Best Practices for Improving Patient Outcomes in Older Patient Population - Episode 2

Cognitive Concerns in Geriatric Patients

Stephanie Chow, MD, MPH: The m component of geriatrics is the mind, and the mind is something that the geriatrician will look at very closely when meeting an older individual for the first time. For any patient, but our older patients in particular, we’re looking for mental health and cognitive challenges, so a geriatrician may choose to do sort of a memory screen. For example, the Mini-Cog, the Mini-Mental Status Exam, or the MoCA [Montreal Cognitive Assessment]. These help clinicians look at different facets of the cognitive status during a cognitive evaluation. For example, attention span, visual-spatial, executive function, verbal fluency, naming tasks, and short-term memory, as well as word recall.

There are various screens for memory and parts of cognition that a geriatrician and a primary care physician, frankly, can do to help identify what parts of the patient’s daily function may be affected. And in this way, he or she can use that as a method for guiding next steps.

If there’s an aspect of an individual’s mind, their cognition, that does have deficits or challenges, it is important for the geriatrician or the primary care provider to seek an individual, or some aide, some form of assistance to help this individual out, whether it is a health care proxy, family, or a friend—somebody who can support them with these roles. For example, paying the bills, making grocery lists, organizing medications in pillboxes. So the m for mind is very important.

The m can also stand for the mental health, the mood portion. So screening for depression, for example, is also very important. The PHQ-2 [Patient Health Questionnaire 2] or PHQ-9 [Patient Health Questionnaire 9] are some easy screening tools that one can use to identify who in the community may be affected by depression or a mood disorder or anxiety. This can be a good time to talk about what support is at hand. Are there counselors who can come into the home? Is there a mental health clinic? Are there support groups that are available? And also, to get to the bottom of why, exactly, this individual is experiencing this depression, or anxiety, or mood disorder.

Alzheimer dementia is the most common form of dementia, and it is 1 that often is characterized by memory loss. It’s something that families notice or begin to notice, but it’s a more gradual course. Iit is often difficult for families to really see the onset. However, after a while they’ll start to notice that with the memory impairment there are also other deficits—forgetting how to do certain functions—and they are causing a lot of disruption to their daily life. It is a complex diagnosis that requires a lot of careful and thorough evaluation. There’s a lot of negative stigma surrounding the diagnosis of Alzheimer dementia. For this reason, it’s very important for geriatricians to counsel family members and patients on what the prognosis is, what to expect, and what the natural course might be.

It’s also important to emphasize maintaining good cognitive stimulation, social support, and the importance of going out and seeking new activities and participating in things, and not to become more isolated just because they feel they can’t remember things or they feel embarrassed. It’s important for family members to really support the patient through this very difficult time and to seek the resources together in a way that the patient may feel supported and not outcast.

If a primary care provider feels that a patient requires more evaluation from a neuropsychiatric standpoint, or a neurological standpoint, it would be a fine time to send the patient to a specialist for evaluation by a neurologist or neuropsychiatrist. This allows for a more thorough screening evaluation to really get to the bottom of why, perhaps, this individual is experiencing memory loss, lack of organization, or other stressors that are very concerning to the patient and their family.

For a patient who is diagnosed with depression or anxiety or a mood disorder, it is very important for that patient to seek appropriate mental health services and care. This may include medication management with a psychiatrist, and should also, importantly, include the addition of psychotherapy counseling with an appropriate therapist. I believe this pairing of the medication plus the counseling is very important in supporting a patient’s overall recovery and overall maintenance of a good mental health picture.

If the patient is blessed to have surrounding community support, it would also be good to have family and friends who are aware of the individual’s mental health struggles, to provide lasting and consistent support throughout this difficult period.

This is something that a patient should know is common in the older population and also in the country at large. It’s something that health care providers are working to solve with greater support in the mental health realm. There are some programs that will send mental health providers into the patient’s home to work with them, to make it easier for those patients who are unable to get out in the community. There are more community support groups. There are more forums online. And there are even—for example, where I work—embedded geriatric psychiatry clinics within the clinic itself, so patients are able to go there and not experience confusion or more stress in trying to find the appropriate clinic.

Transcript edited for clarity.