COGNITIVE CHANGES OF AGING

Normal age-related cognitive declines affect mainly the speed of thinking and attention. In abnormal aging, declines in cognition are more severe and may include other thinking abilities, such as confusion, rapid forgetting or difficulties navigating, solving common problems, expressing oneself in conversation, or behaving outside of social rules (UCSF, 2020).

In older adults, some forms of confusion may be temporary or reversible, while others may be irreversible or indicative of chronic confusion and dementia, including Alzheimer’s disease. Gradual onset of confusion may be reversible if it is related to a treatable or correctible condition such as nutritional deficiency, hypothyroidism, vision or hearing impairment, urinary tract infections (febrile), or depression. Health professionals need to assume that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes.

Medical conditions and lifestyle factors have been linked to an increased risk of cognitive changes as the individual ages, including:

• Diabetes
• Smoking
• Hypertension
• Elevated cholesterol
• Obesity
• Depression
• Lack of physical exercise
• Low education level
• Infrequent participation in mentally or socially stimulating activities
  (Mayo Clinic, 2020d)

Normal Age-Related Changes

Some changes in the ability to think are considered a normal part of the aging process. Many thinking abilities appear to peak around age 30 and very subtly decline with age in most people. These declines most commonly include overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind, and word-finding. Age-related changes in brain structure are a common aspect of aging, contributing to some of the changes in thinking. However, not all thinking abilities decline with age. Vocabulary, reading, and verbal reasoning remain unchanged or even improve during the aging process.

Normal age-associated 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.
  (USCF, 2020)

Delirium

Delirium is a reversible acute state of confusion. It is an organically caused decline from a previous baseline level of mental function that develops quickly, within hours or days, and is a medical emergency associated with increased morbidity and mortality rates. It should not be assumed that acute confusion in an older person is due to dementia.

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, alcohol or drug intoxication or withdrawal. If the underlying disorder is not corrected, irreversible neuronal damage can occur.

Perceptual disturbances are common with delirium. The stimulus is real, but the person misinterprets it, and it often becomes the object of projected fear. Unlike delusions or hallucinations, however, these can be explained and clarified for the person. Visual and tactile hallucinations are also common in delirium (Cooper, 2020; Mayo Clinic, 2020e).

ASSESSMENT AND DIAGNOSIS OF DELIRIUM

Delirium should be considered when a person abruptly demonstrates reduction in awareness of the environment. The person may have difficulty with orientation: first to time, then to place, and last to person, although orientation to person usually remains intact. The person’s level of consciousness may range from lethargy to stupor or from semicoma to hypervigilance.

When assessing an older adult for possible delirium, it is helpful to establish the person’s usual level of cognition by interviewing family or other caregivers. This can include inquiring about past cognitive impairments, especially if the individual has an existing dementia diagnosis.

Delirium usually presents with disorientation and confusion that is most often worse at night and during the early morning. Some individuals, however, may only be confused at night and be lucid during the day. A person with delirium may display agitation or appear to be calm and settled.

Making a diagnosis involves assessments of vital signs, level of consciousness, neurological signs, and signs of infection, hypoxia, or pain. Autonomic signs such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure are often present in delirium.

Common causes of delirium include:

• Infections (meningitis, encephalitis, HIV-related, septicemia, pneumonia, UTI)
• Metabolic abnormalities (acid-base disturbances, hypoxia, fluid and electrolyte abnormalities, hypoglycemia, vitamin deficiency states, endocrinopathies)
• Hepatic or renal failure
• Structural lesions of the brain (primary or metastatic brain tumors, brain abscess)
• Postoperative states
• Miscellaneous causes (sensory deprivation, sleep deprivation, fecal impaction, urinary retention, change of environment)
• Vitamin deficiency states (especially thiamine and vitamin B₁₂)
• Medications at therapeutic doses and levels

There are also important independent risk factors for the development of delirium, including:

• Use of physical restraints
• Malnutrition
• Presence of an indwelling catheter
• Any iatrogenic event
• Use of three or more medications
• Underlying dementia

Diagnostic criteria for delirium include:

• Disturbance in attention
• Change in cognition
• Disturbance that develops over a short period and tends to fluctuate during the day
• Evidence from history, physical exam, or laboratory findings that the disturbance is caused by the effects of a general medical condition and/or intoxicating substance or medication use

Mental status assessment may be done informally through conversation or by using an assessment instrument to screen for suspected delirium. These may include:

• Confusion Assessment Method (CAM) or CAM Intensive Care Unit (CAM-ICU)
• Delirium Symptom Interview (DSI)

Delirium symptom severity can be assessed using the Delirium Detection Scale (DDS) or the Memorial Delirium Assessment Scale (MDAS).

