Cognitive Impairment in Menopausal Women: A Cross-Sectional Study explores the relationship between menopause and cognitive decline, highlighting changes in memory, concentration, and executive function. Written by Divya Shukla, this study provides a detailed analysis of hormonal influences on brain function, potential risk factors, and evidence-based interventions to mitigate cognitive impairment in menopausal women. With a focus on clinical assessment tools, cognitive screening methods, and the role of physiotherapy in neurocognitive health, this book is an essential resource for healthcare professionals, researchers, and women’s health practitioners.
"Cognitive Impairment in Menopausal Women: A Cross-Sectional Study"
Divya Shukla
Student Researcher, Amity Institute of Health Allied Sciences, Department of Physiotherapy, Amity University, India
Abstract
Objective: The aim of the study is to investigate the prevalence and severity of cognitive impairment in women undergoing menopausal phases, as well as any potential association between cognitive changes and other menopausal symptoms.
Methodology: Eighty women in southern Delhi (mean age± 50.5, SD = 5.64 years) were enrolled in a cross-sectional study based on their menopausal condition. The Menopause Rating Scale (MRS) was used to measure menopausal symptoms, whereas the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive abilities.
Results: The prevalence of cognitive impairment increased from premenopause (72.73%) to perimenopause (84.0%) to postmenopausal (90.91%) in women. The prevalence of moderate and severe cognitive impairment was highest in postmenopausal women. Correlation analysis showed that symptoms like heart discomfort, depressive mood, irritability, and anxiety had negative correlations with cognitive functions like naming, attention, and language. Surprisingly, some symptoms like sleep problems, physical or mental exhaustion, and joint or muscular discomfort exhibited positive correlations with certain cognitive functions.
Conclusion: These findings highlight the critical need for addressing cognitive health concerns across all menopausal stages, as the variable degrees of cognitive impairment observed in each group emphasize the prerequisite for tailored interventions and support strategies aimed at preserving cognitive function and promoting overall health and well-being in women throughout their lives. The significant prevalence of cognitive impairment, particularly in postmenopausal women, highlights the risk of cognitive decline and its potential impact on daily life and overall quality of life. This underscores the importance of early detection and intervention to mitigate these risks and promote healthy aging.
Keywords: Menopausal Women, Cognitive Impairment, Menopause Rating Scale (MRS), Montreal Cognitive Assessment (MoCA).
Introduction
Menopause is the expected biological process that marks the end of a woman's menstrual phase. It typically takes place between the ages of 45 and 55, with an average age of 51. It occurs when the female ovaries cease to produce eggs, resulting in an overall reduction in the synthesis of both progesterone and estrogen hormones. Hot flashes, night sweats, irregular menstrual periods, vaginal dryness, insomnia, fluctuations in mood, decreased sex desire, forgetfulness, headaches, joint pain, and bladder problems are all symptoms of a hormonal shift. (1) Menopause can cause cognitive impairment as a result of hormone insufficiency and menstrual cycle irregularities. Hormonal limits, unusually a drop in estrogen may be a factor in a decline in cognitive function, and cognitive obstructions become more prevalent as menopause approaches. Mild cognitive impairment (MCI) is associated with a ninefold increase in the probability of dementia when compared to the general population, while subjective cognitive complaints with average performance on neuropsychological tests are associated with a twofold increase in the risk of dementia. (2)
Cognition refers to the cognitive activities involved in learning information and interpretating it via thought, feeling, and the senses. Menopausal cognitive shrinking may be observed as difficulty with decision-making, remembering and riveting new knowledge, concentrating, thinking clearly, and memory challenges, habitually referred to as "brain fog.” (3) Menopause is accompanied by various kinds of cognitive changes, including personal complaints and diminishing verbal memory and attentional tasks. (4,) These modifications might be affected by hormonal factors, specifically the drop in estrogen levels after menopause. (5) The alteration to menopause can worsen age-related declines in cognition, noticeably in answer speed and visuospatial ability. (6) However, the effects of perimenopause on cognition may be additionally complex, with some studies indicating that it is characterized by a deficit of better scores rather than a decline. (7) More discoveries are required to understand the linkage between menopause and cognitive decline. Menopause-related intellectual decline influences many aspects of a woman's life, involving her job, social connections, emotional well-being, and psychological well-being. Current findings offer insight into these consequences.
