What Is Cognitive Testing — and Should You Ask for It?

Cognitive tests aren’t necessarily a routine part of a doctor’s visit. But they can offer valuable information to help you stay sharp as you age.

Time for your yearly visit. Your doctor will check your blood pressure and weight, measure your sugar levels, and test your balance. You may even get a pep talk about improving your diet and getting more exercise. System by system, your provider will go over everything to help you stay healthy and strong.

But what about your brain? That’s a pretty important system, too. Yet fewer than half of all primary care providers report they evaluate thinking and memory skills in patients over 65.

How come?

Seems like a classic case of miscommunication: Patients are waiting for their doctors to bring it up, while doctors are waiting until they hear concerns from the patient or their family members. Meantime, as many as 18 percent of Americans over age 65 may have mild cognitive impairment (MCI). That’s an early stage of memory loss and decline in thinking skills. And most of them have never been diagnosed.

But the clock is ticking. Without a diagnosis, you could be missing out on treatments that can help. So don’t wait for your doctor to mention it — even if you’re afraid to talk about it.

“It’s so important to bring it up early because there are approaches like lifestyle and exercise that can help,” says Dr. Hillary Lum, M.D., a family physician and member of the American Academy of Family Physicians. She specializes in treating older adults at the University of Colorado Medical Center in Aurora. “Even if you’re feeling anxious about mentioning it — and worried that something may be wrong — speak up.”

Cognitive assessment is simple and quick. What’s more, it can happen right in your provider’s office. Here’s what to expect.

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Start with a Basic Cognitive Screening

When it comes to your body, everything is connected. Often, problems with your heart or lungs may be related to how your brain is working. For example, high blood pressure can cause a series of micro-strokes in your brain. A blood clotting disorder might lead to thinking problems, too, explains Dr. Gary Kennedy, M.D., a geriatric psychiatrist at Mt. Sinai Medical Center in New York. Those kinds of issues may be keeping enough blood from getting to your brain. Some commonly prescribed medications can also lead to cognitive impairment.

If your memory isn’t as sharp as it used to be — or if you keep forgetting names or dates — it could be linked to a reversible health issue, says Dr. Kennedy. “It could be your thyroid not functioning right, or anemia isn’t oxygenating your brain. Even vitamin deficiencies like low Vitamin D can keep you from thinking clearly.”

That’s why your yearly exam is so important. “As I’m seeing new patients, I’m aware of the potential for cognitive impairment,” says Dr. Lum. “If I see any early signs of impairment, I try to do a cognitive assessment as routinely as possible, like the Mini-Cog or the MoCA.”

According to the American Academy of Family Physicians, these are some of the most common testing instruments. Your primary care provider will probably use one of them:

Mini-Cog: Your provider will give you three words and ask you to repeat them back a few minutes later. Then, they’ll have you draw a circle clock, with the hands pointing to a specific time.

Montreal Cognitive Assessment (MoCA). This test takes about 15 minutes. You’ll be asked to memorize a short list of words, name objects you’re shown in pictures, and copy shapes on a piece of paper.

Mini-Mental State Exam (MMSE). In this 10-minute screening, you’ll be asked to count backwards, identify some objects you see in the room, say the date, and name some well-known facts, like the name of the president.

Other in-office assessments might include:

• The St Louis University Mental Status Examination (SLUMS)
• General Practitioner Assessment of Cognition Screening Test (CPCoG)
• Memory Impairment Screen
• Functional Activities Questionnaire

If you pass your test with flying colors, good for you! You’re like nearly 70 percent of older adults. [6] But if your score is low, don’t panic or assume the worst. Here’s what to expect.

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Next Steps After Cognitive Testing

Now that your primary care doctor has some basic information (and some testing in the works), they’ll probably ask you to come back in for a longer evaluation.

“It’s really important to have an in-depth conversation,” says Dr. Lum. “I like to set up a time for the next visit. We dedicate that to talking through what the patient has been noticing and how long it’s been happening.”

She talks to her patients about how they’re managing household chores, looking after their finances, and any unusual symptoms they’ve noticed.

Like Dr. Lum, your primary care doctor will probably go over the results of lab work and answer your questions.

Once all the information has been sorted out, it’s time to figure out exactly what the problem may be. “Primary care doctors can diagnose dementia,” Dr. Lum points out, “but they may not feel comfortable doing so.” Depending on your situation, your provider may refer you to a specialist, who will do more screenings.

You might see a geriatric psychiatrist like Dr. Kennedy. Or, you might have an appointment with a neurologist like Dr. Andrew Dorsch, M.D. He’s the chief of neurological sciences at Rush University Medical Center in Chicago.

“We spend some time putting patients at ease,” says Dr. Dorsch. “We give them a chance to say what’s been going on, and we’ll give family members a chance to tell us what they’ve noticed that doesn’t seem quite right.”

Then it’s time for an in-depth examination that goes something like this:

Lots of questions. “We’re looking for what we need to focus on,” says Dr. Dorsch. “Your answers will help us see what’s going on with your nervous system. We have to ask the right questions to figure out what’s contributing to your cognitive dysfunction.”

You might be asked questions like these:

• How is your memory?
• Do you struggle to find words?
• Are your math skills pretty good?
• Do you get turned around with directions?

Blood work and imaging studies. Your family doctor may have already done some basic lab work, but the specialist may dig a little deeper. “By the time you come to us,” says Dr. Dorsch, “we’ll be looking at the screenings that haven’t been done.

Some tests you might expect are magnetic resonance imaging (MRI) or electrocardiogram (EKG). “These are important to rule out subtle seizures that could keep you from full cognitive health,” explains Dr. Dorsch. You may even have genetic testing, which can show if you have the biomarkers for Alzheimer’s or another dementia.

A diagnosis. When all the testing’s been done, it’s time for your doctor — your primary care provider or a specialist — to diagnose your issue.  “If there’s a pattern of cognitive deficits,” says Dr. Dorsch, “we try to give it a name. Is it Alzheimer’s, for example, or a different kind of dementia?”

A treatment plan. There’s no cure for dementia, but there are ways to slow down its progress, and even to keep mild cognitive impairment from getting worse.

Medication can help. For people with mild to moderate Alzheimer’s, drugs known as cholinesterase inhibitors, like donepezil and rivastigmine, can prevent the breakdown of a brain chemical that is important for thinking and memory. And immunotherapy drugs, such as donanemab, can help people with early Alzheimer’s by reducing the amount of plaque that builds up in the brain.

“These meds don’t cure dementia,” says Dr. Kennedy. “But they can reverse it temporarily for six or eight months.”

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What Happens Next?

Regardless of the diagnosis — whether it’s mild cognitive impairment that’s likely to get better or dementia that’s likely to progress, there are strategies that can help.

But you can’t take steps to solve the issue if you don’t get tested in the first place.

“If you have a concern, get evaluated,” says Dr. Dorsch. “It makes sense to go to your family doctor — after all, they know you better. Get started ruling things out.”

See our sources:
Alzheimer’s facts and figures: Alzheimer’s Association
Mild cognitive impairment (MCI) overview: Alzheimer’s Association
Cognitive evaluation overview: American Academy of Family Physicians
Study on prevalence of dementia and MCI in the U.S.: JAMA Neurology
Study on link between medications and MCI: Neurology
Alzheimer’s disease treatments: National Institute on Aging

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