Continuing Education Activity

As people age, they may experience some decline in their cognitive abilities, which is a normal part of the aging process. However, if this cognitive decline becomes more severe, it can lead to mild cognitive impairment or potentially progress to major neurocognitive disorder or dementia. Cognitive decline is a prevalent issue among individuals older than 60. Dementia encompasses diverse etiologies and types, with Alzheimer dementia being the most prevalent. Alzheimer disease can affect different cognitive functions and significantly diminish an individual's overall well-being. A geriatric assessment can be beneficial in distinguishing between normal aging and more advanced cognitive decline. This activity outlines the evaluation, treatment, and management of cognitive decline, emphasizing the crucial role of an interprofessional team in assessing, treating, and caring for patients with this condition.

Objectives:

• Differentiate between normal aging, mild cognitive impairment, and major neurocognitive disorders to accurately diagnose cognitive impairment.
• Assess the functional and psychosocial needs of older patients with cognitive impairment to develop tailored care plans.
• Communicate effectively with geriatric patients and their caregivers to educate them about cognitive decline, treatment options, and available support resources.
• Collaborate with interdisciplinary healthcare professionals to improve cognitive decline management and provide comprehensive care and support for older patients with cognitive impairment.

Introduction

As the population of older adults grows, healthcare providers may encounter more patients with multiple health conditions, emphasizing the need for specialized geriatric care. Although some cognitive changes are a natural part of aging, the extent of cognitive decline varies considerably among individuals. Healthcare professionals must comprehend age-related cognitive changes to differentiate between normal aging, mild cognitive impairment (MCI), and major neurocognitive disorder (MND).

Synaptic loss is a hallmark feature associated with normal aging. Attention, memory, executive cognitive function, language, and visuospatial abilities all exhibit measurable declines with age. Research indicates a consistent decline in the capacity to process new information and make quick decisions as people age.[1] However, familiar skills, abilities, and knowledge acquired over time remain intact during normal aging. Examples of these preserved abilities include general knowledge and vocabulary.

Patients with MCI show reduced performance in at least one area of cognitive function compared to controls matched for age and education level.[2][3] Affected individuals typically maintain most of their expected cognitive function with no disruption in their activities of daily living (ADLs). Individuals affected by an MND or dementia exhibit a decline in at least one cognitive domain and a significant decrease in functioning, often encompassing ADLs.

A comprehensive geriatric assessment (CGA) assesses the functional, medical, financial, and psychological status of at-risk patients, enabling early intervention, prevention of progression, and providing anticipatory guidance when cognitive impairment is detected.[4] Factors that indicate a CGA include age, cognitive changes, memory concerns, increased frequency of falls, multiple medication usage, frailty, and safety concerns at home.[5] Due to the time constraints of office visits, specific components of the CGA can be conducted during subsequent visits and within the patient's home.

Etiology

Although genetics can contribute to approximately 60% of our cognitive abilities, aging remains the primary cause of cognitive decline. From age 20 to 80, individuals encounter a consistent decline in their abilities to use current circumstances and information to solve problems and make decisions.[3][6] In addition, as auditory acuity diminishes after age 30, an individual's processing speed and sensory perception also exhibit ongoing decline. 

Chronic medical illnesses, hearing or vision loss, cerebral ischemia, head trauma, toxins such as alcohol, and excessive stress hormone levels can collectively interact with the aging process, leading to cumulative damage to the brain and accelerating the natural cognitive decline. A hallmark feature in patients with MCI who progress to Alzheimer disease is an increase in tau protein in the temporal lobe.[7][8]

Epidemiology

The prevalence of cognitive decline, particularly dementia, rises exponentially with advancing age. Therefore, the geriatric patient population will increase by 21% over the next 50 years. Approximately two-thirds of Americans experience some form of cognitive impairment by age 70.[9] Globally, among adults 60 and older, the prevalence of MCI ranges from approximately 7% to 25%. MCI is about 3 to 4 times more common than dementia.[3] 

The incidence of dementia increases exponentially until the age of 90, with a similar occurrence rate between the genders.[10] Alzheimer dementia is slightly more prevalent in women at advanced ages, primarily because of their longer life expectancy. In contrast, men tend to experience vascular dementia at a younger age.

Patients with lower socioeconomic status and less education are at higher risk for cognitive decline.[2][6] Medical risk factors associated with cognitive impairment include cardiovascular disease, high cholesterol, hypertension, diabetes, atrial fibrillation, stroke, and depression.[7][11] In addition, an elevated risk is linked to smoking, excessive alcohol consumption, and a sedentary lifestyle. 

