Declines in cognitive function vary among persons and can include changes in attention,
memory, learning, executive function, and language capabilities that negatively affect
quality of life, personal relationships, and the capacity for making informed decisions
about health care and other matters (1). Memory problems typically are one of the
first warning signs of cognitive decline, and mild cognitive impairment might be present
when memory problems are greater than normal for a person’s age but not as severe
as problems experienced with Alzheimer’s disease (2,3). Some, but not all, persons
with mild cognitive impairment develop Alzheimer’s disease; others can recover from
mild cognitive impairment if certain causes (e.g., medication side effects or depression)
are detected and treated (3). In 2012, the U.S. Department of Health and Human Services
published the National Plan to Address Alzheimer’s Disease, calling for expanding
data collection and surveillance efforts to track the prevalence and impact of Alzheimer’s
and other types of dementia (4). To estimate the prevalence of self-reported increased
confusion or memory loss and associated functional difficulties among adults aged
≥60 years, CDC analyzed data from 21 states that administered an optional module in
the 2011 Behavioral Risk Factor Surveillance System (BRFSS) survey. The results indicated
that 12.7% of respondents reported increased confusion or memory loss in the preceding
12 months. Among those reporting increased confusion or memory loss, 35.2% reported
experiencing functional difficulties. These results provide baseline information about
the number of noninstitutionalized older adults with increased confusion or memory
loss that is causing functional difficulties and might require services and supports
now or in the future.
BRFSS consists of annual state-based telephone surveys of randomly selected noninstitutionalized
U.S. adults aged ≥18 years regarding health practices and risk behaviors linked to
chronic diseases, injuries, and preventable infectious diseases.* In 2011, all 50
states and the District of Columbia conducted the BRFSS survey by landline and cellular
telephones, and the median survey response rate was 49.7%. In 2011, 21 states† included
a 10-question optional cognitive impairment module§ in their BRFSS surveys. Because
only seven of the 21 states conducted cell phone interviews in addition to landline
telephone interviews, this analysis was restricted to landline respondents aged ≥60
years from the 21 states.¶ The median landline response rate among the 21 states was
53.4%, and the rates ranged from 37.4% in California to 66.0% in Nebraska.** This
analysis was further limited to the 59,852 adults aged ≥60 years with nonmissing responses
to the first question in the module.
Respondents who answered affirmatively to the question, “During the past 12 months,
have you experienced confusion or memory loss that is happening more often or is getting
worse?” were categorized as reporting increased confusion or memory loss. Functional
difficulties were identified among these persons if they responded, “always,” “usually,”
or “sometimes” to one of two questions about whether confusion or memory loss interfered
with their “ability to work, volunteer, or engage in social activities,” or caused
them to “give up household activities or chores” that they “used to do.” Additional
questions addressed the need for assistance, getting care or assistance from a family
member or friend, and discussing increased confusion or memory loss with a health-care
provider. Respondents who declined to answer, had a missing answer, or who answered
“don’t know/not sure” were excluded from the analyses involving those variables.
Respondents were categorized by age group, sex, race/ethnicity,†† education level,
disability status,§§ veteran status, and employment status. BRFSS landline weights
were used to adjust for the probability of selection and to reflect the total adult
population in each state by age group, race/ethnicity, education level, marital status,
and home ownership status. To account for the complex sampling design, weighted data
were analyzed using statistical software.
In 2011, 12.7% of respondents reported increased confusion or memory loss during the
preceding 12 months, and 35.2% of those persons reported functional difficulties (Table
1). The percentage reporting confusion or memory loss was significantly higher among
the following: persons aged ≥85 years (15.6%) compared with those aged 60–64 years
(12.0%) and 65–74 years (11.9%); Hispanics or Latinos (16.9%) compared with whites
(12.1%); persons with less than a high school education (16.2%) compared with persons
with more education; persons who reported they were disabled (20.2%) compared with
persons who were not disabled (7.5%); and persons who were unable to work (28.3%)
compared with those who were employed (7.8%), unemployed (16.4%), homemakers (11.8%),
students (3.9%), and retirees (12.3%) (Table 1).
