How to Talk About Cognitive Health With Patients:
A Guide to Broaching Sensitive Topics

Discussing Cognitive Health With Patients Is Often a Challenge

Cognitive and mental health issues have become prevalent in our society today—yet the topic continues to be difficult to discuss with patients. When a patient goes to the doctor to address a problem or for a regular checkup, standard practice is to record their vital signs—the basic indicators of physical health—but the basic indicators of brain health are sometimes ignored. Often, this is because of the stigma or unease attached to questioning someone’s cognitive health. It can be uncomfortable to broach this topic for a variety of reasons, whether patients don’t want to be judged, they simply don’t want to know, or they have some other reason for hesitation. However, avoiding it can lead to missed opportunities for early and accurate diagnosis and treatment. Ultimately, this keeps patients from achieving and maintaining their best cognitive functioning and gets in the way of providing outstanding patient care.

Changing the way patients and providers view proactive cognitive health starts with removing the stigma through intentional, meaningful conversations. Elevating the current standard of care to include regular cognitive checkups gives providers 
an opportunity to diagnose and treat disorders early, ultimately improving 
patient outcomes.

While many patients are aware of well-known diseases associated with cognitive decline, such as Alzheimer’s and other forms of dementia, there are many other conditions that are less known to be tied to cognition, such as cardiovascular diseases, psychiatric disorders, and more. Furthermore, Medicare Advantage Plans include two dementia codes—HCC51 and HCC52—with risk score weights of 0.2-0.5 depending on the individual’s sub-population. These weights are similar in magnitude to other chronic conditions, such as congestive heart failure and diabetes. Unfortunately, many patients are unaware of the day-to-day factors that influence cognition.

Factors That Can Influence Cognition

Internal Factors

Physical pain1Pain Research and Management, The Cognitive Functions in Adults with Chronic Pain: A Comparative Study, Dec 2016

Mental health2Indian Journal of Psychiatry, Cognitive Deficits in Psychiatric Disorders: Current Status, Mar 2006

Other illnesses (e.g., COVID)3Cortex, COVID-19 Associated with Cognitive Impairment: A Systematic Review, Apr 2022

External Factors

Temperature4Frontiers in Physiology, The Impact of Different Environmental Conditions on Cognitive Function: A Focused Review, Jan 2016

Air quality5Harvard School of Public Health, Office Air Quality May Affect Employees’ Cognition, Productivity, Sep 2021

Lifestyle factors (e.g., social or physical activity, sleep)6Frontiers in Neurology, Modifiable Lifestyle Factors and Cognitive Function in Older People: A Cross-Sectional Observational Study, Apr 2019

Discussing the Importance of Cognitive Health

Healthcare has been moving toward a more proactive and patient-centered approach.7Annals of Internal Medicine, Patient-Centered Decision Making and Health Care Outcomes: An Observational Study, Apr 2013 As such, it’s important that clinicians give patients context into their healthcare journey so they can be active participants.

For Healthy Patients: Integrate Cognitive Care Into Health Care

Objective cognitive data, even in healthy patient populations, is invaluable and can provide a baseline for future brain health assessments. At every patient checkup or doctor’s appointment, vitals like blood pressure, motor function, and respiratory rate are measured so that physical health can be monitored over time—why should cognition and brain health be any different?

Establishing cognitive status can help identify any current undiagnosed cognitive concerns, and by maintaining a record of brain health, status changes can be easily detected. While the benefits of integrating cognitive health into healthcare are apparent to some physicians, remember that patients may be unaware or wary of brain health measurements. It’s essential to make it clear to these patients that cognitive health can provide insights into many other components of health. To make the most of those insights, an objective baseline must be established while the patient is generally healthy.

Baseline measures combined with longitudinal monitoring give patients insight into how their brain health is changing over time, allowing them to better collaborate with clinicians to improve or maintain cognitive function.

Discussion Starters

“I'd like to also get a quick measure of your brain health. Your brain is as important as your heart, so we should do a cognitive assessment just like we do a blood pressure check. We can see which areas you're strongest in right now, on a regular day.”

“Let's check your cognitive function again to see if anything has changed. Don't worry, you might do a little bit better or worse than last time, and that's normal, but this will help us see whether your memory, reasoning, concentration, and verbal ability stay steady over time.”

“It's normal to feel like you're getting more forgetful as you get older, but objectively, it looks like you're doing just fine for your age. Let's do another test when there are any changes to your health, medications, or lifestyle, then we can compare those results to today's baseline to see if there are any cognitive symptoms to be concerned about.”

For Patients With Emerging Health Concerns: The Invaluable Baseline

Whether due to a specific event or normal aging, all patients have the potential to transition from the healthy population to the unhealthy population. The level of care that can be provided when a cognitive baseline is established has the potential to significantly improve patient outcomes. This is because a patient’s cognition can be interpreted not only in relation to population norms, but in comparison to a personalized benchmark unique to each patient. An individualized result like this can take some of the guesswork out of interpreting data, such as making assumptions about cognition based on education level or profession. A change in function can provide clinicians with a powerful diagnostic aid for any condition with cognitive symptoms, an objective confirmation of subjective concerns raised by the patient, and may even uncover early warning signs before the patient notices any subjective changes to areas such as memory, attention, and decision-making. Ultimately, a baseline is an invaluable tool for personalized, patient-centered care.