Pathophysiology

With normal aging, the brain usually experiences a size reduction, which is a commonly observed phenomenon. This reduction of the brain's size affects both the gray and white matter and is primarily attributed to a decrease in the development of dendrites, dendritic spines, axons, and synapses.[12] Moreover, there is an increase in segmental demyelination among axons. Gray matter reduction is notably most pronounced in the prefrontal cortex and temporal lobes, whereas the frontal lobe and corpus callosum show the most substantial white matter loss. 

MCI is on a continuum, and patients with amnestic forms often progress to Alzheimer disease. This condition arises from years of excessive production and reduced clearance of amyloid-β peptides, which form neuritic plaques, and hyperphosphorylated tau proteins, which form neurofibrillary tangles.[13] Frontotemporal dementia is characterized by abnormal protein deposits, including tau, TDP-43, and FUS, with hyperphosphorylated tau proteins being the most prevalent. Lewy body dementia and Parkinson disease reveal alpha-synuclein accumulation. Ultimately, these protein changes alter cellular function, leading to biochemical dysfunction, which causes a decline in acetylcholine and dopamine, structural alterations, and the loss of synapses in some cases.[2][14]

History and Physical

Normal age-related cognitive decline does not usually affect daily activities except for driving. However, when functional impairments emerge, it is advisable to conduct an assessment. Common complaints that raise concerns about cognitive decline include memory loss, a decrease in daily functioning, confusion, declining language skills, and alterations in behavior.[2] 

Individuals experiencing genuine age-related cognitive decline may encounter reduced hearing, diminished visual acuity, slower learning of new information, decreased multitasking abilities, longer reaction times, slower cognitive processing speed, and reduced language fluency.[2][15] However, simple copying skills, procedural memory, and remote memory typically remain unaffected. 

Patients with MCI are often aware of their memory impairment, which can frequently lead to distress. In contrast, patients with dementia eventually lose this awareness.[16][17] Healthcare providers must conduct separate interviews with the patient's close friends and family to gather collateral information.[18] In the interview, patients or their family members might describe situations where they rapidly forget things, struggle with placing objects in their proper locations at home, and repeat stories and questions. In addition, they might mention instances where the patient becomes disoriented or lost, discovers unexplained dents in the car, or experiences difficulty finding words. Sometimes, families may speak for the patient and report signs of hyperorality, difficulty learning new routines, behavioral changes, and delusions.[17]

Evaluation

The assessment of age-related cognitive decline is hindered by the lack of specific diagnostic tests, non-pathological brain changes, and challenges in distinguishing pathological signs and symptoms from normal aging.[2]

Identifying and addressing the underlying causes of reversible cognitive decline is a crucial initial step. For example, cognitive impairment may be linked to underlying psychological conditions such as depression or anxiety, which can significantly improve with proper treatment. Additional potential factors that are reversible or treatable include hypo- and hyperthyroidism, polypharmacy, obstructive sleep apnea, delirium, vitamin B12 deficiency, electrolyte imbalances, and sensory deficits.[19] Gathering collateral information from family members, friends, or caregivers is essential alongside patient interviews.

A CGA is a multidisciplinary and multimodal approach to evaluating geriatric patients with cognitive impairment.[19] The CGA can be conducted during hospital admission, office visit, or home visit. The initial evaluation should include the following criteria:

• History of presenting illness
• Medical history from the patient, family members, friends, and caregivers
• Current and previous medications
• Family history with an emphasis on cognitive issues
• Social history, including occupation, education level, living situation, support system, substance use, and advanced care planning
• A comprehensive physical examination 
• Laboratory studies and medical imaging, as necessary
• Review of imaging and laboratory results
• Identification of all professionals involved in patient care

Functional Status

Frailty is characterized by diminished physiological reserve, making individuals more susceptible to external stressors.[20] Frailty encompasses various aspects, including the patient's physical, social, and cognitive abilities. Frailty comprises 2 central components—the frailty index and the frailty phenotype.

