices concerns about a patient will often result in a positive screen for cognitive impairment.

Through simple questions and vigilance, clinicians can catch the first signs and symptoms of cognitive impairment at the stage of mild cognitive impairment before patients have dementia. These individuals may be forgetting names frequently, misplacing objects on a routine basis, repeating themselves often, telling the same story to the same person multiple times, and, perhaps, starting to have some problems with executive function as well. A task such as balancing their bank account or doing other complex work may still be possible, but it takes them longer to do than it used to.

Other concerning symptoms that I see occur with older patients with chronic disorders who have been doing well in terms of taking and refilling their medications on time but then start doing things such as missing medications, forgetting what their medications are, and/or failing to get their lab work done like they used to. These are signs to me that something may be wrong. When any of these types of incidents become a pattern for a patient, I perform cognitive testing on them. There are several screening tools that are available, including the Mini-Cog and the Montreal Cognitive Assessment (MoCA), which are the tools that I frequently use.

For patients with mild cognitive impairment, I perform a complete workup, and I recommend a referral to neurology for potential disease-modifying therapy. From a primary care perspective, I primarily focus on maintaining a healthy lifestyle and excluding other causes of cognitive dysfunction. As patients start manifesting mild dementia with disability due to their cognitive impairment, I will also assess their interest in initiating a cholinesterase inhibitor. Behavioral interventions are important for managing cognitive decline too, as teaching patients and their families about best practices to manage daily life with cognitive dysfunction is key. If patients have evidence of more moderate dementia, I put them on memantine. Finally, I also manage all of their other health concerns and chronic illnesses as well.