Discussion Starters

“Your blood test results are getting close to the cutoff supporting a diagnosis for that condition we’ve been keeping an eye on. Let’s do another brain health assessment to see if the cognitive symptoms are consistent with a change to your health.”

“As we work together to keep you feeling your best, we can have you do these cognitive tests again to compare to your previous results. That way we can try to rule out anything else like health issues, medications, or lifestyle changes that could be causing you to feel less than your best.”

“You mentioned you’ve been experiencing brain fog, right? I’m going to send you a quick cognitive task, then we’ll compare the results to the population and to your baseline result. That way, we'll have a better idea of whether your cognitive concerns are a result of a potential condition or part of life's normal ups and downs.”

For Patients With Clear Health Concerns: Broaching Sensitive Subjects

Cognition and brain function affect the very fabric of who a person is. A decline in cognitive health can be frightening because it may mean that significant changes to quality of life lie ahead. Whether the patient suspects something is wrong or not, introducing the topic in a sensitive manner can create a safe space to explore an assessment, diagnosis, or treatment plan.

It’s important to remember that confusion and loss of short- or long-term memory are some of the most common signs of cognitive decline, whether from an incident, changes to mental and physical health, or aging.8Psych Guides, Cognitive Problems, Symptoms, Causes, and Effects These are all elements that must be considered when talking with patients. These types of impairments can be extremely disorienting and, of course, patients may not remember previous conversations.

For unhealthy populations, it’s particularly important to complete ongoing monitoring and long-term follow-ups. Whether this follow-up is for a specific disease diagnosis, such as mild cognitive impairment (MCI), or a cognitive event, such as traumatic brain injury (TBI), measuring ongoing treatment effectiveness with objective measures makes it possible for clinicians to see if patients are improving or maintaining cognitive function. Clinicians can present this information to patients so they can be involved in making informed decisions about their treatment plan, whether that includes continuing treatment, making adjustments, or trying something new. Especially in the case of more complex, ongoing cognitive issues, completing assessments for long-term monitoring helps maintain the connection between clinician and patient and makes it possible to notice any significant changes early on.

Discussion Starters

“Because we started you on that new medication a few months ago, I’d like to have you complete another cognitive assessment. This will help us determine if this treatment is working or if there have been any unwanted cognitive side effects.”

“Given your current diagnosis, we want to go ahead and do another assessment of your brain health, and keep doing them every few months. This will allow us to see if anything is changing and catch any changes early enough to make educated decisions about treatment options.”

“It’s been a few months since your injury. I know recovery has been gradual, but let’s try a few cognitive function tasks to see how you are progressing since we got started.”

Dealing With Anosognosia

Studies estimate that 60 percent of patients with mild cognitive impairment (MCI) and 81 percent of patients with Alzheimer’s disease exhibit some form of anosognosia, where the patient is unaware of their neurological deficit or psychiatric condition.9StatPearls, Anosognosia, Jun 2022 Because of this, results of cognitive assessments and any subsequent diagnosis should be handled with the utmost sensitivity. While the frightening consequences of a diagnosis may make some patients anxious about discussing results, many surveys indicate that most patients with or without memory impairment would want to know if they had dementia. 10, 11¹⁰U.S. Department of Health and Human Services, Providing and Discussing a Dementia Diagnosis with Persons Living with Dementia (PLwD) and Their Care Partners, Oct 2018
¹¹Clinical Interventions in Aging, Patient Characteristics Associated with Screening Positive for Alzheimer’s Disease and Related Dementia, Sep 2018

Discussion Starters

“Taking this cognitive assessment is important because it can help us identify issues that could be keeping you from being your cognitive best. Everyone experiences brain fog, but sometimes specific problems in cognition are a result of health issues, stress, and other treatable factors. By identifying and treating those roadblocks, you can have more of those days when you feel like your brain is firing on all cylinders.”

“Cognitive decline and cognitive disorders like dementia are frightening and hard to control, but if we are able to catch them early, there is hope for getting started on the long-term lifestyle changes and helpful strategies needed for you to beat, delay, or live with them.”

“I know it can be hard to put measurements to feelings, but completing a cognitive assessment makes that possible. It will help us answer questions like ‘Is this normal aging or memory decline?’ and ‘Could problems at work be due to attentional issues?’ This brain health test will give us measurable evidence of the symptoms you’re having, which will help us communicate and make sure we create the best treatment plan for you.”

“You’re used to doing blood or urine tests, and this is essentially the same thing for your brain. This will give us full visibility into your brain health, so you can work with me, other specialists, or your primary healthcare provider to come up with an individualized plan to address your weaknesses, harness your strengths, and maintain your brain through sickness and in health.”