The 5 areas of assessment for frailty phenotype include:

• Weakness or grip strength less than 20% at baseline
• Unintentional weight loss exceeding 10 lbs in the previous year
• Self-reported poor endurance and energy levels
• Self-reported slow gait speed
• Self-reported low levels of physical activity [21] 

Frailty is the combination of 3 or more characteristics, whereas individuals with 1 or 2 features are considered prefrail. The frailty index is a continuous scale that considers the impact of functional, psychosocial, medical, and age-related deficits, and it has been shown to predict mortality more effectively than the frailty phenotype.[20] Evidence exists indicating a correlation between physical frailty and cognitive impairment.[22]

Frailty can be predictive of cognitive decline, and conversely, cognitive impairment can be predictive of frailty.[17] Patients with poor balance, altered gait, frequent falls, and impaired "get-up-and-go" performance are at an increased risk of developing cognitive impairment.[22] 

ADLs encompass dressing, ambulation and transfers, bathing, toileting, feeding, grooming, and controlling bladder function. Instrumental ADLs (IADLs) include tasks that individuals perform to maintain independent living, such as managing finances, taking medication, driving, cooking, shopping, housework, and answering the phone. Assessing both ADLs and IADLs provides a measure of functional ability.[19] 

Patients experiencing cognitive decline typically exhibit a decline in proficiency in IADLs before ADLs. Screening for functional loss offers valuable insights into the risks and vulnerabilities of these patients. Patients who lose the ability to manage medication, finances, or drive are at risk for adverse outcomes, abuse, and eventual loss of their independence. A performance-based road test is a valuable tool for assessing driving skills. Early intervention based on the results of this test can help mitigate adverse future outcomes. The standard screening tools for assessing functional abilities include the Katz index for ADLs and the Lawton IADL scale.

Gait Speed and Falls

In general, it is common for older individuals to minimize or fail to report instances of falls.[23] The assessment begins by inquiring whether the patient has experienced a fall within the past year. Falls are associated with poorer functional outcomes and elevated mortality rates and frequently cause hospitalization.[19] Gait should be observed when the patient walks into the examination room by direct observation. The get-up-and-go test can evaluate a patient's mobility, postural stability, and gait. If the patient takes more than 12 seconds to complete the test, it indicates an elevated risk of falls and functional decline. Multiple members of the interprofessional team can administer this test. Direct observation is beneficial for identifying patients who require assistive devices for ambulation and physical therapy to improve their strength.

Cognition

Numerous screening tests are available for assessing cognition, with varying levels of detail and sensitivity. The most frequently used screening tests include the Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), and the Mini-Cognitive Assessment (Mini-Cog).[19][24]

Additional tests include the clock drawing test (CDT) and the Saint Louis University Mental Status Examination (SLUMS). A meta-analysis indicates that the sensitivity of screening tools, such as MMSE and MoCA, ranges from 75% to 92%, whereas the specificity falls between 81% and 91%.[25]

Depending on the specific screening test utilized, the assessed domains include language, executive function, abstract reasoning, attention and concentration, memory, and visuospatial skills.

Dementia or MCI cannot be diagnosed with a single test alone. A comprehensive assessment, including screening for depression, should be conducted following a positive screening result. As the scores of these tests can vary over time, it is advisable to repeat the test at regular intervals or following significant medical changes or events for a more accurate assessment.  

Mood Disorders

Depression is not a normal part of aging. People with depression may experience decreased cognitive function, loss of appetite and sleep, and a decreased overall quality of life. Individuals with depression may also exhibit numerous vague complaints, heightened anxiety, preoccupation with financial matters, bodily functions, and difficulty making decisions. Numerous studies have demonstrated that depression can have a negative impact on cognitive function and memory. Notably, depression is found in nearly 40% of older individuals residing in nursing homes. In contrast, its prevalence is generally between 4% and 9% among older adults living in the community.[26][27] Commonly utilized screening tools for depression include the geriatric depression scale (GDS) and the Patient Health Questionnaire-9 (PHQ-9). The United States Preventive Services Task Force (USPSTF) recommends that all individuals 18 and older undergo depression screening, provided that a system is in place to support the diagnosis, treatment, and follow-up based on the screening results.

Polypharmacy

Medications can potentially lead to functional and cognitive impairment in the geriatric population. The American Geriatrics Society (AGS) Beers Criteria provides a comprehensive list of medications that should be avoided in older patients unless the benefits outweigh the risks.[28] The Beers criteria are available on the AGS website.

Healthcare professionals should dedicate time to reviewing their patients' medication lists, particularly when multiple specialties are involved. An effective strategy is encouraging patients to bring their medications in their original bottles to each appointment. Healthcare providers should consider reevaluating the use of anticholinergic drugs, opiates, benzodiazepines, muscle relaxants, sleep medications, and tricyclic antidepressants to prevent polypharmacy and minimize the risk of adverse outcomes. Antihypertensive medications can also potentially induce hypotension, increasing the risk of falls. 