Cognitive impairment linked to menopause might have an impact on job performance and productivity. Cognitive changes during menopause, including forgetfulness and decreased focus, might influence job-related activities, decision-making, and overall workplace efficiency. Women suffering cognitive impairment throughout menopause may have difficulty maintaining optimal work performance and may benefit from workplace adjustments and assistance. (7) Menopausal cognitive impairment can hinder social relationships by interfering with speech, memory of social communications, and handling of emotions. Cognitive impairment can cause social withdrawal, misconceptions in conversations, and difficulties sustaining connections. Addressing cognitive changes and discovering social support can help women overcome these problems and sustain good social connections. (8) Emotional health: Cognitive impairment associated with menopause can have an impact on emotional well-being by contributing to mood swings, frustration, and emotional instability. Anxiety and sadness, which are frequent symptoms of menopause, may be worsened by cognitive deterioration. Lifestyle adjustments, cognitive exercises, and emotional support can help women manage these emotional issues. (9)
Decreased cognition during menopause may result in stress, anxiety, and feelings of inadequacy. Women experiencing cognitive decline may feel unsatisfied or frustrated by memory loss and issues with cognition. Psychological therapies, cognitive training, and health services can assist women in overcoming the psychological burden of cognitive changes during menopause. (10) The study done in rural northern China reported that 28.6% of women were diagnosed with moderate cognitive impairment (MCI) and 11.4% with dementia. Age at menopause, age at menarche, and reproductive period were examined for their link with cognitive impairment in menopausal women. (11) The most recent global prevalence of cognitive impairment is reported to range from 5.1% to 41%, with a median of 19.0%. The prevalence of cognitive impairment varies across the world, with Europe having the greatest rate at 5.1%, followed by North America at 7.1% and South America at 24.3%. Asia has the highest incidence of 6.5%, followed by Africa (18.4%) and Australia (33.3%). These findings highlight the importance of targeted treatment options and support measures for addressing cognitive health issues in varied groups. (12) The nationwide incidence of cognitive impairment in India has been reported to be 7.4% among persons aged 60 and up, with large variation amongst states and communities. According to this estimate, nearly 8.8 million Indians over the age of 60 suffer from dementia. (12) Cognitive impairment prevalence in India varies by area. According to current research, it is predicted to affect 7.5% of people in urban India. In rural India, the estimated prevalence of cognitive impairment is 10.6%. (13)
The frequency of cognitive impairment in postmenopausal women is an important concern, with research pointing to a variety of cognitive abnormalities related to menopause. According to research, cognitive problems are more frequent in postmenopausal women than in premenopausal women, with prevalence estimates ranging from 44% to 62% in population surveys. (3) Furthermore, the fall in estrogen levels after menopause has been correlated to cognitive alterations, such as reported cognitive complaints and altered brain connections, which may be early indicators of neural malfunction in postmenopausal women. (14)
Research highlights menopause's major influence on cognitive function, with subjective cognitive deterioration being a prevalent complaint among menopausal women, with a prevalence ranging from 44% to 62%. (2) Understanding the incidence and severity of this condition is critical for addressing cognitive health issues and directing cognitive well-being treatments. Menopause has been associated with cognitive changes, such as personal complaints and reduced verbal memory, with hormonal factors most likely leading to cognitive loss. Findings reveal an increased prevalence of cognitive concerns within menopause, along with a fall in hormone levels, in particular estrogen, and an inclination for women's cognitive skills to decline over the period. Existing studies, however, produce inconsistent data regarding the effects of hormone treatment on cognition in postmenopausal women, underscoring the need for more studies to understand the complex interrelationship between menopause and cognitive wellness in women. (15)
Methodology
The study protocol was approved by the Institutional NTCC Committee at Amity University, Uttar Pradesh's Amity Institute of Health Allied Sciences, after a comprehensive examination. This necessary approval, which was obtained on October 31, 2023, has the reference number NTCC, MPT-Orthopaedic, October 2023–24,16. The committee's approval guarantees that all ethical rules and regulations are adhered to during the examination procedure. With registration number CTRI,2024,01,061790 for the trial, this investigation was registered with the Clinical Trials Registry India (CTRI).
Participant Selection
This cross-sectional study was conducted from October 2023 to March 2024 among women between the ages of 40 and 60 in southern Delhi. Based on the inclusion criteria, women who met the following criteria were invited to participate in the study: women aged between 40 and 60 years, who were able to speak and understand Hindi or English, and who were willing to provide informed consent. A total of 80 participants were recruited through community-based recruitment strategies, including public places such as gyms and parks, hospitals, etc.
Inclusion and Exclusion Criteria
The inclusion criteria were women aged between 40 and 60 years who were able to speak and understand Hindi or English and who were willing to provide informed consent. The exclusion criteria were pre-existing neurological conditions (e.g., Alzheimer's disease, Parkinson's disease), severe mental health conditions (e.g., schizophrenia, severe depression), patients receiving hormonal replacement therapy or undergoing any surgical procedures, history of cognitive impairment or dementia diagnosis, and use of medications that could significantly impact cognitive function (e.g., sedatives, antipsychotics).
