Who will assess cognitive change?

Cognitive change, osteoporosis and cardiovascular disease are recognized late complications of menopause, and are severe conditions in untreated premature menopause. Two to three times more women than men are affected by dementia. Although oestrogen therapy may have a place in reducing female cognitive decline, there is a need for research, with appropriate methodology, to clarify appropriate interventions. Whereas we routinely measure and manage osteoporosis and cardiovascular complications, the situation regarding measuring and managing cognitive change is unsatisfactory.

The UK National Dementia Strategy 2009 outlines the problems of cognitive decline and dementia; among which it stresses the importance of early diagnosis. ¹ This is an area in which menopause services and clinics could and should have an important input to the strategy; with regard to commissioning a trained and competent workforce for which there is funding from PCTs; in the longer term in developing undergraduate and postgraduate curricula; BMS/RCOG menopause modules already cover cognitive function, the department should be made aware of this expertise. Menopause clinics could and should provide services testing and monitoring cognitive function and giving health and lifestyle advice.

Age-related cognitive decline is the normal decline in cognitive function relative to age, which is a consequence of the ageing process for those over 65 years; 40% of people have this – 1% a year go on to develop Alzheimer's.

Minimal cognitive impairment (MCI) is thought to affect at least 500,000 individuals in the UK; 10% of those over 65 years have MCI, of which 15% go on to develop Alzheimer's every year. The individual's ability to carry on with normal life appears on the outside to be unimpaired. MCI is easily detected with appropriate tests and this is the group where intervention may be most productive.

Dementia is characterized by the development of multiple cognitive defects that are sufficiently severe to cause impairment in occupational or social functioning. ¹ There are three main types of dementia: Alzheimer's disease, vascular dementia and Lewy body dementia. The current prevalence of dementia in the UK is between 500,000 and 750,000. Projected figures for 2050 are between 1.2 and 1.8 million, an increasing social and financial burden.

The evidence base for drugs to treat MCI is limited. Practical steps to slow down cognitive decline include avoiding factors that can damage memory (smoking, drinking, poor diet) and encouraging factors that are beneficial, including dietary and nutritional factors as well as the adage ‘use it or lose it’.

Challenging one's memory together with regular physical exercise helps postpone age-related memory loss. Tango dancing reduces the risk of developing Alzheimer's by a surprising rate of 75%; the same is true of playing chess or the piano. These demand an unusual combination of multi-tasking, mixing mental and physical activities, thereby helping to maintain a robust hippocampus.

Systematic reviews suggest that the herb Ginkgo biloba has beneficial effects on MCI. The key to management is individual assessment of cognitive function using computerized assessment, with individual reassessment over time, to monitor cognitive change and intervention effects. Critics of standard psychologist-administered cognitive function tests such as the mini-mental state examination (MMSE) highlight the inability of such tests to assess all aspects of performance. NICE guidelines would suggest MMSE as the gold standard; although the test was never designed for this role, measuring cognitive change in an individual with MMSE is at best a bit like using ‘red sky at night’ as a predictive test for the weather!

Nevertheless, the most commonly performed test is MMSE, which is used in research and clinical settings. The results are used as a guide to starting and monitoring treatment with anticholinesterase inhibitors in England (NICE guidelines).

Automated cognitive function testing has many advantages: it is the only way to make a definitive assessment of attention and recognition memory, it increases sensitivity and it reduces the variability between investigators’ assessments. Automatic collection of responses and maximized integrity of data save time and effort in reporting the results. The use of automated techniques makes it easier to identify therapeutic effects on the deficits that affect everyday life. ²

An example of the contrast between automated cognitive function testing and the manual MMSE comes from a study on the effect of hypertension on cognition. A multinational trial, randomized, double-blind and placebo controlled, was conducted in 4937 subjects aged 70–89 years. ³ One of the secondary outcomes was to study the treatment effects on cognition using the MMSE. Results using the MMSE showed no difference between treatment and placebo. However, the Newcastle centre of this trial, which had 257 subjects (5.2% of the whole study group), also used computerized memory testing (CDR) as well as the MMSE, and the former did demonstrate significant changes. [The Cognitive Drug Research (CDR) Computerised Cognitive Assessment System was validated in worldwide clinical trials. The system is available online to health-care professionals to assess the attention and memory capabilities of their patients in relation to age and gender-matched norms.]

The Newcastle group showed significantly less decline in attention and episodic memory compared with the placebo group on automated cognitive function testing; these statistical changes were revealed on a (20×) smaller patient group.

As well as showing that not taking blood pressure tablets is bad for memory, these results show that automated testing is more sensitive than the MMSE and raise ethical issues of whether the MMSE should be used in future studies. ⁴

All PCTs currently commission services that might make the diagnosis of dementia. They include general practitioners, old age psychiatric community teams, geriatric medicine and neurology services. Current systems are almost without exception non-prescriptive and lack clarity about where and by whom diagnoses of dementia should be made (over 50% of GPs are unsure in this area). From the Department of Health (DH) consultation, and based on the DH cost-effectiveness case, new specialist services need to be commissioned to deliver good-quality early diagnosis and intervention. There clearly is a role for menopause services in offering health and lifestyle advice, assessing MCI and monitoring progress and interventions.

Competing interests

None declared.