Laboratory studies that may be done include:

• CBC
• Electrolytes
• Glucose
• Renal and liver function tests
• Thyroid function studies
• Urinalysis
• Urine and blood drug screen
• Thiamine and vitamin B₁₂ levels
• Tests for bacterial and viral etiologies, including syphilis
• Sedimentation rate
• Drug screen including alcohol level
• HIV tests
• Tests for other infectious causes if clinically indicated

Other testing may include:

• CT scan or MRI of the head
• EEG
• Chest X-ray
• Lumbar puncture for suspected CNS infection
• Pulse oximetry to diagnose hypoxia
• ECG to diagnose ischemia and arrhythmic causes
  (Alagiakrishnan, 2019)

MANAGEMENT OF DELIRIUM

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.

An individual experiencing delirium has difficulty processing stimuli in the environment, and confusion magnifies the inability to recognize reality. It is helpful to make the physical environment as simple and clear as possible.

Supportive care is aimed at preventing complications. Such measures may include:

• Protecting the airway
• Providing fluids and nutrition
• Assisting with movement
• Treating pain
• Addressing incontinence
• Avoiding use of physical restraints and urinary catheters
• Avoiding change in surroundings and caregiver whenever possible
• Encouraging the involvement of family members or familiar people

Medications such as antipsychotics and benzodiazepines may be used when certain behaviors prevent performance of a medical exam or treatment, when they endanger the person or threaten the safety of others, or when they do not lessen with nondrug treatments (Halter, 2018).

CAUSES OF REVERSIBLE CONFUSION

Type	Possible Causes
(Tabloski, 2014; Meiner, 2015)
Systemic problems	Hypoxia Hypoglycemia Hyperglycemia Dehydration and fluid/electrolyte imbalance Hypercalcemia Hypocalcemia Hypothyroidism Hyperthyroidism Hypothermia Hyperthermia Hypotension Drug-related intoxications Ethanol intoxication or withdrawal Pernicious anemia Pellagra (niacin deficiency) Stress Fecal impaction Febrile status from urinary tract infection Vitamin B12 deficiency
Mechanical problems	Obstruction to cerebral blood flow Increased intracranial pressure Brain cell death or loss Metabolic changes (e.g., high temperature, kidney failure)
Sensori-perceptual problems	Sensory deprivation related to vision or hearing impairment Sensory overload in noisy, crowded settings Lack of variety, lack of personal contacts, and lack of meaning, especially in institutional settings Relocation/transfer from familiar surroundings to unfamiliar surroundings

Mild Cognitive Impairment

Mild cognitive impairment (MCI) 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 (Mayo Clinic, 2020d).

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. People with MCI may experience:

• Forgetting things more often
• Forgetting important events such as appointments or social engagements
• Losing the train of thought or the thread of conversations, books, or movies
• Being increasingly overwhelmed by making decisions, planning steps to accomplish a task, or understanding instructions
• Difficulty finding one’s way around familiar environments
• Becoming more impulsive or showing increasingly poor judgment

People may also experience:

• Depression
• Irritability and aggression
• Anxiety
• Apathy
  (Mayo Clinic, 2020d)

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)

ASSESSMENT OF MCI

There is no specific way to confirm a diagnosis of mild cognitive impairment. The information provided by the patient and the results of various tests can help determine the diagnosis.

Careful medical history may reveal a decline from a higher level, which ideally is confirmed by family or close friend. History shows that, overall, daily activities generally are not affected.

As part of the physical, basic neurological testing may be done to rule out signs of Parkinson’s disease, stroke, tumors, or other medical conditions.

Review of the patient’s medications is an essential part of the assessment, as certain medications may contribute to the risk of cognitive impairment and development of dementia. These may include:

• Benzodiazepines
• Anticholinergics
• Antihistamines
• Opioids
• Proton pump inhibitors

Lab tests that help rule out physical problems that can affect memory are done, including vitamin B₁₂ deficiency or hypothyroidism. An MRI or CT scan may be ordered to rule out brain tumor, stroke, or bleeding.

Mental status testing shows a mild level of impairment for age and education. Brief tests such as the Short Test of Mental Status, the Montreal Cognitive Assessment (MoCA), or the Mini-Mental State Examination (MMSE) may be used (see table). Neuropsychological testing may help to determine degree of impairment, which types of memory are most affected, and whether other mental skills are also impaired (Mayo Clinic, 2020d).

