Filling in the blind spot on cognitive health

The definition of aging has changed from a generation ago. People are living longer, healthier lives, so much so that these days, people turning 60 or 65 years old still feel young. Studies have shown that many adults think of themselves as younger than they really are — up to 20 percent younger.¹ Many older adults are either pushing out retirement or planning a “third chapter” in which they pursue personal passions after leaving their careers.

People feeling healthier for longer is due in part to advances in managing health issues that are commonly screened for in older adults. But despite better care for medical conditions that affect older Americans, there is not as much attention paid to the aging brain — only 16 percent of routine check-ups for adults 65 and older included a cognitive assessment, according to a 2019 Alzheimer’s Association report, compared to conditions such as blood pressure (91 percent), cholesterol (83 percent), and diabetes (66 percent).²

“There is a blind spot when it comes to brain health or getting a ‘checkup from the neck up,’ because that hasn’t been widely integrated into clinical practice and more patient education is needed on the function of their brains,” said Dr. Brandy Matthews, a neurologist and Alzheimer’s disease expert at Eli Lilly and Company. “That lack of awareness has resulted in this type of preventive health, as it relates to the brain, being essentially ignored.”

Rethinking that imbalance involves taking steps to better monitor cognitive health in the same way we would check blood pressure or cholesterol regularly. And that starts with being able to recognize what is “normal” when it comes to cognitive change as we age.

Signs of memory and thinking issues are subtle at first, making them easy to miss or dismiss as just normal aging. Things like repeatedly confusing the steps in a recipe, forgetting groceries in the car, or re-reading a chapter of a book could indicate mild cognitive impairment, or MCI.³

“There are some changes in memory and thinking that happen with normal aging, much like there are changes with vision, hearing, muscle tone, and movement. But these changes are relatively subtle and generally the affected domains would be processing speed or recalling the precise name of a person or an item,” Matthews said. “Whereas in mild cognitive impairment, the deficits are more noticeable and more frequent and expand across other areas of recall, particularly the recent memories. So, things that have happened within the past day or within the past week may become more difficult to recall.”

An estimated 12-18 percent of people over age 60, or almost 14 million Americans, have MCI, according to a 2022 Alzheimer’s Association special report.⁴ MCI is defined as changes in memory or other thinking skills serious enough to be noticeable, but not serious enough to interfere with everyday activities. Of those, the report stated that 10-15 percent go on to develop dementia each year.⁴

One such person is Rebecca Chopp, an Alzheimer’s advocate and former university president. “Looking back now, my husband and I can see that there were changes going on, but I was older. I just started [thinking], you know, ‘oh it’s age,’ or, ‘oh, I’m too busy,’ something like that,” Chopp said.

“I told my primary care physician, an amazing person who realized something has changed in this woman’s body,” Chopp said. “She did a series of tests, asked me if she could give me a cognition test. I thought, ‘I’ll pass that,’ and I didn’t. And that led to another test.”

As Chopp learned, taking early action when first noticing subtle signs of cognitive change is important in order to get to the root cause. While there’s no single cause or outcome of MCI, potential causes could include drug-drug interactions,⁵ depression, neurologic disorders, or vascular disease.³ In some cases, MCI can indicate an early stage of Alzheimer’s — as it did for Chopp.³

To make a diagnosis, practitioners will first conduct a cognitive assessment, then move into a full diagnostic workup. When it comes to Alzheimer’s disease, it’s important to rely on biomarkers indicating disease pathology, not symptoms alone. “Even with an expert evaluation, there’s often a mismatch of the clinical diagnosis with the underlying biology or the neuropathological changes that are occurring in the brain,” Matthews said. “The biomarkers can help confirm that diagnosis.”

A biomarker is a biological sign that can be used to measure the presence of a disease in the body.⁶ There are several types of biomarker tests available: Positron emission tomography (PET) scans, cerebrospinal fluid (CSF) tests, and emerging blood tests.

Many of these tests look for the buildup of amyloid plaque, one of the hallmarks of Alzheimer’s, which can indicate the presence of disease years before major symptoms arise. Biomarker testing may increase healthcare professionals’ confidence in an Alzheimer’s diagnosis in patients with cognitive impairment and help inform patient care.

“In the early stages of Alzheimer’s disease, there is accumulation of a sticky protein that’s called amyloid beta into clumps that are referred to as plaques. This happens in the brain but outside of the brain cells, and then initiates a series of events or cascade of other abnormalities,” Matthews said. “A different sticky protein, tau, accumulates in what are called tangles within the brain cells or the neurons, and there’s an associated activation of the brain’s immune system that creates inflammation.⁷ And all of this activity makes it difficult for the brain cells or neurons to talk to one another and communicate.”

