Which Doctor Should I See for Dementia and Cognitive Decline?

Repeating questions as though they’re being asked for the first time. Forgetting conversations. Misplacing items more frequently than usual. Difficulty finding just the right word, or remembering a person’s name. Getting turned around or lost in a familiar place. Losing your train of thought or the thread of conversations. Changes in mood and emotions, as well as an increase in impulsivity, irritability or poor judgment.

Any and all of these could be signs of being tired, stressed, or overwhelmed. But, especially in older adults, they could also be early signs of cognitive decline or dementia.

What Are Cognitive Decline and Dementia?

Cognitive decline refers to a reduction in mental capabilities. This can occur with age, or it can result from a brain injury or stroke, or even a B12 vitamin deficiency.

Cognitive decline can sometimes lead to dementia, a term that “just indicates that a person has a brain condition that causes severe enough cognitive impairment that they need help from someone else to do activities they used to be able to do independently,” says Dr. Douglas Scharre, director of the division of cognitive neurology at the Ohio State University Wexner Medical Center in Columbus.

Dementia isn’t a single disease; rather it’s a term describing a group of symptoms that are associated with a decline in cognitive function. “There are hundreds of causes of dementia,” Scharre says, including:

Alzheimer’s is the most common form of dementia. According to the World Health Organization, about 55 million people worldwide have dementia, and Alzheimer’s disease accounts for about 60% to 70% of these cases. While dementia is common among older people, the WHO reports that it’s a disease state that’s not a normal part of aging.

Because there are so many potential causes of dementia, “many types of doctors treat folks with dementia,” Scharre says. “Those doctors with the most expertise to help brain causes of dementia are usually neurologists. However, psychiatrists, geriatricians, and some primary care providers have the knowledge to diagnose and treat these conditions.”

Symptoms of Cognitive Decline and Dementia

Dr. Mark W. Albers, assistant professor of neurology at Harvard Medical School, says the symptoms of cognitive decline may start out subtly and maybe only noticeable to the patient. This is a stage called “subjective cognitive decline, where the person senses that they’re having some cognitive issues with short-term memory and word-finding, particularly with proper names.” He says visual perception problems (confusing similar-looking words or reversing letters or numbers, for example) may also emerge, but many people can still work around these problems and carry on almost normally.

But these conditions typically progress, and as they do, symptoms may become more problematic.

“Once the patient can no longer compensate and they’re having difficulty performing their daily functions either at work or at home, that’s where you’d cross over into what’s considered dementia,” Albers says.

This tipping point is highly subjective and often dependent on the type of work a person does. Albers gives the example of a courtroom lawyer who has to have the right word at just the right time, and must be able to pivot arguments in an instant based on evidence that’s just been presented.

This all requires a fully functioning short-term memory, and so for individuals with these sorts of highly articulate and time-sensitive jobs, changes in cognition may interfere with work much faster than for someone who is under less time pressure or who can work from notes or employ other strategies to compensate for any loss of memory or other changes in cognitive function.

When to See a Doctor for Changes in Cognition

No matter the type of job you have, if you notice changes in cognition, it’s important to see a doctor before your symptoms begin interfering with your life. But who’s the right person to see for such complaints? “Like in all diseases, the front line is the primary care physician,” Albers says.

Scharre agrees, saying the PCP should be your first stop in dealing with cognitive issues. “The PCP needs to get a complete medical history, family history, social history, current medication list and a review of any loss of abilities to perform day-to-day activities,” he says.

During this initial visit, the PCP will likely perform a physical exam and administer a cognitive assessment. Scharre has developed a self-administered gerocognitive exam, called SAGE (gerocognitive refers to cognitive ability as one ages), that patients can take at home and bring in to the office for scoring. MoCA – the Montreal Cognitive Assessment – is another common test your doctor may use.

“If there is evidence of cognitive impairment or cognitive decline by history and/or cognitive assessment, then the physician should order lab tests” to look at the levels of various compounds in your blood such as cholesterol and B12 and markers that indicate how well your liver and thyroid are functioning, Scharre says. This helps rule out whether a condition like liver disease or a thyroid imbalance could be causing the symptoms.

Beyond those blood tests, your doctor may also order a CT scan or an MRI. These are two imaging tests that offer a view of structures inside the brain. Alzheimer’s and other forms of dementia cause changes to the structures of the brain that can sometimes be seen with imaging tests.

“These evaluations should result in a diagnosis,” Scharre says, but sometimes it’s not clear cut. Your doctor may refer you to a neurologist or cognitive specialist for further testing and for care after a diagnosis has been made.

Dementia Treatment

“Treatment of dementia requires an interdisciplinary approach,” says Hayley Kristinsson, a neuropsychologist with UCI Health in Orange, California. This means that many patients will need support from more than just their PCP or a neurologist.

