Could you be over- or under-estimating the extent of your cognitive issues?
Over-estimating the extent of cognitive glitches may add to undue worry. Some people have a family history of dementia or genetic predisposition for Alzheimer’s disease that makes them understandably anxious about their future. Under-estimation risks not starting intervention at an early neurodegenerative stage when you have the most potential for effective treatment to reverse cognitive problems. Others simply remain unaware of their gradual cognitive decline. Denial can be merciful when you’re not ready to face a diagnosis of something like pre-Alzheimer’s, especially when you don’t yet appreciate the potential for effective treatment or you’re not ready to take on the demands of lifestyle change and extensive holistic therapy.
In Dr. Bredesen’s vast experience, by the time people report senior moments, there’s usually something wrong. Early, subtle abnormalities in cognition commonly go on for a decade before a medical diagnosis of mild cognitive decline.
Getting a baseline cognitive assessment is essential.
A sensitive, clinically-validated cognitive assessment can measure your cognitive functioning relative to others your age. As Dr. Dale Bredesen recommends, everyone over the age of 45 years should get an objective, quantitative, baseline cognitive assessment for future comparison before any cognitive problems arise or worsen.
Results of average or typical cognitive functioning can be welcome news. If you score normally, for example at the age-matched 50th-percentile overall, it could still be problematic if this result lies significantly below your previous score, say in the 85th percentile just a few years ago. A majority of adults believe themselves to be above average; this, of course, is not mathematically possible. Thus, it’s best to obtain objective baseline measures of cognitive functioning for future comparison.
Without a previous baseline cognitive assessment, if you believe you have declined from your previous cognitive performance, known as “subjective cognitive impairment“, then further medical evaluation is warranted. I tend to see a lot of high performing individuals who fall in this category. I encourage addressing any underlying pathology along with optimizing lifestyle and environment as early as possible for their best possible healthspan and brain function going forward.
Cognitive impairment is not as narrow as typical memory loss. People describe their subtly slowed pace of thinking, difficulties articulating, attenuated ability to figure things out, word choice errors, and impediments to orchestrating complex tasks, etc., below their previous cognitive capabilities. Many of the quick, cheap cognitive tests do not detect early signs of impairment in a variety of cognitive domains.
A clinically-validated cognitive assessment will help guide your best path forward toward optimal vitality and cognitive clarity, yet most people remain understandably hesitant to take a cognitive test. Emotions range from subtle apprehension to pained anxiety over the possibility of not performing well. Recognizing cognitive decline could jeopardize how a person sees themself and their future. Tuning out cognitive symptoms and procrastinating to take a cognitive assessment can seem less burdensome in the short-term; nonetheless, establishing your personal baseline and identifying impairment as early as possible is vital to brain health outcomes over the long-term.
The pathological changes of Alzheimer’s begin in the brain 20-30 years before the first obvious signs of cognitive impairment. This is when a person’s cognitive function may remain “normal” in the eyes of their primary care physician, but a brain scan, blood test, or spinal fluid test would detect neurodegeneration. If you are over the age of 45 and haven’t had a quality cognitive assessment, the time to test is now. A test such as the CNS-VS (see below) that assesses a dozen cognitive domains can identify suboptimal cognitive performance. Brain exercises that challenge the low scoring cognitive domain, especially when practiced while you’re still relatively healthy, can measurably improve domain-specific performance, shoring up your weakest link to help avoid developing clinical impairment in later life.
Braving the test
I always try to ease a person’s mind before administering a cognitive test. Oftentimes, those who start out nervous end up breezing through a MoCA test. Other times, those who initially describe their memory issues as quite modest perform in a way that reveals much more significant cognitive impairment. I try to help people do their best without wasting mental energy on self-judgment about their performance. One test, the CNS-VS, is a more sensitive assessment designed to be cognitively challenging for all thereby, nearly everyone doubts their performance while taking the CNS-VS, including those who are young, healthy, and high-functioning. Cognitive tests are meant to gauge age-matched cognitive functioning and are NOT designed as a measure of intelligence.
We need to test and not guess. That’s why I offer cognitive testing in my individual PreCODE/ReCODE™ health coaching, group coaching., support group, and single paid consultations. (To ensure that individuals will receive appropriate medical follow-up in the event of a lower score, I do not offer stand-alone cognitive testing to the general public.) Please do not boot-strap any brain health program without completing a cognitive assessment. Sweeping memory or cognitive issues under the rug without proper evaluation jeopardizes your future. Uninformed people may falsely attribute your concerns to “normal aging” or “stress” when they could be early symptoms of underlying pathology. It’s a common and heart-breaking error to delayed initiation of treatment past the point when cognitive decline is likely reversible. Please test and treat early.
A few good cognitive assessment options
MoCA
The MoCA (Montreal Cognitive Assessment) is a quick screening test for Mild Cognitive Impairment (MCI) when a person reports memory or cognition problems. A certified practitioner, like myself, takes around 15 minutes to administer the MoCA examination of memory performance, executive function, calculation, and verbal function. Although a MoCA score of 26-30 is considered normal, Dr. Bredesen considers a score below 28 to be cause for concern.