MINI–MENTAL STATE EXAMINATION

Category	Points	Questions
1. Orientation to time and place	10	The patient is asked to provide information on the time (e.g., year, season, month, date, and day of week). (1 point each) The patient is asked to provide information on the present location (e.g., state, county, city, hospital, and floor). (1 point each)
2. Registration	3	The patient is asked to repeat three named prompts (apple, table, penny). (1 point each)
3. Attention and calculation	5	The patient is asked to spell the word WORLD backwards. (Points given up to first misplaced letter, e.g., 2 points for “DLORW”)
4. Recall	3	The patient is asked to recall the three objects memorized in “registration” above. (1 point each)
5. Language	2	The patient is asked to name two objects when they are displayed (pencil and watch). (1 point each)
6. Repetition	1	The patient is asked to speak back a phrase (“No ifs, ands, or buts”). (1 point)
7. Complex commands	6	The patient is asked to follow complex commands, which may involve drawing a shown figure. (6 points)

MANAGEMENT AND PREVENTION OF MCI

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.

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, 2020d)

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).

NORMAL VERSUS DEMENTIA-RELATED COGNITIVE CHANGES

Ability	Changes Related To:
	Normal Aging	Dementia
(Alzheimer’s Society, 2021c)
Short-term memory and learning new information	Sometimes forgetting people’s names or appointments but remembering them later Occasionally forgetting something you were told Misplacing things from time to time (e.g., mobile phone, glasses, or the TV remote) but retracing steps to find them	Forgetting the names of close friends or family Forgetting recent events Asking for the same information over and over (e.g., “Where are my keys?”) Putting objects in unusual places (e.g., putting house keys in the bathroom cabinet)
Planning, problem-solving, and decision-making	Being a bit slower to react or think things through Becoming less able to juggle multiple tasks, especially when distracted Making a bad decision once in a while Occasionally making a mistake when doing family finances	Getting very confused when planning or thinking things through Having a lot of difficulty concentrating Frequent poor judgment when dealing with money or when assessing risks Having trouble keeping track of and paying monthly bills
Language	Sometimes having a bit of trouble finding the right word Needing to concentrate harder to keep up with a conversation Losing the thread if distracted or if many people are speaking at once	Having frequent problems finding the right word or frequently referring to objects as “that thing” Having trouble following or joining a conversation Regularly losing the thread of what someone is saying
Orientation	Getting confused about the day or the week but figuring it out later	Losing track of the date, season, and passage of time
Visual perceptual skills	Vision changes related to cataracts or other changes in the eyes	Problems interpreting visual information (e.g., having difficulty judging distances on stairs, misinterpreting patterns such as a carpet, or reflections) Recognizing an object but being unable to remember what it is used for
Mood and behavior	Sometimes being weary of work, family, and social obligations Sometimes feeling a bit low or anxious Developing specific ways of doing things and becoming irritable when a routine is disrupted	Becoming withdrawn and losing interest in work, socializing, or hobbies Getting unusually sad, anxious, frightened, or low in self-confidence Becoming irritable or easily upset at home, at work, with friends, or in comfortable or familiar places

Problems that may develop later in the dementia disease process include:

• Mobility issues, which may result in serious or life-threatening injuries
• Decline in managing self-care activities (e.g., dressing, bathing, eating)
• Incontinence of bowel and/or bladder
• Inappropriate or aggressive behaviors
• Wandering
• Hallucinating or having delusions

In general, the more severe the symptoms, the shorter the life expectancy (AGS, 2020).

Causes of dementia in older adults include:

• Alzheimer’s disease, which destroys brain cells
• Blockages in blood vessels to the brain, which limit blood flow or triggers mini-strokes (multi-infarct dementia or vascular dementia)
• Other diseases such as Parkinson’s disease, which affects movement and, later, mental abilities and mood
• Serious head injuries
• Some brain tumors
• Heavy alcohol use for more than 10 years
• Hypo- or hyperthyroidism
• Vitamin B₁₂ deficiency
• Certain brain infections (e.g., HIV encephalopathy)
• Certain drugs and reactions to combinations of drugs
• Growth of abnormal structures in the brain (e.g., Lewy body dementia)
• Shrinking of certain parts of the brain causing frontotemporal dementia (also known as Pick’s disease)

Dementia often has more than one cause. 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. Alzheimer’s accounts for nearly 70% of all cases of dementia, and vascular dementia accounts for greater than 10% (AGS, 2020).

ASSESSMENT

Assessment begins with a medical and social history. A review of prescription and OTC medications, supplements, herbals, and other remedies may also indicate causes of dementia. Clinicians also assess for signs of depression and other physical and mental health problems that can cause dementia-like symptoms.

