After about age 50, everyone has trouble occasionally finding words and experiences lapses in memory. The decision we all struggle with is whether those lapses indicate the need for a doctor’s assessment of our cognitive abilities. As a physician and researcher in the field of aging and cognition for more than 20 years, I’ve discovered a handful of clues that can help older adults and their friends or family make that decision.
Paying bills, taking the many pills doctors prescribe, using the remote control, traveling outside the home — managing life’s daily tasks presents numerous real-world tests of our cognition. Mistakes, errors or subtle declines in performing the well-rehearsed activities of our daily living can be signs of cognitive changes that need medical attention.
The fact is, these activities tap into elegant webs of cognitive abilities. Take, for example, paying a bill. It involves many steps: opening the envelope, taking out the checkbook or logging on to the computer or app, filing the document, sending off the payment. Each of these tasks tests our ability to attend to and recall facts (such as where we left the checkbook or what password we used for the app), to understand and manipulate information, and to follow steps in a particular sequence.
Of course, problems performing daily activities may be caused not by cognitive but physical changes. Losses in high-frequency hearing, cloudy vision from cataracts, and fatigue from frail muscles commonly cause slow but relentless declines in performing day-to-day tasks. What's more, cognitive and physical problems often affect us at the same time.
Another common warning sign is repeating questions or stories — asking a question, hearing the answer and asking the same question 15 minutes later. Or telling the story of a recent event, like the grandchildren’s visit last weekend, and then repeating it. We all have our favorite anecdotes, but repeating new stories can be concerning.
Another cause for concern is forgetting the day of the week (asking on a Friday, “Is today Monday or Tuesday?”). Once upon a time, forgetting the date (“Is it the 5th or the 6th?”) was a sensitive sign, but the habit is fading as smartphones and computers replace the need to keep track of dates (a nice example of how technology can assist us despite changes in our cognition).
These signs in yourself or a loved one mean you should make an appointment with a medical professional, specifically one who is skilled at “working up adults with memory problems” (go ahead and ask when making the appointment). The doctor’s job is to decide whether changes in managing money, medications, technology or transportation (such as forgetting a favorite bus route), repetition of questions or stories, or troubles with time are signs of dementia, mild cognitive impairment or cognitive aging.
The Causes Explained
Dementia describes disabling problems in multiple cognitive abilities. The essential word here is “disabling.” The person needs assistance because of measurable declines in abilities such as memory, attention and language. Dementia is concerning because it is usually caused by diseases, the most common one — but not the only one — being Alzheimer’s.
Mild cognitive impairment, more commonly known as “MCI,” describes a more, well, milder set of measureable cognitive changes. The person takes longer to complete tasks and makes a few errors, but overall, she’s managing. Some patient’s MCI is caused by a disease like Alzheimer’s disease. Some are not. Sorting that out is a medical matter.
Where MCI ends and dementia begins is a fuzzy border. The judgment of a skilled clinician is key to making the call, and, frankly, experts can disagree.
Cognitive aging describes the cognitive changes experienced after adult development ends, typically after 50 years of age, in people who are free of either MCI or dementia. Cognitive aging is highly variable. Some people experience it; others don’t. It typically includes declines in our ability to find words and remember and to think through new information, especially under pressures of time or emotion.
Most people with MCI and cognitive aging manage to carry on in life, but they’re at risk of making grave errors in financial matters, leaving them fleeced of wealth. I once had a patient who lost $900,000 of his million-dollar savings to a lottery scam. His problem was subtle declines in judgment and decision-making skills caused by cognitive aging. Sometimes aging is not “just aging.”
Enlisting a Trusted Network
This patient and, sadly, too many others like him lead me to a key observation and a bit of advice. Monitoring ourselves and our minds is difficult. One of my patients with dementia caused by Alzheimer’s disease answered my question, “Are you having any problems with your memory?” with this wise and ironic observation: “If I was having problems with my memory, how would I remember that?”
He’s right. Each of us needs a trusted network to watch over us, and someone from that network should accompany us to the doctor to lend his or her observations. Families are smaller and more dispersed, so technology becomes ever more useful. Every week I check on my father’s bank accounts online and receive email alerts for every transaction.
Money, medications, technology and transportation.
Did you remember the four words? If not, that, too, may be a reason to have your memory assessed.
Jason Karlawish, M.D., is a professor at the University of Pennsylvania's Perelman School of Medicine and codirector of the Penn Memory Center. He is also a member of the Global Council on Brain Health, an international collaborative of scientists, health professionals, scholars and policy experts convened by AARP to help older adults maintain and improve their brain health.