Three Questions with Dr. Steven DeKosky

Valerie PatmintraExpert Interviews

Deputy Director, McKnight Brain Institute; Aerts-Cosper Professor of Alzheimer’s Research; Associate Director, 1Florida AD Research Center’ and Professor of Neurology & Neuroscience, University of Florida

Q: Why is early detection so critical to preventing cognitive decline among older adults and what are some of the barriers to early detection?

One of the major reasons why early detection or pre-disease detection is so critical is because the new therapies emerging for Alzheimer’s disease will be most beneficial for those with evidence of the disease in their brains but no cognitive manifestations. This is a time when the brain effects are still minor. With new treatments being developed and approved, it gives us more reason to screen people to identify those with normal cognitive aging vs. those with early Alzheimer’s or other neurodegenerative disease.

There is some disagreement on which cognitive screening test is best, and we know that none are perfect. The Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), St. Louis University Mental Status (SLUMS) Exam, the Mini-Cog, and several other rapid screening tests are available, but there isn’t consensus on which one to use. My advice is to choose one, become familiar with it, and use it consistently so you get used to how people answer. The MoCA is one of the most popular, but the SLUMS is also good. The Mini-Cog is the fastest because you can assess the patient during an appointment by asking them to draw a clock and three additional objects in five minutes. In general, the more extensive the testing, the more valid the results will likely be. That is part of the balance that must be considered in a busy clinician’s office.

Q2: What do you see as some of the major advances in the field of cognitive aging?

From new medical school curricula to publicly available brain health materials, there is a lot more information on brain health now compared to when I first started. Many medical centers now have programs focused on promoting brain health through various methods. Before dementia became more widely known, we were only seeing patients come in with severe or moderate-severe dementia– because that’s when they recognized their cognitive losses were greater than normal aging. With increasing public knowledge of Alzheimer’s disease and dementia, people began to come into memory clinics earlier, with mild memory or cognitive changes, and we did not have a way to accurately differentiate normal aging from the initial stages of a disease. Brain health programs have aided our understanding of the remarkable variability in normal brain aging and provided advice and support to the community.

To differentiate normal aging from the very early changes of a neurodegenerative disease, approval of blood tests that will screen for various dementias, especially Alzheimer’s, in these early phases are advancing rapidly; some are FDA approved. The golden age of studying normal memory changes in aging and differentiating it from Alzheimer’s began when tracers were developed for Positron Emission Tomography (PET) allowing detection of the amyloid plaques characterizing Alzheimer’s disease scans in living people. This method proved effective in determining who had Alzheimer’s and who didn’t. Older people who have a negative amyloid scan and are cognitively normal can participate in studies while they and the researchers know they do not have Alzheimer’s and any cognitive changes are due to normal aging—and can be studied for normal aging changes.

With new, extremely sensitive blood assays, some of which have already been approved by the FDA, we will be able to detect the abnormal proteins in the blood, potentially eliminating the more expensive scans, it will be a very important advancement in the field. Negative blood screens would also enable studies of cognitive changes in normal aging.

Q3: What do you see as the greatest challenge in helping people manage their cognitive health over time? 

While there are steps we know people can take to maintain their cognitive health over time, we can’t prove definitively that the strategies work. There is a lot of logic behind the recommendations for preserving cognition, however, like the number one rule that everything that helps your heart is also beneficial to the brain. From maintaining lipids in the normal range, to exercise, diet, hypertension control, and the maintenance of mental activities and social interactions, we know these strategies are all effective for both heart and brain health. 

We also need to publicize the fact that people should start considering these healthy habits earlier – starting in midlife – to preserve cognition, and emphasize the importance of managing other lifestyle factors. Cholesterol and vascular risk factors tend to elevate in midlife, elevating the risk for dementia later in life. People who don’t control these factors in middle age are at higher risk for dementia and neurodegenerative disease as they age. Educating people about the importance of these factors, which are modifiable, will also optimize maintenance of brain health.

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