If family or caregiver is present, it is helpful to ask about noticeable changes in the person’s physical and mental abilities, mood, personality, decision-making, behavior, and possible delusions or hallucinations the person may have experienced.

Mental status can be evaluated using the Mini-Mental State Exam. Complete neurological and physical examinations are done, including blood and other lab tests to rule out underlying problems and reversible causes. A brain scan may be requested if indicated (AGS, 2020).

MANAGEMENT

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

Medications that are often prescribed for those with dementia include cholinesterase inhibitors such as donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Excelon).

Memantine (Namenda) is approved by the Food and Drug Administration for treatment of moderate to severe Alzheimer’s disease. Memantine is in a class of medications called MNDA receptor antagonists and works by decreasing abnormal activity in the brain. It is not effective in earlier stages, and there is no information on its effectiveness for other dementias. The most common side effects are constipation, dizziness, headache, and agitation.

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 Treatments

Nondrug interventions are tailored to the person’s symptoms and needs in collaboration with the patient and caregiver and may include:

• Exercise programs that include both aerobics and strength training may improve memory and slow down mental decline.
• Occupational therapy, including ADL training and environmental adaptation can improve function through compensation or adaptation.
• Pet therapy promotes improved mood and behaviors.
• Aromatherapy uses fragrant plant oils to stimulate olfactory receptors that in turn stimulate the part of the brain linked to regulation of emotions. It is widely used to relieve symptoms of anxiety and depression.
• Massage therapy may help manage symptoms such as anxiety, agitation, and depression.
• Music therapy may improve cognitive function and quality of life.
• Art therapy and artistic engagement may help to ease common behavioral symptoms of dementia such as anxiety, agitation and depression. It may also boost mood and self-esteem and possibly help stimulate memory.
  (Mayo Clinic, 2019c; Alzheimer’s Society, 2021a, 2021b; AOTA, 2021a; Laguipo, 2021; Moreno-Morales et al., 2020; Fisher Center, 2021)

Inconsistent evidence has been reported about the benefits of cognitive training, cognitive stimulation, and cognitive rehabilitation (group or individual) (Lee et al., 2019).

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 need further assessment (Koch, 2020).

It is important not to patronize older people with dementia. 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 them “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.

Recommendations for effective communication include:

• Communicate in a dignified adult manner, using short sentences and speaking slightly more slowly and clearly.
• Do not resort to simple or easier words by assuming the patient has lost a more sophisticated vocabulary.
• Allow a period of silence for the person to think before answering.
• Try to communicate in a conversational way.
• 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 the following, which require concentration and memory:
  • Asking “Remember when…?” questions
  • Saying, “I just told you that.”
  • Telling a patient, “Your husband died 10 years ago.”
  • Asking, “What did you do this morning?”
  • Asking, “Do you recognize me?”
  • Using long, complex sentences such as, “Let’s go for a short walk, and then we can go to lunch before we meet George.”
  (Alzheimer’s Society, 2021b; Koch, 2020)

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. For example:

• With a patient who repeatedly asks for his wife who has been dead for several years, rather than trying to remind him of that fact, it is more helpful to redirect the conversation by asking him to talk about his wife. If the patient will not remember what he is told, say, “She called and said she would be here later for a visit.” Although it appears to be a fib, this statement is really a way of reassuring instead of distressing the patient.
• With a patient who resists an activity, saying “I have to go to the barn and feed the chickens,” telling her she does not have chickens can result in a distressed response and feelings of anger, defiance, or frustration. Instead say, “Tell me about your chickens.” This distraction allows for a more positive outcome, as the person diverts attention from the task she believes must be accomplished to a more pleasant discussion about her long-gone chickens (Quinn-Szcesuil, 2020).

Physical Therapy

Aggression and depression are common traits throughout the course of Alzheimer’s disease. Physical therapy helps stabilize aggression through regular exercise by assisting patients with active movements and stretches that release endorphins, which trigger a positive feeling that can alleviate depression.

Alzheimer’s disease often affects balance, which can lead to a higher risk for falls. Physical therapists work with patients to build muscle memory so that muscles will continue to know how to respond even when the brain is not able to register obstacles such as an unstable surface.

Physical therapy can provide opportunities to practice and strengthen the ability to keep doing daily activities and can help in setting up a safe environment.

Physical therapy also helps slow the loss of memory by encouraging physical activity that improves the flow of blood to the brain. One study found that regular physical activity, 40 minutes, four times a week over one year led to an increase in volume of the hippocampus, the part of the brain responsible for memory (Jo, 2018).