Additional tools for assessing the appropriateness of prescriptions include the Screening Tool to Alert Doctors to the Right Treatment (START) and the Screening Tool of Older Persons' Prescriptions (STOPP). When evaluating the appropriateness of a medication, factors to consider include the time required to achieve medical benefits, the patient's capacity to manage and adhere to the medication regimen, and the overarching treatment objectives.[5] Notably, regularly revisiting the process of selectively discontinuing medications for older patients is crucial. 

Diet and Nutrition 

A nutritional assessment involves assessing a patient's capacity to prepare, swallow, and digest food, as well as their overall appetite level. Objective measurements used to determine nutrition include body mass index (BMI), height, and weight. As older individuals have reduced physiological reserves, they are at an increased risk of malnutrition, particularly during acute illnesses or hospitalization. A study demonstrated that a BMI below 23 kg/m² is correlated with a higher mortality rate.[29]

When a patient reports significant weight loss, healthcare professionals should consider cognitive, social, dental, medical, and financial factors. 

Social and Financial Support

Social health is a vital aspect of an individual for their overall well-being. A comprehensive social history assessment evaluates the patient's living conditions, eligibility for care resources, support network, community engagement, caregiver requirements, physical activity routines, and financial situation.[4][30]

Making a well-informed decision about the most suitable living arrangement for the geriatric population after assessing home safety, injury risk, financial stability, and caregiver support is essential. Shared decision-making should also be involved.[4] Healthcare professionals should screen for caregiver burnout and, if necessary, offer alternatives for living arrangements and provide referrals to support groups. 

Sexual health constitutes a significant component of a CGA. An open discussion about sexually transmitted infections, sexual dysfunction, and impotence creates a safe environment for considering potential treatment options.[4]

Approximately 10% of the geriatric population experiences abuse, with women being more likely to be victims than men. Typically, the most common abusers in elder abuse cases are spouses or adult children. Risk factors for elder abuse include poor socioeconomic status, social isolation, and compromised physical health.[31]

Abuse can take various forms, including neglect, financial exploitation, or physical, verbal, and sexual abuse. Indications of abuse may include the presence of abrasions, lacerations, fractures, decubitus ulcers, subtle signs of caregiver intimidation, frequent urinary tract infections while in a living facility, an inability to afford medications or renew prescriptions, deterioration of chronic medical conditions,  signs of malnutrition and dehydration, and inadequate hygiene.[31]

Healthcare professionals are obligated to report suspected cases of elder abuse. Therefore, seeking support from law enforcement and social work or adult protective services is essential when abuse is suspected.

Hearing

While assessing older patients, it is crucial to consider age-related hearing loss, also referred to as presbycusis. This condition can lead to suboptimal performance on cognitive assessments, increased risk of social isolation, misunderstandings in communication, heightened anxiety or depression, and cognitive fatigue during the assessment process.[32] Furthermore, it is essential to investigate alternative causes of hearing loss, including factors such as cerumen impaction, head trauma, ototoxic medications, and any pathological conditions involving inflammation of the auditory system, cranial nerves, or meninges.[32]

Hearing impairment can be assessed using techniques such as finger rub, whispered voice, or audiometric tests.[33] As hearing loss is associated with cognitive decline, therefore, treating hearing loss may contribute to preventing and slowing cognitive decline.[34] The USPSTF and the American Academy of Family Physicians (AAFP) do not recommend hearing screening for adults older than 50 due to limited data on the potential benefits and harm caused by such screening.[33] 

Vision 

Visual acuity in low-light settings decreases with age. This can manifest as reduced spatial contrast sensitivity, diminished color discrimination, and difficulty adapting to darkness.[35][36] Diminished vision can significantly affect the quality of life and ADLs in the geriatric population, potentially leading to decreased ability to live independently. Common conditions contributing to age-related visual impairment include macular degeneration, cataracts, diabetic retinopathy, and glaucoma.[35]

Although the USPSTF and AAFP do not recommend routine vision screening for asymptomatic older adults, assessing vision in the office using a Snellen chart is possible. Critical elements of a comprehensive visual assessment of patients include evaluating the visual field, acuity, color and contrast discrimination, the utilization of visual and non-visual cues, and the subjective assessment of lighting conditions.[35] Visual deficits can lead to adverse consequences such as an elevated risk of falls, decreased accessibility, postural instability, and an increased likelihood of automobile collisions.[36]

Urinary Incontinence

The prevalence of urinary incontinence rises with age, which can lead to consequences such as urinary tract infections, decubitus ulcers, sepsis, and an elevated mortality risk.[19] Feelings of embarrassment and emotional stress can result in self-imposed limitations on sexual and social activities in patients, which may contribute to depression.[19] Screening questions should inquire whether the patient has experienced loss of bladder control within the past year and if this has occurred on more than 6 distinct days. Furthermore, a comprehensive assessment should encompass the patient's prior urological surgeries, fluid intake patterns, and mobility assessment.[19]

