Friday Q&A: Possible Cognitive Problems

Q: I have a question related to aging and yoga, but from the perspective of the teacher. I teach 2 classes weekly for an aging population. A good number of these students have come weekly for a few years, so I get to know them pretty well, and I get to see their progress. I have noticed that one student seems to struggle with some of the cognitive aspects of the practice, but not consistently. Here's an example. Very commonly, we do Supta Padangusthasana (reclining hand to big toe pose). I teach it with a bit of detail (that the strap goes over the ball of the foot, that the front hip points are level, etc.). Some weeks, this student is right on it, getting the whole pose put together with the details. Other weeks, she's much slower, starts on the other side, puts the strap over her heel, keeps her knees bent, comes out of the pose, then looks around and realizes we're still in the pose. I often have to start her from scratch, while the rest of class is already set up. I find myself addressing her more often than anyone else, not because she may need an extra moment to get there, but because she doesn't seem to know where we're going. 
I have asked her to sit in the front and in the center, in case her hearing was the issue. I instruct most of the class directly in front of her in case she needs to see me. I have no problem with speaking louder, repeating myself, and demonstrating the pose before the group tries it out. These all go with the territory of teaching. I expect that my students won't remember all the details form week to week, so I'm no trying to progress them rapidly through advanced asana. My concern is that occasionally, she seems very out of sync with my basic expectations of understanding instruction, and I don't know if I am observing some sort of cognitive decline.
I am a yoga teacher and a yoga therapist, so I know the scope of my profession. It's not my place to diagnose. What I wonder is, how would a yoga teacher go about having a conversation that would ask delicate questions about cognition or memory? I have double-checked with her on hearing, vision, and overall suitability of the class for her needs. She loves coming, and I know how much the class has improved her achy hip and low back. Have you ever encountered this particular teaching conundrum? How would you look at this? And, if she is beginning to show some cognitive decline, at what point would a gentle level yoga class become inappropriate? She does have to drive to get to class!
A: For all the teachers out there, especially those who are working with older adults, this is a very relevant question. In fact, I have a student who is occasionally displaying similar signs of cognitive changes, although most classes, she is following the class instructions nicely. However, it has been noticeable enough at times that I have asked a colleague of mine who also teaches this student if they have observed the same distracted, inattentive, and tendency to get lost behavior that I have. And, indeed, this teacher noted the same occasional tendency, a definite change from the many years this student has been in our classes. We have even discussed approaching one or two classmates who seem to be friends of this student to see if they have observed similar spells of poor cognition, but have not yet moved forward with that possible next step. For now, we are practicing concerned observation. 
Periodic mental lapses, like the ones you are observing in your student, can be some of the first signs of changes that could fall into the realm of what is now called Mild Cognitive Impairment (MCI). In this condition, changes in memory and other aspects of brain function, such as decision making, spatial awareness, and others, become apparent to both to the individual having them and to family and close friends. These changes are bad enough to be noticed by sufferers and family, but not serious enough to interfere with daily activities. Some, but not all, people with MCI can go on to develop dementia, including Alzheimer’s disease. But the earlier the condition is identified, the better, as there are some reversible causes of cognitive and memory changes (mentioned below). And earlier diagnosis can allow the person who may go on to develop dementia time to be able to more fully participate in decisions about their future care, as well as the opportunity to include or increase activities and treatments that could delay full onset of more profound symptoms. The challenge for friends and family is that people who start to become suspicious they are developing dementia can become quite fearful and often experience denial. So a gentle approach may be required to even broach the subject.
It could certainly be argued that addressing these changes with your student is not your job as a yoga teacher. And yet you are not diagnosing a condition, so much as noting a change in abilities that could very likely benefit from further attention. And if your student is noticing these temporary lapses in memory and attention, she may already be worried about dementia or Alzheimer’s disease, but may want to deny their presence for any number of reasons. As a concerned teacher and friend, you could share your observation of her “easy distractibility” and ask if she has noticed this as well. Instead of directly addressing dementia, you could mention that you have read (here!) that there are several reversible causes of poor attention and memory lapses, such as thyroid imbalances, medications, undiagnosed urinary tract infections, and B12 deficiency that might be worth getting checked out with her family doctor. You might also ask her if any friends or family have mentioned noticing these temporary lapses as well, and if they have expressed concern and what they have suggested she do, if anything. 
And as I have considered for my student, if your student has a close friend in class, perhaps you could ask the friend if they have noticed any of these changes lately, just to help you get a better picture of the frequency of these episodes. 
If your student sees a doctor and is diagnosed as having MCI, there are several recommended strategies in our yoga toolbox that may delay onset of more serious cognitive changes (although the research jury is still out on the full impact of these strategies):

1. Exercising regularly with an active asana practice for heart, cardiovascular system, and brain health benefits (see Featured Sequence: Brain Health Practice).
2. Controling cardiovascular risk factors, such as high blood pressure, high  cholesterol, type 2 diabetes and pre-diabetes, smoking, being overweight or obese, and unhealthy eating habits, by using other yoga tools, such as stress management techniques and using restorative yoga to rest your heart (see Techniques for Improving Heart and Cardiovascular Health).
3. Engaging in socially and mentally stimulating yoga activities that keep the brain healthy (see How to Foster Brain Health with Yoga and How Yoga Sequences are Brain Aerobics). 

These are all areas which yoga can address nicely, either alone or more likely as an adjunct to what her health care team prescribes. So, it makes sense to try and keep our students in classes for as long as their condition permits. It does call on us as teachers to be able to “juggle two classes at once,” giving some special attention to the person who might be having a day of poorer function while also engaging the rest of class. In all likelihood, most teachers out there have been doing this already for some time, but this kind of challenge may require more patience and understanding than other issues you have worked with in the past. 
And it may be that at some point your class may no longer be appropriate for this student, when she requires too much of your time in a public class setting to stay safe and be redirected. So it might be worthwhile now to start looking for classes or yoga therapists in the community that specialize in working with people with early dementia to have a referral ready for the student and her family if that time arrives. In the meantime, keep offering the wonderful opportunity to all your older adults to do yoga together—it’s good for their brains! 
—Baxter 
Note from Baxter: If I observed that a student seemed truly confused throughout class, I’d certainly check in with them directly after class to make sure they seemed oriented enough to drive home. If it were clear they were not, I’d make arrangements for them to be driven home, regardless of what the cause. 
Note from Nina: I have a slightly different take on this. I think that if someone is showing possible cognitive problems and they are still driving a car, this is situation that calls for urgent action. You could be saving lives! Of course, taking action on this problem is awkward and uncomfortable—and it’s especially difficult bringing up the subject of stopping driving with older people—but because you mentioned that the student in question is still driving in general, I would encourage both you, the teacher who has written to us, and any other teachers out there in the same situation to move forward with taking action on your concerns about possible cognition problems as soon as possible. There may be some resistance—or it could be that you turned out to have misunderstood the situation—but at least you will have done your best. 
As for her staying in your class, I think it's your call based on whether or not you are able to easily keep her safe—you should not have to keep watching her at every moment—and whether she is  distracting the rest of the class.
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