Memory changes are a common concern among older adults and their families. Forgetting where you left your keys, struggling to recall a name, or occasionally losing track of a thought, these experiences are familiar to almost everyone as they age. But knowing where the line falls between normal aging and something more clinically significant can be genuinely difficult, both for patients and for the people who care about them.
At Dr. Maryam Khan’s primary care practice in Lutherville-Timonium, MD, cognitive health screening is incorporated into routine geriatric care as a standard component of comprehensive senior health management. Early identification of cognitive impairment allows for timely evaluation, appropriate management, and planning, while there is still time to act.
Normal Aging vs Mild Cognitive Impairment vs Dementia
These three categories represent a spectrum, and distinguishing between them has significant clinical implications:
| Category | Key Features | Impact on Daily Life |
| Normal aging | Occasional word-finding difficulty, slightly slower recall, learning new technologies takes longer | Daily activities, judgment, and independent function are preserved |
| Mild Cognitive Impairment (MCI) | Noticeable decline in memory or other cognitive domain beyond what is expected for age; often noted by patient or family | Daily activities largely preserved, though complex tasks (finances, medications) may become harder |
| Dementia | Significant decline in memory plus at least one other cognitive domain (language, judgment, visuospatial ability) | Affects ability to function independently in daily life; safety may be compromised |
| Approximately 15 to 20% of people aged 65 and older have MCI. Of those, roughly 10 to 15% per year will progress to dementia. Importantly, MCI does not inevitably progress, some patients remain stable, and some improve, particularly when reversible contributing factors are identified and addressed. |
Reversible Causes of Cognitive Impairment
One of the most important aspects of cognitive evaluation is ruling out reversible causes before attributing cognitive decline to a progressive neurodegenerative process. Conditions that can mimic or contribute to cognitive impairment include:
• Medication effects: Many medications cause or worsen cognitive symptoms in older adults, particularly anticholinergics, benzodiazepines, opioids, and certain antihistamines (see polypharmacy article for full discussion)
• Depression: Depression in older adults frequently presents with prominent cognitive symptoms, including difficulty concentrating and memory complaints, rather than the low mood more typical of depression in younger adults
• Hypothyroidism: Low thyroid function slows cognitive processing and can produce memory impairment that improves with thyroid hormone replacement
• Vitamin B12 deficiency: B12 deficiency is common in older adults and can cause neurological effects including cognitive impairment, which is often reversible with treatment
• Sleep disorders: Sleep apnea and chronic sleep deprivation are associated with cognitive impairment; treating sleep apnea has been shown to improve cognitive function
• Alcohol use: Chronic alcohol use, even at levels below traditional definitions of alcohol use disorder, can impair cognitive function in older adults
• Urinary tract infections and other infections: Acute infections frequently cause sudden-onset confusion (delirium) in older adults that resolves with treatment but can be mistaken for dementia
Cognitive Screening Tools Used in Primary Care
Several validated, brief cognitive screening tools are used in primary care settings. Dr. Khan uses these tools as part of the Medicare Annual Wellness Visit and when cognitive concerns are raised:
Mini-Cog
A two-component screening tool: the patient is asked to remember three words, draw a clock face, and then recall the three words. The Mini-Cog takes approximately 3 minutes and has good sensitivity for detecting dementia in primary care.
Montreal Cognitive Assessment (MoCA)
A more comprehensive 10-minute assessment covering multiple cognitive domains: memory, attention, language, executive function, and visuospatial ability. The MoCA is more sensitive for mild cognitive impairment than the MMSE and is increasingly used in primary care settings.
Mini-Mental State Examination (MMSE)
A widely used 30-point test covering orientation, registration, attention, recall, and language. While the MMSE has been extensively validated, it is less sensitive for mild impairment than the MoCA.
What Happens After a Positive Screening Result?
A cognitive screening tool is not a diagnostic test, it identifies patients who warrant further evaluation. When a screening result is below the expected range, Dr. Khan’s next steps typically include:
• Laboratory evaluation: Complete blood count, metabolic panel, thyroid function tests, and vitamin B12 level to identify reversible causes
• Medication review: Assessment of the current medication list for cognitive-impairing agents
• Depression screening: PHQ-9 or equivalent to evaluate for depression as a contributor
• Referral for neuropsychological testing: When the clinical picture is complex, formal neuropsychological testing by a neuropsychologist provides a detailed cognitive profile that guides diagnosis and management
• Neurology or geriatric psychiatry referral: For patients in whom the evaluation supports a neurodegenerative diagnosis, subspecialty referral assists with diagnosis confirmation and management planning
The Importance of Early Identification
The most common question families ask after a dementia diagnosis is: ‘Why didn’t anyone catch this sooner?’ Early identification of cognitive decline allows for several important actions that are not possible after the disease has progressed significantly:
• Advance planning: The patient can participate meaningfully in decisions about healthcare directives, financial planning, and designation of a healthcare proxy while cognitive capacity allows it
• Safety planning: Early identification allows time to assess and address driving safety, medication management, and home safety before these become crises
• Family preparation: Families and caregivers can begin learning about the disease, understanding what progression looks like, and identifying resources before the acute demands of caregiving become overwhelming
• Pharmacological management: Cholinesterase inhibitors (donepezil, rivastigmine) and memantine are modestly effective at slowing functional decline in Alzheimer’s disease when started in the early stages
Talking to Dr. Khan About Cognitive Concerns
If you or a family member have noticed changes in memory, judgment, word-finding, or the ability to manage complex tasks like finances or medications, these observations are clinically important and should be brought to a primary care visit. The conversation is not about confirming fears; it is about understanding what is happening and determining the most appropriate next steps.
Cognitive screening is now a standard part of the Medicare Annual Wellness Visit. Patients who are due for an AWV have an automatic opportunity for this evaluation each year.
| For cognitive health screening or a geriatric evaluation in Timonium, MD, contact Dr. Maryam Khan, MD at (443) 577-4010. Located at 1205 York Rd, Suite 11, Lutherville-Timonium, MD 21093. Medicare and commercial insurance accepted. Accepting new patients. |