Menopausal Status Participants were categorized according to their menopausal status based on the Stages of Reproductive Aging Workshop (STRAW) criteria. The STRAW criteria define three stages of menopause: premenopause, perimenopause, and postmenopause.
Premenopause is characterized by regular menstrual cycles without significant changes in cycle length or menstrual flow. Perimenopause is a transitional phase that includes the years leading up to menopause, when hormonal variations begin, leading to irregular menstrual cycles, changes in flow, and symptoms like hot flashes and night sweats. Postmenopause begins 12 months after the final menstrual period and lasts throughout the rest of a woman's life. (16)
Instruments and Tools
The Menopause Rating Scale (MRS) is a health-related quality of life scale invented to assess menopausal symptoms and their impact on women's well-being. The scale contains 11 items, each signifying a specific symptom, and is scored on a 5-point Likert scale, with a minimum score of 0 and a maximum of 4 for severe signs. The total score is computed by adding up the scores of each item, with higher scores representing more severe symptoms affecting the quality of life. (17)
The MRS is classified into three elements: psychological, somatic, and urogenital symptoms. The psychological aspect includes symptoms such as mental and physical exhaustion, irritability, and anxiety. The somatic dimension covers joint and muscular discomfort, hot flashes, and sleep problems. The urogenital component includes symptoms related to vaginal dryness and urinary issues. The combination for each element is analyzed by adding up the scores of the resultant items, and the total score is the sum of the aspect scores. (18)
The MRS has confirmed its high reliability and validity. Reliability measures, such as constancy and test-retest stability, are reliable across countries, although the sample size for test-retest reliability was small. Validity has been well-known through comparisons with other scales like the Kupperman Index and the generic quality-of-life scale SF-36, which disclosed sufficient correlations, signifying adequate criterion-oriented validity. In terms of scoring interpretation, higher total scores suggest more severe symptoms affecting the quality of life. The MRS is generally accepted internationally and has been interpreted in multiple languages, including English, French, German, Indonesian, Italian, Mexican/Argentine, Spanish, Swedish, and Turkish. (19)
The Montreal Cognitive Assessment (MoCA) is a cognitive screening tool intended to assess various cognitive domains, comprising attention, concentration, executive functions, memory, language, visuospatial skills, conceptual thinking, calculations, and orientation. The MoCA estimates that these cognitive functions are accomplished by specific tasks such as drawing a line connecting numbers and letters in ascending order, copying a cube accurately, drawing a clock with specific instructions, recalling words previously presented, and answering orientation questions about the date and place.
The MoCA's scoring practice allows clinicians to assess various cognitive functions and verify an individual's cognitive status based on their performance-based tasks. A score below 26 may point out mild cognitive impairment or cognitive deficits that demand further evaluation and monitoring. (20, 21,22) The Montreal Cognitive Assessment (MoCA) has been discovered to have high sensitivity and specificity in identifying cognitive impairment. Studies have testified that the MoCA is a useful screening tool due to its high sensitivity and specificity at accurate cut-off scores. For example, one report found that the MoCA had a sensitivity of 95% for positive normal cognition (score more than or equal to 26) and a specificity of 73% for excepting cognitive impairment (score less than 26) in an old age psychiatry setting. On the other hand, the specificity declined to 37% when mentioned but not cognitively impaired individuals as comparisons. In general, the MoCA has been shown to be valuable for differentiating between individuals in need of further assessment and those with normal cognitive function, drawing attention to its utility in clinical practice for cognitive screening. (23)
Data collection procedures
Data collection involved in-person interviews, during which participants completed the MRS and MoCA. Demographic information was also collected. All data were recorded and organized in an Excel spreadsheet for statistical analysis. The study followed ethical guidelines, ensuring that participants provided informed consent and were assigned unique ID numbers to protect their privacy.
Results: The statistical analysis of menopausal women's demographic variables and cognitive evaluation scores discovered significant insights into the relationship between menopausal phases and cognitive function.
