We All Age Differently

Presidential candidate Nikki Haley’s recent comments about her parents — suggesting that all people decline cognitively as they age — got my attention. It’s simply not true and it made me angry.

However, as someone prone to action rather than anger (!), I decided to write today’s newsletter, both to combat age-shaming, as well as to provide insight into preventative healthcare and assessments of cognition.

My Recent Primary Care Visit

I have had the same primary care physician for more than 20 years. We have a fabulous relationship and I feel fortunate to be working with her. At this point, of course, I have certain expectations about how my yearly appointments progress.

But at my last visit, the medical assistant said that since I had recently turned 65, we would be conducting an Initial Preventive Physical Exam (IPPE)Also known as the “Welcome to Medicare” preventive visit, this exam uses diagnostic, screening, and physical examination tools to practice prevention, promote good health, and establish a baseline upon which to measure future evaluations. All positive goals that we espouse!!

Medicare pays for just one IPPE assessment per lifetime and it must be provided within the first 12 months after the start of Part B coverage.

Note that the IPPE is not the same as an Annual Wellness visit (AWV). This examination is for patients who’ve had Medicare coverage for longer than 12 months after the month they became eligible for Medicare Part B and who didn’t have an IPPE or AWV within those past 12 months. 

Yes, it is all confusing, but we love the focus on prevention!

Baseline Screening

The IPPE has nine components, two of which caught me off guard. Not because I was unaware of them, but because I felt much too young to have these tests done (another reminder of the milestone I had reached!). These two tests are for depression and cognition.

The truth is, despite having attended hundreds of appointments with clients and family members during which these tools are used, I found myself becoming really anxious about my performance. It was humbling, but it gave me greater insight into what clients experience as well as how my presence during these tests may further add to their anxiety and affect their performance.

Testing for Depression

To test for depression, a physician can select from various standardized screening instruments recommended by the American Psychiatric Association. Being tested for depression did not bother me too much because, fortunately, I’m in good shape in this regard. 

But I am pleased that this has become standard, as depression often goes undetected and can have major implications.

Testing for Cognition

This test, on the other hand, threw me. As with depression, there are numerous tests used. The cognitive tests focus on identifying early signs of cognitive impairment and/or dementia. The Montreal Cognitive Assessment (MoCA) is the one I see most often in primary care practices. Impairment level is based on objective scoring, with a maximum potential score of 30. Another test, less frequently used, is the Mini-Mental State Examination (MMSE)

One element of the MoCA requires repeating five spoken words immediately, then again five minutes later. Happily, I could recall the words — not just five minutes later but for days afterward. (I can only remember three of them today. Hmmm!)

The other element involved drawing a clock with the hands indicating a time of 10 minutes to eleven. Fortunately, I did just fine with this one, too. But I had a chuckle thinking about one client whose husband lovingly helps her practice before each visit to her neurologist!

Just the Beginning

One of the most important things to remember about these tests is that they are not the end, but the beginning of an assessment. Their primary use is to determine if a person requires further testing, to rule out medical causes of decline that could potentially be reversible, or to identify exactly what someone may be experiencing. 

These additional tests are part of a neuropsychological evaluation which is conducted by a neuropsychologist. They provide much more detail regarding brain function by assessing mental capabilities such as reading, the use of language, attention, learning ability, reasoning, memory, and problem solving, as well as mood and behavior.


I hope that we can all embrace aging for ourselves and our loved ones, and that we do all we can to stay as healthy as possible and enjoy our time on this earth. Prevention is key, as is early detection of issues such as cognitive decline so that, potentially, its progression can be delayed. Towards that end, establishing a baseline of cognitive functioning is important! 

My very wise father, who is approaching his 90th birthday in June, takes great care of his health and we both help mom take the best care of hers. He has always said that getting older is much better than the alternative and that looking down at the green grass is better than looking up at the brown roots! Both points of view make me smile.