Advanced Care Planning

Advanced care planning involves determining the patient's treatment goals and specifying the level of medical care they desire if they cannot make decisions due to a severe illness. The essential stages in this process include evaluating the patient's willingness, designating surrogate decision-makers, articulating and recording the patient's views on medical care and quality of life, and translating these values and preferences into a clinical management and treatment plan.[37]

Laboratory Testing

Suggested lab tests for this condition include vitamin B12, complete blood count, and serum thyroid-stimulating hormone. In addition, depending on clinical suspicion, further laboratory tests may be ordered. 

Neuroimaging

Patients with acute or rapidly progressive cognitive changes or concerns about a structural lesion should undergo a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain. Although some guidelines suggest an MRI for all dementia patients, others recommend it for younger patients with focal findings and symptoms lasting less than 2 years.

Treatment / Management

Identifying and managing risk factors linked to cognitive impairment and dementia are crucial components of developing a treatment plan for the patient.[12] No pharmacological agent is capable of reversing cognitive impairment associated with normal aging. Besides ensuring adequate baseline nutrition, minimal evidence supports nutritional interventions in patients with cognitive deficits.[38] Without a clear deficiency, antioxidants, vitamins, and herbal supplements offer no discernible benefit.[12] Treating vitamin B12 deficiency and hypothyroidism can improve cognitive function.

Lifestyle modifications have a positive impact on the risk of cognitive decline. Engaging in regular physical activity, participating in cognitively stimulating activities, maintaining an active social life, quitting smoking, and adopting healthy dietary habits all contribute to a reduced risk of cognitive decline.[11] The precise mechanism of linking physical activity to reducing MCI risk remains poorly understood. The management of fragility entails regular exercise, nutritional support, and the avoidance of polypharmacy.[20]

Quitting smoking leads to a reduction in oxidative stress and neuroinflammation. Similarly, when alcohol consumption is discontinued, there is a decreased risk of nutritional deficiency and the potential for alcohol-related neuronal damage. Addressing hearing loss can involve avoiding ototoxic medications, in-office cleaning of the external auditory canal, using assistive hearing devices, and engaging in audiological rehabilitation.[33] For visual disturbances, the use of corrective lenses can enhance functional performance. 

Treating depression can significantly improve the quality of life and functioning among the geriatric population. Treatment options for depression are multimodal and encompass various approaches, including medications and psychosocial, cognitive behavioral, and electroconvulsive therapies.[39] Depression can be resistant to treatment in certain older patients. Therefore, it is essential to exercise extra caution when determining dosages and monitoring the adverse effects of antidepressant medications.

Differential Diagnosis

Aging changes processing speed, sensory perception, concept formation, abstraction, and mental flexibility. A comprehensive CGA enables healthcare professionals to distinguish between normal cognitive decline associated with aging and common conditions that can mimic or contribute to cognitive decline. The common conditions that may add to cognitive decline include:

• Infections of the urinary tract, pneumonia, sepsis, and abscesses
• Vitamin B12 and folic acid deficiencies
• Hypo- or hyperthyroidism
• Hypo- or hyperglycemia
• Hypoxemia
• Hypo- or hypernatremia
• Delirium
• Depression 
• Pathological grief reaction
• Medications such as benzodiazepines, anticholinergics, and antihypertensives
• MCI 
• Alzheimer disease 
• Pick disease
• Lewy body disease 
• Vascular and multi-infarct dementia 
• Frontotemporal dementia 
• Parkinson dementia
• Alcohol-related dementia 
• Creutzfeldt-Jakob disease  

Prognosis

A total of 67% of the geriatric population will experience some form of cognitive decline by age 70. Worldwide, each year, 15% of this population will develop MCI. The average annual transition rate from MCI to any form of dementia is 12% in the general population and increases to 20% in patients at higher risk. Patients with MCI, particularly those with late-life onset of persistent neuropsychiatric symptoms, are more likely to progress to dementia.[40] According to some estimates, 12% of patients with MCI return to normal cognitive function within 3 years of their initial presentation.[3][12][40] 