Table 1: Demographic Details of Menopausal Women
Illustrations are not included in the reading sample
The age distribution displayed that 32.5% were between 45-49 years old, 31.2% were between 50-54 years old, 21.3% were 55 years of age or older, and 15.0% were less than 45 years old. The mean weight of the participants was 61.6 kg (SD = 5.9), with a range from 49 kg to 75 kg and a median weight of 62 kg. About menopausal status, the majority of the study population (55.0%) was postmenopausal, followed by 31.2% in perimenopause and 13.8% in premenopause. Similarly, the menstrual history data discovered that 55.0% had stopped menstruating, 31.2% had irregular periods, and 13.8% had regular periods. The educational background of the participants was diverse, with 48.8% having an education above high school, 30.0% having a high school education, and 21.2% having less than a high school education. The majority of the study population (83.8%) was married, followed by 10.0% who were widows, 2.5% who were separated, 2.5% who were unmarried, and 1.2% who were divorced. In terms of employment status, most of the study population (72.5%) were housewives, followed by 23.7% who were working and 3.8% who were not working. The physical activity level of the participants was predominantly mild (53.8%), followed by moderate (33.8%), sedentary (8.8%), and vigorous (3.6%).
Table 2: Prevalence of Cognitive Impairment by Menopausal Status
Illustrations are not included in the reading sample
The table presents a detailed analysis of the prevalence of cognitive impairment among women based on their menopausal status. Examining the data reveals distinct trends in cognitive health across different stages of menopause. Among the premenopausal women in the study, comprising 11 individuals, 8 were identified as suffering cognitive impairment, resulting in a prevalence rate of 72.73%. This suggests a notable proportion of premenopausal women exhibit cognitive challenges. The standard deviation of 5.91 indicates some variability in cognitive impairment scores within this group, with a mean score of 19.91. Moving to the perimenopausal group of 25 women, 21 were found to have cognitive impairment, leading to a prevalence rate of 84.00%. This demonstrates a higher prevalence compared to the premenopausal cohort. The standard deviation of 5.85 suggests relatively consistent cognitive impairment scores within this group, with a mean score of 19.70. In the largest group of postmenopausal women, totalling 44 individuals, 40 were identified as having cognitive impairment, resulting in the highest prevalence rate of 90.91%. This indicates a significant prevalence of cognitive challenges among postmenopausal women. The standard deviation of 4.87 suggests less variability in cognitive impairment scores within this group, with a mean score of 18.51. Overall, the data highlights a clear trend of increasing prevalence of cognitive impairment in premenopausal, perimenopausal and postmenopausal women.
Illustrations are not included in the reading sample
Fig:2.1 prevalence rate of cognitive impairment across menopausal phase
Table 3: Cognitive Impairment Levels Across Menopausal Status
Illustrations are not included in the reading sample
The table represents the distribution of cognitive impairment among women categorized by their menopausal status. The results show that cognitive impairment is a common issue across all menopausal stages, with instable degrees of severity.
Premenopause:
The premenopausal group of 11 women showed a significant prevalence of cognitive impairment, with 6 women demonstrating mild cognitive impairment, 4 women displaying moderate cognitive impairment, and 1 woman experiencing severe cognitive impairment. This suggests that cognitive challenges are already present in premenopausal women, which may have implications for their overall health and well-being.
Perimenopause:
The perimenopausal group of 25 women demonstrated an even higher prevalence of cognitive impairment, with 11 women exhibiting mild cognitive impairment, 10 women displaying moderate cognitive impairment, and 4 women experiencing severe cognitive impairment. This indicates that cognitive challenges are more widespread and severe in perimenopausal women, which may be related to the hormonal changes and other physiological adjustments occurring during this stage.
Postmenopause:
The postmenopausal group of 44 women showed the highest prevalence of cognitive impairment, with 22 women exhibiting mild cognitive impairment, 19 women displaying moderate cognitive impairment, and 3 women experiencing severe cognitive impairment. This suggests that cognitive challenges are most prevalent and severe in postmenopausal women, which may be related to the loss of estrogen and other hormonal changes that occur after menopause. Overall, the data highlights the importance of addressing cognitive health concerns across all menopausal stages. The varying degrees of cognitive impairment observed in each group underscore the need for tailored interventions and support strategies aimed at preserving cognitive function and promoting overall health and well-being in women throughout their lives.