You may receive the MoCA test through your health insurance if you relate concerns about memory loss to your doctor. I’m also able to provide a MoCA test during a series of coaching sessions or a single consultation, either over videoconference or in-person (or by phone when that’s the only option). MoCA results from our meeting are your private record and never shared anywhere else without your explicit authorization. Although it’s a simple test, a trained professional needs to carefully administer and score a MoCA in a standardized, repeatable manner for the score to be accurate and reliable when comparing changes over time. Unfortunately, I have seen numerous self-administered MoCA scores wildly mismatched from the person’s actual cognitive status, giving them a false impression.
A perfect MoCA score can be cause for celebration. Nevertheless, it doesn’t rule out subclinical cognitive impairment below your previous high functioning as the MoCA is not a sensitive of a tool (consider taking the CNS-VS below). If you cannot confidently say that you’re happy with BOTH your cognitive test results AND with your brain fully functioning in daily life, then consult a doctor for further evaluation.
CNS-VS
CNS-VS (Central Nervous System-Vital Signs) is an online test you take from the comfort of your home or in the clinic. The CNS-VS test is more appropriate for those at the stage of prevention, for people with subtle cognitive concerns, and for high achievers likely to preform perfectly on the MoCA despite some cognitive decline below their previous norm. The CNS-VS test can detect signs of Subjective Cognitive Impairment (SCI) that the MoCA won’t pick up. It takes about a half-hour to evaluate fifty evidence-based markers of cognitive functioning.
A CNS-VS test and Full Report of age-matched performance in twelve cognitive domains is available to anyone who I see in a coaching session or consultation. I’ve completed basic training with CNS-VS to help you understand your report. I currently charge an add-on fee of $50 for the CNS-VS–$40 is required to directly pay CNS-VS for each online test. Though my time arranging the test is worth more than $10, I subsidize the test expense because I value an objective, detailed, clinically-validated measure of cognitive functioning to guide lifestyle and therapeutic decisions going forward.
A subscription to Apollo Health’s ReCODE™ or PreCODE™ includes access to CNS-VS tests or shorter NeuroQ tests, respectively. If not subscribed to Apollo Health, a $50 CNS-VS fee added to my consultation or coaching will include a Full CNS-VS Report (while Apollo Health charges an extra $35 for a CNS-VS Report beyond the summarized scores). The CNS-VS report can help the person considering PreCODE™ or ReCODE™ or other options, due to family history of dementia, other risk factors, budget concerns, readiness, etc., make a more informed decision.
Additional Tests
The Saint Louis University Mental Status (SLUMS) Examination is a brief cognitive assessment designed to detect Mild Cognitive Impairment, pre-Alzheimer’s, or dementia, but not earlier cognitive decline. It is similar to the MoCA described above. I administer the SLUMS upon request, but prefer the more widely recognized and utilized MoCA. Other quick, common, simple assessments for mild cognitive impairment (MCI) or Alzheimer’s include the MMSE, Cogstate, ADAS-Cog, and ACE-R.
A full neuropsychological examination is a much more comprehensive option that may be ordered by your doctor. It entails a multi-hour extensive evaluation of multiple cognitive and psychological domains, often performed by a geriatric psychologist, geriatric psychiatrist, or neurologist.
For a very loose cognitive gauge, you can get an overall percentile result of memory and executive functioning for your age with a paid subscription to the brain training apps BrainHQ or Luminosity. These brain games provide some measures cognitive performance, but neither are clinically-validated tests such as the MoCA and CNS-VS.
A quantitative magnetic resonance imagery (MRI) scan of brain anatomy is often recommended as part of a “cognoscopy”. NeuroQuant or NeuroReader quantitative analysis of the MRI provides relative volumetric measurements that additionally help with brain health diagnosis and tracking progress over time. If you are at high risk of dementia, talk with your doctor about referring you for a quantitative MRI in conjunction with a cognitive assessment. More advanced testing may include FDG-PET, amyloid/tau-PET, quantitative EEG, CSF amyloid/tau, and blood tests.
The Alzheimer’s Questionnaire known as the AQ-21 is a clinically-validated tool to help distinguish normal cognitive aging from impairment. Your significant other answers 21 yes/no questions on the AQ-21, for a total of 0-27 points. Higher scores reflect more cognitive dysfunction. A score of 0-4 is generally regarded as no cause for concern. Dr. Bredesen recommends follow-up on any who score 3 or above. If interested, here’s a link to the AQ-21 for a spouse or loved one to provide input.
Overall, choose the cognitive testing matched to the extent of your cognitive issues.
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Kudos to those of you who take the leap toward getting a cognitive assessment!
If your test happens to reveal impairment, seek appropriate medical work-up for diagnosis and guidance with the most promising course of personalized treatment. The full Bredesen ReCODE Protocol™ with guidance from a ReCODE™ practitioner(s) is the only therapy demonstrated to reverse subjective cognitive impairment, mild cognitive impairment, and early stage Alzheimer’s Disease (K Toups et al 2021). Please also explore my website for resources to help you begin your journey toward stopping further cognitive decline or reversing it.
If your results reveal your good fortune at the stage of prevention, please keep it that way by living a brain healthy lifestyle that can be nurtured and optimized with professional guidance.
Nurture Brain Health 