The APOE ε4 allele is the most consistently identified genetic risk factor for the progression of MCI to Alzheimer-type dementia (MCI-AD). Individuals with amyloid pathology have a 40.8% probability of transitioning from asymptomatic to MCI due to MCI-AD, with a 5.3% annual probability of reverting to the asymptomatic stage.[41] The annual transition probability from MCI-AD to mild AD is 21.8%, from mild-to-moderate AD is 35.9%, and from moderate-to-severe AD is 28.6%. The rates of reverting to a less severe category are 3%, 1.8%, and 1.5%, respectively.[41]

The risk of Alzheimer disease is increased by various factors, including the presence of deep white matter lesions combined with Hachinski ischemic scores greater than 4, the APOE ε4 allele, the clusterin (CLU) risk variant genotype, and having more than 6 genetic markers associated with Alzheimer-type dementia. Other contributing factors include the amnestic subtype of MCI, psychiatric symptoms such as anxiety, depression, or apathy, and diabetes or prediabetes. Clusterin plays a role in regulating apoptosis. Risk factors that increase the likelihood of mixed or vascular dementias include prediabetes, diabetes, carotid stenosis, depression, hypotension, and atrial fibrillation.[42] Vascular disease is the most common comorbidity associated with a more rapid progression of cognitive impairment.

Some favorable factors encouraging the possible return to normal cognition include those using medications to control for vascular risk factors, successful treatment of depression, lack of APOE ε4 allele, higher scores on cognitive testing, and greater hippocampal volume observed on imaging.[12]

Complications

Individuals may experience a decline in decision-making, problem-solving, planning, response sequencing, and multitasking abilities as they age. This cognitive change is anticipated and should not significantly impact most ADLs. However, patients having driving difficulties should undergo a road test to evaluate their abilities.

Patients who develop MCI can usually independently manage their ADLs, but there is a risk of progression to dementia as a potential complication. Complications of cognitive decline and dementia include:

• Inability to perform ADLs
• Increased risk for infection
• Behavioral disturbances
• Hallucinations and psychosis
• Frequent falls
• Increased mortality
• Personality changes and agitation
• Poor nutrition
• Depression
• Unrecognized pain
• Caregiver fatigue and burnout
• Abuse
• Fractures due to falls
• Death
• Incontinence
• Dysphagia
• Disinhibition [43][44][43]

Deterrence and Patient Education

With the rising number of geriatric patients, healthcare professionals must prioritize assessing the functional status of their patients. Aging is accompanied by certain normal cognitive changes that typically do not impair a patient's ability to perform self-care tasks. A CGA involves a multidisciplinary team evaluating the patient's functional, physical, financial, and emotional well-being. The primary aim of a CGA is to optimize the patient's health throughout the aging process. Key areas to address include minimizing polypharmacy, assessing falls, evaluating frailty, monitoring mood, and evaluating ADLs in patients. A CGA may involve primary care and specialty clinicians, nurses, pharmacists, occupational and physical therapists, psychologists, dentists, audiologists, podiatrists, dieticians, and opticians. A CGA will likely require more than one office visit or home visit.

Early detection of cognitive impairment enables the identification of underlying causes and the implementation of interventions that may prevent or slow the progression of dementia. A holistic overview of the patient's care and treatment goals prevents unnecessary medical interventions, invasive procedures, restricted diets, and screening procedures that involve frequent blood draws.[44] Regular counseling sessions, access to community resources, and participation in social support groups can help patients and their caregivers connect with others facing similar issues, thereby reducing fear, isolation, and burnout.

Enhancing Healthcare Team Outcomes

Providing geriatric care and caring for patients with cognitive impairment necessitate a collaborative effort among healthcare professionals. Although different specialties in the interprofessional healthcare department address specific issues, the most significant benefit is derived when they integrate multiple assessments into a cohesive plan. Multidisciplinary healthcare professionals, including clinicians, nurses, healthcare agencies, pharmacists, social workers, dieticians, and psychologists, must collaborate and maintain clear communication to deliver optimal patient care for the geriatric population.

Safety planning, assessing the patient's living conditions, and evaluating their functional and nutritional status are all equally crucial in monitoring their medical conditions. A CGA can help reduce morbidity, mortality, infection, fall rates, and the progression to more severe symptoms. Utilizing a standardized centralized electronic record system across specialties to schedule appointments and manage medications is crucial for preventing adverse outcomes and promoting adherence.

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References

1.

Murman DL. The Impact of Age on Cognition. Semin Hear. 2015 Aug;36(3):111-21. [PMC free article: PMC4906299] [PubMed: 27516712]

2.

Jongsiriyanyong S, Limpawattana P. Mild Cognitive Impairment in Clinical Practice: A Review Article. Am J Alzheimers Dis Other Demen. 2018 Dec;33(8):500-507. [PubMed: 30068225]

3.