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Fig 3.1: Severity of Cognitive Impairment
Table 4: Correlation Coefficients Between Menopausal Symptoms and Cognitive Functions
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*Significant (p<0.05); **Significant (p<0.001)
The correlation analysis between menopausal symptoms and cognitive functions discloses various associations within the sample population . sleep problems, which exhibited a statistically significant modest positive correlation (r = 0.11, p < 0.05) with visuospatial/executive function. This suggests that individuals experiencing sleep disturbances may paradoxically demonstrate slightly enhanced performance in tasks related to spatial responsiveness and executive control. On the other hand, symptoms such as heart discomfort displayed consistently negative correlations across multiple cognitive functions, with statistically significant associations observed in naming (r = -0.35, p < 0.001), attention (r = -0.47, p < 0.001), and language (r = -0.41, p < 0.001). These results indicate a notable decline in cognitive performance across these domains among individuals undergoing heart discomfort. Similarly, depressive mood, irritability, and anxiety exhibited statistically significant negative correlations across naming, attention, and language, further signifying compromised cognitive function in individuals affected by these psychological symptoms. However, among the predominantly negative correlations, some symptoms established unexpected positive associations with cognitive functions. For instance, physical and mental exhaustion exhibited a statistically significant small positive correlation with abstraction (r = 0.24, p < 0.05), indicating possible cognitive aids or variations in individuals experiencing exhaustion. Additionally , joint and muscular discomfort exhibited statistically significant moderate positive correlations with attention (r = 0.56, p < 0.001) and delayed recall (r = 0.46, p < 0.001), indicating upgraded attentional focus and recall abilities among individuals with these discomforts. These findings highlight the complex relationship between physical symptoms and cognitive functioning. While some symptoms are associated with cognitive decline, others may be linked to subtle enhancements or adaptations in specific cognitive domains. Understanding these associations is dominant for developing targeted interventions to preserve cognitive health and mitigate the impact of physical symptoms on cognitive functioning. Overall, these correlations provide perceptions of potential relationships between menopausal symptoms and cognitive functions within the studied population.
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Fig 4.1: correlation of menopausal symptoms and cognitive function
Discussion
The findings of this study provide significant insights into the relationship between menopausal phases and cognitive function. The outcomes indicate that cognitive impairment is a common issue across all menopausal stages, with varying degrees of severity. The prevalence of cognitive impairment increased from premenopause to perimenopause to postmenopause, with the highest prevalence observed in postmenopausal women. The correlation analysis between menopausal symptoms and cognitive functions discovered various associations within the sample population. Sleep problems, which revealed a statistically significant modest positive correlation with visuospatial/executive function, suggest that individuals experiencing sleep disturbances may inconsistently demonstrate slightly enhanced performance in tasks related to spatial responsiveness and executive control. On the other hand, symptoms such as heart discomfort displayed consistently negative correlations across multiple cognitive functions, with statistically significant associations observed in naming, attention, and language. The study's results have implications for women's health during menopause. Menopause is a critical phase of cognitive aging for women, and the results suggest that postmenopausal women are at an advanced risk of cognitive impairment. The study also highlights the possible impact of specific menopausal symptoms on cognitive function, suggesting that addressing these symptoms may help improve cognitive function during menopause. The report's results are consistent with previous research that has found a link between menopausal symptoms and cognitive changes in women. However, the study's discoveries contribute to the current frame of knowledge by providing a more complete analysis of the relationship between specific menopausal symptoms and cognitive function. (24,25)
These results indicate a notable decline in cognitive performance across these domains among individuals undergoing heart discomfort. The study's findings also highlight the importance of addressing cognitive health concerns across all menopausal stages. The varying degrees of cognitive impairment observed in each group emphasize the need for tailored interventions and support strategies aimed at preserving cognitive function and promoting overall health and well-being in women throughout their lives. The implications of these findings are significant, as they suggest that cognitive challenges are already present in premenopausal women and increase in severity as women progress through menopause. This underscores the importance of early detection and intervention to mitigate these risks and promote healthy aging. Furthermore, the study's findings emphasize the need for a comprehensive approach to addressing cognitive health concerns, incorporating both physical and psychological factors. The limitations of this study include the relatively small sample size and the potential for selection bias. Future studies should aim to replicate these findings with larger, more diverse samples to further validate the results. Additionally, the study's findings should be considered in the context of the broader literature on menopause and cognitive function, as well as the potential interactions between menopausal symptoms and cognitive health.262728
Conclusion
These findings highlight the critical need for addressing cognitive health concerns across all menopausal stages, as the variable degrees of cognitive impairment observed in each group emphasize the prerequisite for tailored interventions and support strategies aimed at preserving cognitive function and promoting overall health and well-being in women throughout their lives. The significant prevalence of cognitive impairment, particularly in postmenopausal women, highlights the risk of cognitive decline and its potential impact on daily life and overall quality of life. This underscores the importance of early detection and intervention to mitigate these risks and promote healthy aging.2930313233
Conflict of interest: none
Acknowledgment:
The authors would like to express their gratitude to all participants who generously contributed their time and insights to this study. Special thanks to the research team for their dedication and support throughout the project.
[...]
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- Divya Shukla (Author), 2024, Cognitive Impairment in Menopausal Women. A Cross-Sectional Study, Munich, GRIN Verlag, https://www.hausarbeiten.de/document/1571784