In order for more people with Alzheimer’s disease to get a timely diagnosis, as Chopp did, a more proactive approach to recognizing early signs of cognitive changes will be needed. One simple step to making cognitive health screening more routine is a greater awareness of the fact that such an assessment is covered by Medicare during yearly wellness visits. But there are other operational challenges to early detection that will need to be overcome.

“One of the main barriers is a lack of healthcare professional confidence in the tools, in their ability to interpret the tools, and in the ability to integrate this type of assessment into their typical workflow because it’s time-consuming and [that time is] not necessarily well reimbursed,” Matthews said.

“The lack of screening for changes in cognition is related to the fact that there hasn’t been wide adoption of assessment of memory and thinking even for patients who have symptoms. In medicine, it tends [to be] that… there’s adoption of tests for screening by healthcare professionals after there’s been adoption of these tests and experience using the tests for patients who actually have symptoms.”

Examples of currently used cognitive assessments include the Mini Mental State Evaluation (MMSE), the Mini-Cog©, the General Practitioner Assessment of Cognition (GPCOG), the Montreal Cognitive Assessment (MoCA), and the SLU Mental Status Exam (SLUMS). These written or verbal tests can be administered by non-specialists to help evaluate cognitive impairment or dementia before referral to a specialist.

The population of those with Alzheimer’s disease is expected to grow to 12.7 million by 2050, according to the Alzheimer’s Association, and those patients will be competing for care from a limited number of specialists.⁴ For that reason, primary care physicians will be an increasingly important part of the diagnostic process. By administering regular cognitive assessments, and partnering with neurologists, geriatricians, and radiologists on further assessments as well as biomarker testing, PCPs can help get to the root cause of a patient’s cognitive changes sooner.

Supporting healthcare professionals in taking a more proactive approach to cognitive screening will require both more experience administering tests to gain confidence, but also more education that performing such assessments may actually benefit patients and improve outcomes.

“Historically, there has been a lack of urgency to do this type of assessment because of a sense that there was nothing to be done for patients. But we are in a new era where it’s clear that a timely and accurate diagnosis can yield benefits for patients,” Matthews said. “We will need to continue to invest in medical education to inform healthcare professionals and to help facilitate reimbursement for their time in engaging in this type of assessment, such that it could be integrated into workflow in a more seamless fashion.”

The advantages of timely diagnosis for patients include identifying those who may benefit from available disease-modifying therapies that target the underlying biology of Alzheimer’s disease or accessing clinical trials for current and future therapies. It also allows time for lifestyle modification (such as changes to diet and exercise) that may support cognitive well-being, as well as potentially more time and agency to plan for one’s future.⁸

“The timely diagnosis for me meant that I could keep writing the story, but I could write a different story,” Chopp said. “I would’ve, had I not been diagnosed, just continued with my career, and that was all good — I loved my job — but this gave me the chance to write a different story, to do things that I had never imagined doing or that I had always wanted to do. So, it allowed me to have whole new chapters in my life that I wouldn’t have had otherwise.”

If you’re noticing memory and thinking issues piling up, go to More Than Normal Aging to learn more about what you can do.

PP-AD-US-0580 12/2023 ©Lilly USA, LLC 2023. All rights reserved.

Sources:

¹ Rubin, D.C., Berntsen, D. People over forty feel 20% younger than their age: Subjective age across the lifespan. Psychonomic Bulletin & Review 13, 776–780 (2006). https://doi.org/10.3758/BF03193996

² Alzheimer’s Association. 2019 Alzheimer’s Disease Facts and Figures Report. Available at: https://www.alz.org/media/documents/alzheimers-facts-and-figures-2019-r.pdf. Accessed September 20, 2023.

³ National Institute on Aging. What is Mild Cognitive Impairment? Available at: https://www.nia.nih.gov/health/what-mild-cognitive-impairment. Accessed September 20, 2023.

⁴ Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures Report. Available at: https://alz-journals.onlinelibrary.wiley.com/doi/abs/10.1002/alz.12638. Accessed September 20, 2023.

⁵ Chippa, V., Roy, K. Geriatric Cognitive Decline and Polypharmacy. StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK574575/. Accessed September 20, 2023.

⁶ National Cancer Institute Dictionary. Biomarker. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/biomarker. Accessed September 20, 2023.

⁷ Bright Focus Foundation. The Progression of Alzheimer’s Disease. Available at: https://www.brightfocus.org/alzheimers-disease/infographic/progression-alzheimers-disease. Accessed September 20, 2023.

⁸ Galvin JE, Aisen P, Langbaum JB, et al. Early stages of Alzheimer’s disease: evolving the care team for optimal patient management. Front Neurol. 2021;11:592302.