Subjective cognitive impairment: When to be concerned about ‘senior moments’
Thorough evaluation can differentiate benign memory problems from dementia
Table 4
Differential diagnosis of SCI
| Cause of cognitive impairment | Potential mechanism |
|---|---|
| ARCD | Allostatic load, ‘wear and tear’ from a lifetime of physiological or psychological stresses and adaptations |
| Anemia | Neuronal hypoxia |
| Alzheimer’s disease | Amyloid and/or tau-mediated neurotoxicity, neuroinflammation |
| Cerebrovascular disease | Neuronal ischemia and hypoxia, neuroinflammation |
| Vitamin deficiencies (eg, B1, B12, folate, D) | Impaired neuronal and neurotransmitter function |
| Inadequate protein intake | Impaired neuronal function |
| Anticholinergic drug use | Decreased cholinergic neurotransmission |
| Alcohol use | Direct neurotoxicity and indirect causes such as malnutrition or head injury |
| Depression, anxiety | Hippocampal dysfunction with or without atrophy |
| Obstructive sleep apnea | Neuronal hypoxia, neuroinflammation |
| Head injury | Neuronal and synaptic loss |
| ARCD: age-related cognitive decline; SCI: subjective cognitive impairment Source: References 28,29,31,32 | |
CASE CONTINUED: No measurable deficits
Ms. F’s medical history is remarkable for coronary artery disease, hypothyroidism, hypertension, hyperlipidemia, cataracts, arthritis, back surgery (secondary to spondylosis), and foot surgery. Ms. F denies a history of alcohol or illicit substance abuse. She smoked tobacco for 30 years (2 packs per day), but quit 5 years ago after her heart attack. Physical exam is unremarkable except for mild obesity (body mass index = 31 kg/m2).
Ms. F’s mental status exam reveals anxious mood and affect. Her recall is 2 out of 3 items. Her MMSE score is 29/30 (1 point lost on recall) and her Geriatric Depression Scale33 score is 2/15, indicating minimal depressive symptoms. On neuropsychological testing, Ms. F demonstrates high average intellectual abilities; compared with others her age, she performs within expectations on all measures. That is, she performs within the above-average to low-average range on measures of attention, working memory, speed of processing, expressive language, learning, memory, visual spatial abilities, executive functioning, and knowledge of basic health and safety information.
Enhancing neuroplasticity
We recommend neuroplasticity-based interventions to treat SCI and promote healthy brain aging.20,29 For a checklist clinicians can use to promote healthy brain aging and thus improve patients’ cognitive health see this article at CurrentPsychiatry. com. Table 51,29 lists cognitive strategies to improve memory and maintain cognitive vitality.
Enhancing brain plasticity and neurogenesis requires engaging older adults in demanding sensory, cognitive, and motor activities on an intensive basis.34 Therapeutic stimulation of neuroplasticity and neurogenesis might contribute to functional “repair” of the diseased adult brain before damage to whole neuronal networks has ensued.29 An important treatment component is reassuring patients with SCI that they do not have AD or MCI. Treating comorbid anxiety and depression and reversible causes of cognitive complaints is key to successful outcomes.
Table 5
Strategies to improve memory and maintain cognitive vitality
| Strategy | Description |
|---|---|
| Mindfulness | Focus on 1 task at a time rather than trying to multitask. Research shows that cognition is more efficient in this manner |
| Cognitive strategies | Use mnemonics (such as ROY G BIV to remember the colors of the rainbow). Make associations for information, such as when meeting someone new, relate their name to someone else you know well. Use cues such as memory notebooks to prompt information recall. Engage in learning new and challenging cognitive activities, such as a new language, a music instrument, or dance. Consider computer-based brain exercises |
| Rehearsal | Practice information you want to remember, such as repeating the information several times or writing it down |
| Be patient | Getting frustrated when you have memory difficulties makes it more challenging to remember information |
| Exercise (mental and physical) | Engage in mental activities, such as reading and crossword puzzles. Do something that you are interested in, rather than making it a chore. Research has demonstrated that physical exercise also aids memory |
| Diet | What is good for the heart is good for the brain. Fruits, vegetables, food rich in omega-3 fatty acids (eg, fatty fish such as salmon), whole grains, spices (eg, turmeric), and small amounts of tree nuts (eg, walnuts) are recommended as part of a balanced diet |
| Source: References 1,29 | |
CASE CONTINUED: Reassurance and risk reduction
Ms. F’s psychiatrist reassures her that she does not have AD. She receives genetic counseling and decides to forgo genetic testing. Her psychiatrist educates Ms. F about the risks of OTC supplements—especially increased risk of bleeding because she takes aspirin and clopidogrel—and lack of data supporting their use. Ms. F is counseled that a healthy lifestyle, including regular exercise, Mediterranean diet with increased intake of omega-3 fatty acids, learning new things, and being socially active, is the safest way to promote brain health. Over 3 months, Ms. F discontinues all supplements except the vitamins and omega-3, starts exercising, resumes piano lessons that she stopped 10 years ago, and becomes a vegetarian. She continues to have mild SCI but she says she is not bothered by it and feels satisfied that she is doing all she can to promote her brain health.