Eshkoor SA, Hamid TA, Mun CY, Ng CK. Mild cognitive impairment and its management in older people. Clin Interv Aging. 2015;10:687-93. [PMC free article: PMC4401355] [PubMed: 25914527]

4.

Tran HT, Leonard SD. Geriatric Assessment for Primary Care Providers. Prim Care. 2017 Sep;44(3):399-411. [PubMed: 28797368]

5.

Tatum Iii PE, Talebreza S, Ross JS. Geriatric Assessment: An Office-Based Approach. Am Fam Physician. 2018 Jun 15;97(12):776-784. [PubMed: 30216018]

6.

Hugo J, Ganguli M. Dementia and cognitive impairment: epidemiology, diagnosis, and treatment. Clin Geriatr Med. 2014 Aug;30(3):421-42. [PMC free article: PMC4104432] [PubMed: 25037289]

7.

Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014 Dec 17;312(23):2551-61. [PMC free article: PMC4269302] [PubMed: 25514304]

8.

Doecke JD, Pérez-Grijalba V, Fandos N, Fowler C, Villemagne VL, Masters CL, Pesini P, Sarasa M., AIBL Research Group. Total Aβ₄₂/Aβ₄₀ ratio in plasma predicts amyloid-PET status, independent of clinical AD diagnosis. Neurology. 2020 Apr 14;94(15):e1580-e1591. [PMC free article: PMC7251518] [PubMed: 32179698]

9.

Hale JM, Schneider DC, Mehta NK, Myrskylä M. Cognitive impairment in the U.S.: Lifetime risk, age at onset, and years impaired. SSM Popul Health. 2020 Aug;11:100577. [PMC free article: PMC7153285] [PubMed: 32300635]

10.

Jorm AF, Jolley D. The incidence of dementia: a meta-analysis. Neurology. 1998 Sep;51(3):728-33. [PubMed: 9748017]

11.

Kivipelto M, Mangialasche F, Ngandu T. Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease. Nat Rev Neurol. 2018 Nov;14(11):653-666. [PubMed: 30291317]

12.

Sanford AM. Mild Cognitive Impairment. Clin Geriatr Med. 2017 Aug;33(3):325-337. [PubMed: 28689566]

13.

Honig LS. Translational research in neurology: dementia. Arch Neurol. 2012 Aug;69(8):969-77. [PMC free article: PMC3644591] [PubMed: 22473767]

14.

Mesulam M, Shaw P, Mash D, Weintraub S. Cholinergic nucleus basalis tauopathy emerges early in the aging-MCI-AD continuum. Ann Neurol. 2004 Jun;55(6):815-28. [PubMed: 15174015]

15.

da Costa JP, Vitorino R, Silva GM, Vogel C, Duarte AC, Rocha-Santos T. A synopsis on aging-Theories, mechanisms and future prospects. Ageing Res Rev. 2016 Aug;29:90-112. [PMC free article: PMC5991498] [PubMed: 27353257]

16.

Petersen RC, Doody R, Kurz A, Mohs RC, Morris JC, Rabins PV, Ritchie K, Rossor M, Thal L, Winblad B. Current concepts in mild cognitive impairment. Arch Neurol. 2001 Dec;58(12):1985-92. [PubMed: 11735772]

17.

Tangalos EG, Petersen RC. Mild Cognitive Impairment in Geriatrics. Clin Geriatr Med. 2018 Nov;34(4):563-589. [PubMed: 30336988]

18.

Tabert MH, Albert SM, Borukhova-Milov L, Camacho Y, Pelton G, Liu X, Stern Y, Devanand DP. Functional deficits in patients with mild cognitive impairment: prediction of AD. Neurology. 2002 Mar 12;58(5):758-64. [PubMed: 11889240]

19.

Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011 Jan 01;83(1):48-56. [PubMed: 21888128]

20.

Lee H, Lee E, Jang IY. Frailty and Comprehensive Geriatric Assessment. J Korean Med Sci. 2020 Jan 20;35(3):e16. [PMC free article: PMC6970074] [PubMed: 31950775]

21.

Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA., Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56. [PubMed: 11253156]

22.

Arai H, Satake S, Kozaki K. Cognitive Frailty in Geriatrics. Clin Geriatr Med. 2018 Nov;34(4):667-675. [PubMed: 30336994]

23.

Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Sep 23;65(37):993-998. [PubMed: 27656914]

24.

US Preventive Services Task Force. Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Cognitive Impairment in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Feb 25;323(8):757-763. [PubMed: 32096858]

25.

Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015 Sep;175(9):1450-8. [PubMed: 26052687]

26.

Hu SH, Chuang YH, Ting YF, Lin KY, Hsieh CJ. Prevalence of depressive symptoms in older nursing home residents with intact cognitive function in Taiwan. Res Nurs Health. 2018 Jun;41(3):292-300. [PubMed: 29574780]

27.

Luppa M, Sikorski C, Luck T, Ehreke L, Konnopka A, Wiese B, Weyerer S, König HH, Riedel-Heller SG. Age- and gender-specific prevalence of depression in latest-life--systematic review and meta-analysis. J Affect Disord. 2012 Feb;136(3):212-21. [PubMed: 21194754]

28.

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. [PubMed: 30693946]

29.

Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr. 2014 Apr;99(4):875-90. [PubMed: 24452240]

30.

Wieland D, Hirth V. Comprehensive geriatric assessment. Cancer Control. 2003 Nov-Dec;10(6):454-62. [PubMed: 14652521]

31.

Lachs MS, Pillemer KA. Elder Abuse. N Engl J Med. 2015 Nov 12;373(20):1947-56. [PubMed: 26559573]

32.

Völter C, Götze L, Dazert S, Wirth R, Thomas JP. Impact of Hearing Loss on Geriatric Assessment. Clin Interv Aging. 2020;15:2453-2467. [PMC free article: PMC7779803] [PubMed: 33408469]

33.

Michels TC, Duffy MT, Rogers DJ. Hearing Loss in Adults: Differential Diagnosis and Treatment. Am Fam Physician. 2019 Jul 15;100(2):98-108. [PubMed: 31305044]

34.

Golub JS, Brickman AM, Ciarleglio AJ, Schupf N, Luchsinger JA. Association of Subclinical Hearing Loss With Cognitive Performance. JAMA Otolaryngol Head Neck Surg. 2020 Jan 01;146(1):57-67. [PMC free article: PMC6865840] [PubMed: 31725853]

35.

Watson GR. Low vision in the geriatric population: rehabilitation and management. J Am Geriatr Soc. 2001 Mar;49(3):317-30. [PubMed: 11300245]

36.

Owsley C. Vision and Aging. Annu Rev Vis Sci. 2016 Oct 14;2:255-271. [PubMed: 28532355]

37.

Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015 Mar;99(2):391-403. [PubMed: 25700590]

38.

Coley N, Vaurs C, Andrieu S. Nutrition and Cognition in Aging Adults. Clin Geriatr Med. 2015 Aug;31(3):453-64. [PubMed: 26195103]

39.

Casey DA. Depression in Older Adults: A Treatable Medical Condition. Prim Care. 2017 Sep;44(3):499-510. [PubMed: 28797375]

40.

McGirr A, Nathan S, Ghahremani M, Gill S, Smith EE, Ismail Z. Progression to Dementia or Reversion to Normal Cognition in Mild Cognitive Impairment as a Function of Late-Onset Neuropsychiatric Symptoms. Neurology. 2022 May 24;98(21):e2132-e2139. [PMC free article: PMC9169943] [PubMed: 35351783]

41.

Potashman M, Buessing M, Levitchi Benea M, Cummings J, Borson S, Pemberton-Ross P, Epstein AJ. Estimating Progression Rates Across the Spectrum of Alzheimer's Disease for Amyloid-Positive Individuals Using National Alzheimer's Coordinating Center Data. Neurol Ther. 2021 Dec;10(2):941-953. [PMC free article: PMC8571434] [PubMed: 34431074]

42.

Campbell NL, Unverzagt F, LaMantia MA, Khan BA, Boustani MA. Risk factors for the progression of mild cognitive impairment to dementia. Clin Geriatr Med. 2013 Nov;29(4):873-93. [PMC free article: PMC5915285] [PubMed: 24094301]

43.

Vogelgsang J, Wolff-Menzler C, Kis B, Abdel-Hamid M, Wiltfang J, Hessmann P. Cardiovascular and metabolic comorbidities in patients with Alzheimer's disease and vascular dementia compared to a psychiatric control cohort. Psychogeriatrics. 2018 Sep;18(5):393-401. [PubMed: 29993172]

44.

Volicer L, McKee A, Hewitt S. Dementia. Neurol Clin. 2001 Nov;19(4):867-85. [PubMed: 11854104]

Disclosure: Samender Randhawa declares no relevant financial relationships with ineligible companies.

Disclosure: Dona Varghese declares no relevant financial relationships with ineligible companies.