AGE-RELATED COGNITIVE CHANGES
Normal age-associated cognitive changes include difficulties with memory, but:
- They do not noticeably disrupt daily life.
- They do not affect ability to complete tasks as usual.
- There is no difficulty learning and remembering new things.
- There is no underlying medical condition causing the difficulties.
(UCSF, 2020)
In older adults, some forms of confusion may be temporary or reversible (e.g., due to infections, depression), while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease. Health professionals should begin with the assumption that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes (Mayo Clinic, 2020c).
Delirium
Delirium is a reversible acute state of confusion that develops quickly and is a medical emergency. Delirium is more common in older adults and can be traced to one or more contributing factors, including severe or chronic illness, changes in metabolic balance, medications, infection, surgery, or alcohol or drug intoxication or withdrawal. If the underlying disorder is not corrected, irreversible neuronal damage can occur (Mayo Clinic, 2020d).
Medical management of a patient with delirium involves treating the underlying organic cause, and the goal of management is to keep the patient safe and free from falls and injury while attempting to identify the cause. Supportive care should aim at preventing complications.
Preventive strategies include providing orienting communication; reducing restraints; encouraging early mobilization; focusing on dehydration; and allowing for uninterrupted sleep by turning down the lights and prohibiting care providers from waking patients at night to take vital signs (Halter, 2018).
Mild Cognitive Impairment (MCI)
Mild cognitive impairment is the stage between expected cognitive decline due to aging and dementia. It is characterized by problems with memory, language, thinking, or judgment. These changes, however, are not severe enough to significantly interfere with daily living and one’s usual activities.
There is no single cause of MCI and no single outcome for the disorder. MCI may increase the chances of later development of dementia, but some people never get worse and a few eventually improve (Mayo Clinic, 2020c).
Experts classify mild cognitive impairment based on the thinking skills affected:
- Amnestic MCI primarily affects memory. A person may start to forget important information that they would previously have recalled easily.
- Nonamnestic MCI affects thinking skills other than memory, including ability to make sound decisions, judge the time or sequence of steps needed to complete a complex task, or visual perception.
(AA, 2021)
Currently there are no drugs or other treatments approved specifically for mild cognitive impairment. Cholinesterase inhibitors approved for Alzheimer’s disease may be prescribed, but they are not routinely recommended for MCI (Mayo Clinic, 2020c).
Research has found certain factors that may reduce the risk of cognitive impairment, including:
- Avoiding excessive alcohol use
- Limiting exposure to air pollution
- Reducing risk of head injury
- Not smoking
- Managing diabetes, cholesterol, hypertension, obesity, and depression
- Practicing good sleep hygiene and managing sleep disturbances
- Eating a nutrient-rich diet low in saturated fats
- Engaging socially with others
- Exercising regularly at moderate to vigorous intensity
- Wearing a hearing aid if hearing loss is present
- Engaging in mentally stimulating activities
(Mayo Clinic, 2020c)
Dementia
Dementia is an umbrella term for a collection of symptoms of cognitive decline including disruptions in short-term memory, learning new information, planning, problem-solving, decision-making, language, orientation, visual perceptual skills, mood, and behavior, all of which interfere with daily activities. Dementia, however, is not a result of normal aging of the brain (CDC, 2020b).
Dementia often has more than one cause involving damage to the brain from a number of different sources, and those with Alzheimer’s disease may also have vascular dementia. Alzheimer’s disease and vascular dementia are the most common forms of dementia in older adults (AGS, 2020).
MANAGEMENT AND PREVENTION
There is no cure for dementia, but there are medications, treatments, and strategies that can slow decline and help patients with dementia utilize their abilities to function as well as possible in order to have the highest possible quality of life. These involve:
- Identifying, treating, and monitoring underlying problems that increase the risk of dementia and can worsen symptoms (e.g., heart disease and diabetes)
- Checking for and treating problems that can contribute to mental health changes (e.g., depression, pain, hearing or vision loss)
- Monitoring for development of new medical problems
- Monitoring for medication side effects
- Teaching caregivers how best to manage symptoms and behavioral problems and to find caregiving, financial, and legal support
(AGS, 2020)
Medications that are often prescribed for those with dementia include cholinesterase inhibitors and MNDA receptor agonists. Antipsychotic drugs, antidepressants, and mood stabilizers may help control specific behaviors that may present in the patient diagnosed with dementia, but effectiveness is limited, and they are associated with an increased risk of death (AGS, 2020).
Nonpharmaceutical interventions are tailored to the person’s symptoms and needs in collaboration with the patient and caregiver. These may include physical therapy exercise programs, occupational therapy, pet therapy, message therapy, aromatherapy, or art therapy.
There is no way to prevent all types of dementia, but there is evidence that the risk can be reduced with a healthy lifestyle, including participating in regular activity and maintaining good heart health (Alzheimer’s Society, 2021a).
COMMUNICATING WITH THE PATIENT WITH DEMENTIA
It can be difficult and challenging to care for patients with dementia. It is helpful to remember that every behavior being expressed is the patient’s way of trying to communicate experiences, fears, prejudices, feelings, values, and beliefs that may require further assessment (Koch, 2020).
People with dementia retain the ability to interpret tone and body language, which is very important for them in making sense of the world. If a caregiver talks to them as if they were children, they will likely know they are being talked down to. It is best to avoid using baby talk, calling adults “Dear” or “Sweetie,” or speaking in a high-pitched, sing-song voice. This is likely to result in irritation and contribute to aggressive and uncooperative behavior and to the patient being labeled as “difficult.” It is always best to call the person by name.
Individuals with dementia are often living in an alternate reality, and it may do more harm than good to attempt to orient them to the current reality. The caregiver must enter the patient’s reality and work on that level.
Recommendations for effective communication include:
- Communicate in a dignified adult manner, using short sentences and speaking slightly more slowly and clearly.
- Do not assume the patient has lost a more sophisticated vocabulary and resort to simple or easier words.
- Allow a period of silence after speaking for the person to think before answering.
- Try to communicate in a conversational manner.
- Avoid asking ask question after question. As the disease progresses, ask questions that require a yes or no answer, and break down requests into single steps.
- Offer choices when making a request for which the patient might resist. For example, “Do you want to take a shower before breakfast or after breakfast?” instead of, “It’s time to take a shower.”
- Whenever possible, avoid distractions such as background noise that can make it difficult to hear, listen attentively, or concentrate.
- Avoid criticizing, correcting, and arguing. When listening to someone with dementia, it is pointless and counterproductive to argue about what the person is saying.
- Avoid asking questions that require concentration and memory to answer, such as “What did you eat this morning?”
(Alzheimer’s Society, 2021b; Koch, 2020)