Reviewing the Results

Upon completion of the test, you will calculate or receive results with information about the patient’s cognition. It’s critical that you then take the time to explain the results to the patient and let them know what happens next. Remind patients that not every test is expected to reveal abnormalities and that it is normal and expected for an individual to be better in some areas and worse in others. In the case of cognitive assessments, a score in the average range is expected. Even highly educated populations will not be above average in all or any areas, because cognition is just one part of overall health, quality of life, environment, and success.

Every healthcare provider should develop criteria for when to raise a concern with a patient based on their professional training, patient population, and contextual information about the patient (e.g., education, comorbidities, subjective reports).

Take a peek at an example of an ideal cognitive assessment report

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Interpreting Trends

Expectations for trends might be different depending on methodology and the patient objectives. If the goal is to maintain brain health or avoid side effects, a lack of change is a positive sign. If the goal is to demonstrate improvement during recovery from an acute condition, providers may be expecting to see significant improvement. By assessing and reassessing patients as needed, modern cognitive reports are helpful instruments in the toolkit that contribute to a holistic patient profile. It's important to continue leveraging questionnaires and other subjective assessments throughout treatment and monitoring in order to observe parallels between different measures and strengthen clinical decision-making.

Interpreting patient trends and tracking progress will depend on the specific objective for that patient.

Meaningful Change

When an individual has completed more than one assessment and longitudinal data is being collected, changes in function can be compared. Certain cognitive assessment solutions will be able to evaluate and identify meaningful changes, which signify that a change in performance (relative to baseline assessment results) is outside the bounds of variations that typically occur due to everyday fluctuations. A lack of meaningful change means the difference was not extremely unusual in the general population or compared to previous assessment results; however, subtle changes or a rising trend line still add value to the overall patient profile and have meaning for each patient.

If a patient’s results do indicate a meaningful change, speak with the patient and try to understand their general state during the reassessment. For example, if the patient was in a distracting setting or was having a stressful day, reassess and see if the score improves.

Explaining Cognitive Assessment Results With Patients

After the provider has taken the time to fully understand the results of the assessment, communicating them to the patient is the next step. It is up to the individual provider whether they want to share reports with patients directly or simply take notes to discuss.

Some providers find it helpful to prepare scripts or templates that will resonate with their patient group, starting with a high-level overview—a starting point is provided in the Quick Reference Guide below. Using objective terminology like “below average for your age group” or “higher than your last assessment” can help put patients at ease. As you move into interpretation, avoid assigning any judgment to results, and don’t focus exclusively on potential deficits, because assessing and emphasizing strengths when disclosing results helps patients understand why certain diagnoses can be less likely or which concerns are purely subjective and normal.

Discussion Starters

“Your memory scores are a bit below average for your age. Are you noticing any increased forgetfulness in your day-to-day life?"

"You mentioned you've been struggling with anxiety. That could be one reason why your working memory results are lower than other areas of cognition—now we have objective results tracking the brain fog issues you've been experiencing. Let's talk about treating anxiety so your brain can be at its best."

“Your concentration results are above average. Perhaps your trouble focusing in long lectures is not a cognitive issue—let’s explore any potential hearing problems and physical comfort.”

When deficits are revealed, some patients may actually be relieved by a low score, because it validates the subjective struggles they’ve seen in their everyday lives. They can now see that their concerns are measurable, a health expert is aware of them, and they can finally be addressed. When cognitive concerns are likely due to treatable or temporary conditions, such as mental health disorders or injuries, then a cognitive assessment can reveal tangible metrics that motivate patients to put effort into improvement.

If there is a cognitive disorder to diagnose, such as dementia, studies suggest that this be disclosed over several visits with the involvement of family or care partners.12U.S. Department of Health and Human Services, Providing and Discussing a Dementia Diagnosis with Persons Living with Dementia (PLwD) and Their Care Partners, Oct 2018 A diagnosis of a cognitive disorder can be highly stigmatizing and accompanied by significant life changes. Delivering this news in a patient-centered manner can include:

• Identifying personhood, life goals, and care preferences
• Telling the patient and care team what they can expect over time
• Providing ways to respond to changes to minimize distress, maximize independence, and increase quality of life

Cognitive decline over time can happen so slowly that a patient does not realize the gravity of the situation. Alternatively, they may notice changes in their cognition but are afraid to seek help out of fear of diagnosis or stigmatization. The subjects of cognitive function and brain health can be scary for patients. The more comfortable providers can make them, the more likely they are to see this practice as a basic standard of care and include cognitive health in all aspects of healthcare.

Broaching the sensitive topic of brain health with patients regularly can help them understand this increasingly essential aspect of healthcare, whether they currently have concerns or not. It is important to be proactive with patients as well as within a practice. Create a plan of action for starting the conversation by communicating the importance of measuring cognitive health, preparing patients for upcoming assessments, and presenting results in a way they will be comfortable with. Talking about cognitive health with patients will help to remove the stigma and open them up to regular assessments. Ultimately, this ongoing evaluation will make a significant difference in your patients’ health outcomes and quality of life.