Depending on the nature and type of dementia, treatment may also involve:

“Physicians from other specialties may also be involved depending on the patient’s individual needs,” Kristinsson says. “However, neurologists are often the primary diagnosticians.”

Albers notes that because lifestyle factors have been shown to be effective in slowing the progression of cognitive decline and dementia, you may want to seek out a nutritionist to help you make the right changes. “The physician can cover (nutrition and dietary changes) at a high level, but to sit down and go through what you eat in a week and make concrete suggestions about helpful substitutions – that’s a nutritionist.”

Seek A Doctor with Expertise in Dementia

Scharre says providers with a special interest in cognitive disorders will likely be able to offer you the best care. “If the doctor does not seem to feel that an evaluation for diagnosis and treatment of the cognitive problem is that important, then it’s time to get a second opinion.”

Kristinsson agrees. “I recommend seeking out a geriatrician or neurologist who specializes in neurodegenerative disorders. Most medical centers provide information on their websites about providers and specialties. If you’re not sure who to make an appointment with, try calling the neurology department and they can assist you with finding the most appropriate provider.”

You may have more luck finding a cognitive specialist and have more options if you visit a larger or university-based hospital, Scharre says. This is often where you can find clinical trials that may offer more or newer treatment options than smaller facilities, which may lead to better outcomes for some patients.

“Physicians involved in clinical trials for cognitive disorders are often at the cutting edge for diagnosis and treatment,” Scharre says. The National Institutes of Health provides a searchable list of all ongoing clinical trials. Searching on the condition you or a loved one is dealing with – cognitive disorders, dementia or Alzheimer's disease – may give you some additional options for treatment.

Come Prepared for Your Appointment

When you do visit with a doctor, make sure you come prepared with a list of all your medications and their dosages and frequency. You should also take the time to fill out any questionnaires or paperwork the doctor has requested prior to your first visit. “The more information your doctor has, the better equipped they will be to treat you,” Kristinsson says.

She notes that when you’re seeking care for dementia, you’ll likely be asked many, many personal questions and you should expect to be asked to repeat your story several times to different providers. “Questions may seem irrelevant at times, but dementia impacts all areas of your functioning and your provider needs sufficient detail to render an accurate diagnosis.”

Another important thing to bring to a doctor’s visit for cognitive issues is a loved one. “In our clinic we require patients bring a caregiver or somebody,” Albers says. “The other word we use, which is kind of an awkward word, is an ‘informant.’ Often, it’s the spouse and/or kids, but somebody else who can provide an outside, independent perspective on what they’ve noticed over time.”

He continues, “I think that’s the No. 1 requirement because in this field, the story, the history is so important and the patient is doing their best to give you the best history they can. But particularly among people with memory problems, it’s inherently going to be problematic.” The patient may not even realize the full extent of the problem or may not be willing to admit it out loud.

Kristinsson agrees that “one of the most important things is to bring a family member or friend with you.” Someone who knows you well and can help provide information about your current level of functioning can assist the clinician in making an accurate diagnosis.

Treatment Can Help

Although many people assume that dementia or a steep reduction in cognitive function is simply part of getting older, Albers says it doesn’t have to be.

“Increasingly with more and more research on aging, we are learning that successful aging really doesn’t involve this degree of decline.” He says that while some changes in cognitive function are normal, “I think we’re redefining what is considered normal aging and what our aspirational goal ought to be.”

It’s not inevitable that you’ll end up with dementia and intervening early can make a big difference in your quality of life.

While dementia is irreversible, there are treatments that can slow the progression of the disease, Kristinsson says. “Treatment of dementia depends on the type (of dementia) in addition to where the patient is in the disease process.”

Some treatments focus on helping patients adjust to their current level of functioning. This may include modifications to the patient’s living environment to ensure safety or adding caregiving services. “If you’re considering alternative treatments such as dietary supplements, I strongly recommend that you consult with your doctor,” Kristinsson cautions.

“Many of these treatments are not FDA-approved and have not undergone sufficient scientific research. A supplement may be called ‘natural’ but can still contain powerful substances that have not met FDA standards and can lead to adverse reactions when combined with prescription medicines. Make sure to check with your doctor before starting anything new.”

Albers adds that “there’s evidence that lifestyle modifications can slow that decline.” The four main areas of lifestyle intervention are:

Lastly, Kristinsson notes that “caregivers take on a great deal of responsibility and have to cope with watching their loved one decline as the disease progresses.” This can be enormously stressful, so she encourages caregivers to “seek out supportive and educational resources, such as caregiver support groups.” The Alzheimer’s Association, for example, offers lots of caregiver resources on its website.

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