Since the Han Dynasty (206 BCE–220 CE), when civil service exams evaluated intellectual abilities, people have used cognitive assessments to identify special talents or, more commonly, to detect problems.
We’ve come a long way in 2,000 years! Today, neuropsychological batteries—combinations of assessments to detect dementia, learning disabilities, and cognitive impairments from chronic conditions or acute events—are widely used. Yet, far too often, these assessments are administered reactively, only after severe deficits are evident. By the time a neuropsychologist, neurologist, or geriatrician looks “under the hood,” it’s often too late for meaningful prevention.
Chronic illnesses affect approximately 129 million Americans—a population as large as Mexico’s. For many, cognitive impairment is a greater concern than physical symptoms. For instance, both type 1 and type 2 diabetes are linked to reduced neuropsychological abilities, sometimes starting early in life. Hypertension can also lead to cognitive decline, as can multiple sclerosis, epilepsy, lupus, and various cancers, to name a few. Moreover, the 5–6 million Americans admitted to intensive care units (ICUs) annually often experience new challenges with thinking, reasoning, and memory, sometimes more severely than other clinical populations. Sadly, few individuals with these conditions receive cognitive testing unless they request it or have an exceptionally attentive provider. This is problematic because early screening with a brief test or comprehensive battery can identify concerns that physicians can address proactively, while establishing a baseline for tracking future changes.
For years, we’ve been taught that cognitive problems are inevitable, rarely preventable, and that dementia is an unstoppable decline. Today, we know better. Allowing for caveats, it’s often possible to prevent, mitigate, or even reverse certain forms of cognitive impairment, including those tied to medical conditions or events. Interventions like improved diet, vigorous exercise, immersion in nature, sleep hygiene, and cognitive rehabilitation can make a difference. Their effectiveness hinges on early implementation—acting sooner yields better results, while delays reduce their impact or render them ineffective. Yet, these interventions cannot be tailored or initiated without first identifying a problem, and cognitive testing remains the best tool for that purpose.
Administering neuropsychological tests—whether comprehensive batteries, moderately difficult assessments, or simple tools like the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam (MMSE)—at routine exams or near a disease diagnosis presents challenges. These tests can be costly, access to neuropsychologists is limited in rural areas and small towns, and administering them to linguistically diverse populations can be difficult. While these barriers are daunting, it’s time to treat cognition as a vital sign, routinely assessed and never ignored. A practical starting point is empowering primary care providers to administer simple cognitive tests and integrating psychologists into primary care and specialty settings—including settings where they are rarely employed—to evaluate patients with early signs of diseases with cognitive implications, like those mentioned here and many others. A bigger goal is to change our entire paradigm related to how we think about cognitive testing: To make cognitive testing as “routine” as taking blood pressure at a clinic visit. We’re not there yet, but we can get there.
As science evolves and advances, we’ll gain deeper insights into how chronic diseases, aging, or hospital stays contribute to cognitive impairment. But knowledge alone is insufficient unless it translates into better patient care. Routine cognitive screening and detailed testing, with a focus on early identification—including with populations experiencing cognitive problems that are routinely ignored or overlooked—are critical steps toward that goal. After all, an ounce of prevention is worth a pound of cure.
Joshua Baker is a research coordinator. James Jackson is a psychologist.