Among those reporting increased confusion or memory loss, significant differences
in the percentage with functional difficulties were found among the same demographic
groups, although in some cases the patterns differed. For example, the percentage
with functional difficulties was significantly higher among adults aged 60–64 years
(44.7%) compared with 65–74 years (29.0%) and 75–84 years (32.6%) and among blacks
or African Americans (61.6%) compared with whites (29.1%) and Asians/Native Hawaiians
or Other Pacific Islanders (16.2%) (Table 1). By state, the percentage reporting increased
confusion or memory loss ranged from 6.4% in Tennessee to 20.0% in Arkansas. Among
those with increased confusion or memory loss, the percentage with functional difficulties
ranged from 21.3% in Wisconsin to 52.2% in West Virginia (Table 2).
Among persons reporting increased confusion or memory loss, those with functional
difficulties were significantly more likely than those without functional difficulties
to report needing help (81.0% compared with 38.2%), getting help from a family member
or friend (46.5% compared with 6.0%), and discussing their increased confusion or
memory loss with a health-care provider (32.6% compared with 12.1%). In addition,
those who reported functional difficulties were more likely to report being unable
to work (32.8% compared with 9.6%) (Table 3).
Editorial Note
Age is the best-known risk factor for Alzheimer’s disease (the most common cause of
dementia), and more than 90% of cases occur in persons aged ≥60 years (2). Research
shows that Alzheimer’s disease causes changes in the brain years and even decades
before the first symptoms appear, and a better understanding about normal age-related
cognitive decline could provide important insights for future prevention efforts (1,2).
A systematic review found that among the primary care populations studied, as many
as 66% of all dementia cases were undiagnosed, with the majority of missed cases classified
as mild to moderate (5). Missed or delayed diagnosis impedes the ability to identify
and intervene for treatable causes and to provide timely and accurate information
and resources to patients and their families.
Public health surveillance provides the ability to track and monitor trends and identify
health disparities to understand the magnitude of the problem, plan for future resource
and service needs, inform interventions, and guide research efforts. However, public
health surveillance of dementia is limited and complicated by methodologic challenges
associated with identifying cases in the community (6). For these reasons, one suggestion
is that public health surveillance of these conditions be broadly focused and address
outcomes related to functional impairment rather than etiology (6). BRFSS provides
an opportunity to respond to the national call for expanded surveillance efforts by
tracking self-reported confusion or memory loss that is currently causing functional
difficulties among noninstitutionalized adults and could progress to a more serious
state of impairment.
The BRFSS results for 21 states described in this report indicate that 12.7% of persons
aged ≥60 years report increased confusion or memory loss in the preceding year, and
among these persons, 35.2% report functional difficulties. The findings show that
increased confusion or memory loss generally increased with age, but the percentage
reporting functional difficulties among persons aged 60–64 years was as great as among
persons aged ≥85 years and greater than among persons aged 65–84. These findings suggest
a need for future studies to examine the relationship of age and functional difficulties
caused by increased confusion or memory loss. For example, younger persons might face
challenges obtaining diagnostic testing because health-care professionals might not
suspect symptoms, or access to employer-sponsored benefits could be placed in jeopardy
if employed persons lose their jobs or are unable to work (7).
Among persons reporting functional difficulties, only 32.6% report discussing their
symptoms with a health-care provider. Early and accurate diagnosis provides opportunities
for individuals and families to initiate financial planning, develop advance directives,
enroll in clinical trials and anticipate care needs. Some causes for cognitive decline
are reversible (e.g., depression, infections, medication side effects, or nutritional
deficiencies), but they can be serious and should be treated by a health-care provider
as soon as possible (2). Misperceptions about dementia-related conditions might lead
to delayed diagnosis (4), and understanding cultural beliefs and public perception
is important for meeting national goals for increasing awareness. For example, studies
conducted with diverse groups of older adults found that terminology used to describe
brain health and beliefs about cognition varied among racial/ethnic populations (9).
