COGNITIVE CHANGES OF AGING

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.
  • There is no underlying medical condition causing the difficulties.
    (UCSF, 2023)

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. Abnormal changes result in mild cognitive impairment (MCI) and dementia. MCI does not affect the person’s ability to carry out everyday tasks, while dementia indicates cognitive difficulties are impacting those abilities.

Delirium

Delirium is a reversible acute state of confusion that develops quickly, within hours or days, and is typically the result of a medical problem. Delirium is a medical emergency associated with increased morbidity and mortality rates.

Symptoms of delirium are sometimes confused with symptoms of dementia. Differences are described in the table below.

COMPARING DELIRIUM AND DEMENTIA
Delirium Dementia
(Mayo Clinic, 2022b; Iglseder et al., 2022)
Onset Occurs within a short time Usually begins with minor symptoms that worsen over time
Attention Impaired ability to maintain focus In early stages, generally alert; sluggishness or agitation not typical
Change in symptoms May come and go rapidly several times during the day Better and worse times of day, but memory and thinking skills typically constant

MANAGEMENT OF DELIRIUM

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 is aimed at preventing complications.

Psychotropic medications may be necessary if symptoms make it difficult to perform a medical exam or provide treatment, put the person in danger or threaten the safety of others, or do not lessen with other forms of management (Mayo Clinic, 2022).

Mild Cognitive Impairment

Mild cognitive impairment is characterized by problems with memory, language, thinking, or judgment that are not severe enough to interfere with daily living and one’s usual activities (Mayo Clinic, 2023c). MCI may increase the chances of later development of dementia, but some people never get worse and a few eventually improve.

Experts classify MCI 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.
    (AS, 2023)
PREVALENCE OF MCI

MCI is common in older adult populations.

  • Approximately 12%–18% of people ages 60 or older are living with MCI.
  • An estimated 10%–15% of people living with MCI develop dementia each year.
  • One third of people living with MCI due to Alzheimer’s disease develop dementia within five years.

(AA, 2023a)

MANAGEMENT AND PREVENTION OF MCI

Treatment may include cholinesterase inhibitors for those whose main symptom is memory loss. They are not, however, recommended for routine treatment of MCI, haven’t been found to affect progression to dementia, and can cause side effects.

Lifestyle interventions include:

  • Exercising regularly at a moderate to vigorous intensity
  • Eating a Mediterranean-style diet
  • Reducing alcohol intake
  • Managing blood sugar
  • Maintaining a healthy weight
  • Treating hearing problems
  • Management of chronic health issues such as depression, high cholesterol, or hypertension
  • Preventing head injury
  • Discontinuing tobacco use
  • Getting consistent, good-quality sleep
  • Engaging in mentally stimulating activities and having a higher level of education
  • Being social to make life more satisfying
  • Engaging in memory training and other cognitive training
    (Harvard Health Publishing, 2021).

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, 2023).

There are three stages of dementia: early, middle, and severe.

During the early stage, the person has problems managing medicines, finances, and driving. Memory worsens, as does judgment, and the person has mood changes. During this stage, people may only require a bit of assistance with daily living.

During the middle stage, the person develops problems with walking and performing daily activities, the memory worsens, and the person has a tendency to get lost or wander and become repetitive. The person may become agitated, aggressive, depressed, or anxious. People in this stage may not be able to remain in their homes.

During the severe stage, the person has increasing problems with personal care, including dressing, bathing, and eventually eating. There may be difficulty talking or recognizing loved ones.

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
  • Checking for and treating problems that can contribute to mental health changes
  • Monitoring for development of new medical problems
  • Limiting polypharmacy and avoiding certain medications that can affect cognition
  • Monitoring for medication side effects
  • Teaching caregivers how to manage symptoms and behavioral problems and to find caregiving, financial, and legal support
  • Assessing driving ability
  • Advance care planning (since diminished capacity is inevitable)
    (Press & Buss, 2023; AGS, 2023)

Medications that are often prescribed for those with dementia include cholinesterase inhibitors such as donepezil (Aricept, Adlarity), galantamine (Razadyne), and rivastigmine (Excelon). Antipsychotic drugs, antidepressants, and mood stabilizers may help control specific behaviors that may present, but effectiveness is limited, and they are associated with an increased risk of death.

Memantine (Namenda) is approved for treatment of moderate to severe Alzheimer’s disease. In 2023, the FDA approved lecanemab (Leqembi) for mild Alzheimer’s disease. Aducanumab (Aduhelm) has also been approved for treatment of Alzheimer’s disease (Mayo Clinic, 2023d).

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

  • Environmental interventions
  • Reality orientation
  • Validation therapy
  • Reminiscence therapy
  • Dementia support groups
  • Exercise programs
  • Occupational therapy
  • Pet therapy
  • Aromatherapy
  • Massage therapy
  • Music therapy
  • Art therapy
    (Mayo Clinic, 2023d; Mauk, 2023; DA, 2022)
COMMUNICATING WITH THE PATIENT WITH DEMENTIA
  • Communicate in a dignified adult manner, using short sentences and speaking slightly more slowly and clearly; allow sufficient time for responses.
  • Maintain eye contact, being aware of cultural preferences for such.
  • Lower the tone of voice to accommodate age-related hearing changes.
  • Use nonverbal cues; point to or demonstrate what is wanted.
  • Do not resort to simple or easier words by assuming the patient has lost a more sophisticated vocabulary.
  • Repeat instructions as often as necessary.
  • Observe carefully for a person’s nonverbal cues.
  • Try to communicate in a conversational way.
  • Avoid asking 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.”
    • (AS, 2023; Mauk, 2023)