Have you thought about your memory lately?
According to the CDC, 11% of people over age 45 have Subjective Cognitive Decline, a form of cognitive impairment that can be one of the earliest noticeable symptoms of Alzheimer's disease and related dementias. That's 1 in 9. And while all these people are aware of the decline, few discuss it with health care providers.
Subjective cognitive decline is exactly what it sounds like. It's subjective, meaning a person notices a worsening of their own thinking abilities and memory, but the decline cannot be verified by standard tests.
"Neurocognitive decline is a growing public health issue, and neurologists in this area of memory care are concerned," says Columbia gynecologist Mary Rosser, MD, PhD, who is working with Stephanie Cosentino, PhD, a Columbia neuropsychologist, to develop screening tools to detect subjective cognitive decline and more advanced forms of memory loss including dementia among her older patients.
Because many women skip an annual exam with an internist but keep their yearly gynecologist appointment, OB-GYNs are often the first doctors who encounter their patients' cognitive problems. Due to their unique relationship with patients, OB-GYNs are well suited to screen for a range of chronic diseases and conditions that impact the overall health of women.
For Rosser, it represents an opportunity to get ahead of health problems that arise when brain function declines. "We're looking at women's cognitive health as part of annual well woman visits to mitigate the future impact for our patients, and hopefully slow progression to Alzheimer's disease and other dementias," she says. "Adulthood has many stages. Well woman checkups need to go beyond breast and pelvic exams."
Subjective cognitive decline, Alzheimer's, and women
About as many women as men have subjective cognitive decline, but the condition in women is more strongly associated with subsequent dementia, including Alzheimer's disease. The reason is unknown but thought to be related to hormones unique to women.
"Women are at increased risk for Alzheimer's Disease, making up more than two thirds of all cases. Despite this increased risk, women often receive diagnoses later than men," says Cosentino.
"Cognitive testing doesn't pick up cognitive changes until they are more pronounced," says Rosser, "so earlier detection of these subtle differences is more valuable for the patient."
Early identification enables investigation into causes and monitoring of cognitive change over time. The hope is that identification of subjective cognitive decline may help doctors recognize brain issues like Alzheimer's in women earlier.
Screening women over 60 for subjective cognitive decline
Currently, screening for subjective cognitive decline in Columbia's gynecology offices is still in development.
Rosser and Cosentino recently tested a short survey that showed the value of screening. For 31 months, patients 60 and older who came in for a well woman exam at the practice were asked if they'd like to participate.
In addition to establishing the feasibility of memory screening at the well woman exam, the researchers also wanted to determine how many women would screen positive, and how many would want to pursue further evaluation with a memory specialist. Jillian Joyce, research program coordinator for the well woman screening, presented their findings at last year's Alzheimer's Association International Conference, the world's largest forum devoted to advancing dementia science.
"We are catching an appropriate number of women," says Rosser. About 17% of survey takers screened positive, defined by endorsement of at least one item, and half of the women who screened positive chose to pursue a full clinical evaluation.
The screening does not determine the cause of the issue, or whether it is reversible or not, says Cosentino, "but if women are concerned about their memory functioning and interested in a clinical evaluation, we determine through history, neurocognitive testing, and a range of other diagnostic tests (bloodwork, neuroimaging) what the likely cause is."
Not all memory issues are signs of cognitive decline
Many primary care providers do not explicitly ask older adults about their memory, or they dismiss memory complaints as part of normal aging, says Cosentino. "Some memory difficulties come with normal aging, but we want to make sure that any woman worried about her memory has an opportunity to share her concern."
Rosser notes one of the best reasons to talk to a health care provider about changes in memory and thinking is the possibility the change is caused by something less ominous, such as vitamin B12 deficiency or thyroid irregularity. Basic blood tests can often reveal what's really happening. Many problems can be treated and resolved without seeing a neurologist.
Other circumstances that can lead to cognitive issues at any age include:
- Alcoholism
- Brain diseases, such as tumor or infection
- HIV
- Hypothyroidism
- Lack of sleep and sleep apnea
- Medication
- Minor head trauma or injury
- Stress, anxiety, depression
- Vitamin B12 deficiency
Another important reason for screening is to raise awareness, says Rosser. "There may be no need to treat issues immediately. Sometimes, issues can be monitored at regular intervals and surveilled for stability or progression"
Ultimately, she says, "Cognitive disorders not only impact the individual, but also their loved ones who may act as caregivers. We can screen people, and we should."
References
Mary L. Rosser, MD, PhD, NCMP, is the director of Integrated Women's Health at Columbia University's Department of Obstetrics & Gynecology, the Richard and Ellen Levine Assistant Professor of Women's Health at Columbia University Vagelos College of Physicians and Surgeons, and an obstetrician-gynecologist at ColumbiaDoctors.
Stephanie Cosentino, PhD, is a professor of neuropsychology in the Department of Neurology, the Gertrude H. Sergievsky Center, and the Taub Institute for Research on Alzheimer's Disease and the Aging Brain at Columbia University Vagelos College of Physicians and Surgeons.
