Setting the record straight about assessments

In an article published in The Wall Street Journal last month, a retired physician named Dr. Seth Stern reported that he began experiencing cognitive deficits at age 59. Having dementia running in his family, he was attuned to the possibility that he may be experiencing the initial signs of cognitive decline.

The article (which is behind a paywall) goes on to state that, “It is nearly impossible for people such as Dr. Seth Stern to be diagnosed with dementia because neurocognitive testing is normed to a 12th-grade education level.” This statement is misleading: While it is true that highly educated people can present challenges in detecting impairment, neuropsychologists are skilled in using cognitive tests that have been designed to detect decline in people with greater than a 12th grade education (i.e., tests are normed for highly educated people).

Let’s unpack this a little further.

Yes, it is true that the detection of cognitive impairment in high-functioning older adults is often difficult. This is in part because high-functioning persons tend to have increased cognitive capacity—also known as “cognitive reserve.”

Cognitive reserve can result in later expression of clinical symptoms. Dr. Yaakov Stern, a professor of neuropsychology at Columbia University, defined it as, “the ability to optimize or maximize performance through differential recruitment of brain networks, which perhaps reflect the use of alternate cognitive strategies.”

Importantly, high-functioning individuals may maintain a high level of verbal skills, which can serve to mask any cognitive impairments.

The WSJ article also suggests that primary care doctors are often reluctant to diagnose dementia early on for a variety of reasons, among them a concern that “nothing can be done.” This may have been true in the past, but presently there are several effective treatments for dementia when detected early, and several other treatments under trial right now.

(Current data on Alzheimer’s drugs under trial in 2023 was released earlier this month; you can access 2022 data here.)

Given the challenges in detecting cognitive impairment in highly educated people, neuropsychologists can serve an important function. Skilled in detecting cognitive deficits, neuropsychologists identify and characterize impaired cognitive functions as well as those functions that have been spared. Furthermore, neuropsychologists work closely with other medical specialists to determine underlying neuropathology and to predict clinical outcomes.

The role of neuropsychology is likely to be elevated with the introduction of medications such as Aducanumab, which can be a treatment option for early-stage dementia and result in people having increased time to participate independently in activities of daily living.

Expanding healthcare teams to include primary care physicians, geriatric specialists, neurologists, and neuropsychologists will help to initiate interventions that may delay progress of cognitive disorders. Providing more comprehensive approach also will provide an opportunity for patients and families to collectively participate in making care decisions and health care plans.

Dr. Perry is Executive Director of NAN.