Increased confusion or memory loss and functional difficulties were reported among
all racial/ethnic groups in this analysis, with persons identifying themselves as
black or African American reporting the highest levels of functional difficulties
compared with other groups.
What is already known on this topic?
Cognitive decline can negatively affect a person’s life and might progress into a
more serious state of impairment or dementia. Memory problems typically are one of
the first warning signs of cognitive decline, and up to two thirds of conditions that
meet the criteria for dementia are undiagnosed. When diagnosed early and accurately,
opportunities exist to treat potentially reversible causes, initiate financial planning,
develop advance directives, enroll in clinical trials, and anticipate care needs.
National plans call for expanding data and surveillance efforts to track dementia
and its impact on individual and population health in the United States.
What is added by this report?
Approximately one in eight adults aged ≥60 years surveyed from 21 states reported
increased confusion or memory loss in the preceding year. Among these persons, 35.2%
experienced difficulties resulting from confusion or memory loss. Wide variation in
these results was found across the 21 states. Respondents who reported functional
difficulties were significantly more likely than those who did not to report needing
help (81.0% compared with 38.2%), getting help from a family member or friend (46.5%
compared with 6.0%), and talking with a health-care provider about their increased
confusion or memory loss (32.6% compared with 12.1%).
What are the implications for public health practice?
These findings underscore the need to facilitate discussions with health-care and
service providers so that linkages can be made to accurate information and needed
services. They also indicate the importance of state-based surveillance to estimate
the magnitude of the problem among older adults living in the community.
Among those reporting increased confusion or memory loss and functional difficulties,
81.0% report needing assistance, and only 46.5% report getting help from a family
member or friend. The need for care could precede or follow a diagnosis of dementia
and escalates over time (8). Care could be provided by family members and friends
or through paid services. Understanding who is at risk for requiring care now or in
the future can help with anticipating needs and associated costs.
Wide variation observed among the 21 states might be the result of different cultural
or other factors and indicates the importance of state-based data on this subject.
Understanding cultural and social contexts is important when communicating public
health messages (8). Future studies of state-specific data examining associations
between increased confusion or memory loss and potential risk factors for dementia
such as cardiovascular disease, diabetes, depression, or physical inactivity (3) might
provide more insights that could also help explain the variations observed across
states.
The findings in this report are subject to at least five limitations. First, data
are self-reported, not validated by any clinical measurement, and might be subject
to recall bias. Second, the survey design is cross-sectional, and causality of specific
diseases or conditions cannot be inferred. Third, although questions underwent multiple
rounds of cognitive testing to ensure that respondents understood the questions, given
misperceptions surrounding dementia (4,7,8), respondents might provide the most “socially
acceptable” answer, which could vary by race/ethnicity or geography, and could account
in part for the variability observed among states. For example, blacks or African
Americans might be less likely than whites to report cognitive decline (10). Furthermore,
whether increased confusion or memory loss interferes with a respondent’s ability
to accurately describe functional difficulties is unknown. Fourth, these results might
underestimate confusion or memory loss and functional difficulties because BRFSS does
not include residents of nursing homes or other facilities where a high percentage
of people with cognitive impairment reside, and results were limited to landline telephone
survey responses and did not include cell phone respondents. Finally, response rates
among the 21 states were low and varied widely, ranging from 37.4% to 66.0%.
In May 2012, The U.S. Department of Health and Human Services released the National
Plan to Address Alzheimer’s Disease (4), which includes a call to strengthen data
and surveillance efforts. CDC’s Healthy Brain Initiative is working with the Alzheimer’s
Association and numerous other national, state, and local partners to develop a set
of public health actions to promote cognitive health as a vital, integral, component
of public health and also to address issues related to cognitive impairment for persons
living in the community and their care partners (i.e., informal and paid caregivers
and health-care providers). This report provides a baseline estimate of the extent
of self-reported increased confusion or memory loss and functional difficulties occurring
in the preceding year among noninstitutionalized persons aged ≥60 years who might
require services and supports now or in the future. The findings underscore the need
to facilitate timely discussions with health-care and service providers so that linkages
can be made to accurate information and needed services.