Assessing and addressing cognitive impairment in the elderly A look at the research into cognitive impairment

By Graham J. McDougall Jr., PhD, RN, FAAN, FGSA

of the internation - 2. Develop a comprehensive plan ALL SEGMENTS Cognitive decline al population are living longer, and to respond to these needs in dif - Early research in the 1980s identi - many will experience . ferent agencies and organiza - fied 12 areas included in cognitive Policymakers are focused on the tions. function: cost estimates of caring for elders 3. Evaluate and expand compre - • span with cognitive impairment. The hensive systems of support. • concentration World Alzheimer Report 2016 , from 4. Train health professionals to de - • intelligence Alzheimer’s Disease International, a tect cognitive impairment in its • judgment global federation of 85 Alzheimer’s early stages and assist patients to • learning ability associations, highlighted the need manage their care. • memory to make dementia an international In this article, I’ll describe the • orientation health priority. The numbers in the recent methods of assessing and • perception report are staggering: 47 million diagnosing cognitive impairment, • people are estimated to be living synthesize the evidence of both • psychomotor ability with dementia worldwide, with the psychosocial and pharmacologic • reaction time number projected to increase to treatments to prevent or ameliorate • social intactness. more than 131 million by 2050. The cognitive decline, and evaluate the Not all of these areas need to be report recommends that nations de - mechanisms developed to prevent assessed to determine a patient’s velop a plan to address dementia, and treat cognitive impairment. global cognitive function; however, removing the stigma around it, and it’s essential to evaluate memory protecting the human rights of performance and executive func - these individuals. tion. As neuroscientists have stud - The United States has weighed CNE ied the using neuroimaging, in on the issue as well. In 2011, 1.28 contact executive function was found to be hours the Centers for Disease Control associated with the frontal lobes and Prevention published Cogni - and higher order processes. These LEARNING OBJECTIVES tive Impairment: A Call for Action, functions are evident in cognitive 1. Explain how to assess . Now! The publication emphasized activity involving planning, initia - 2. Describe the problem of cognitive incidence, cost, and surveillance impairment. tion, maintenance, and adjustment of the aging Baby Boomer genera - 3. Discuss interventions for cognitive of goal-directed behavior. tion. It focused on state-level poli - impairment. What’s the difference between cy, with discussion of four target The author and planners of this CNE activity have normal cognitive aging and cogni - areas. disclosed no relevant financial relationships with tive decline and impairment? This any commercial companies pertaining to this 1. Gather data to understand the activity. See the last page of the article to learn question can be answered as a se - impact, burden, and needs of how to earn CNE credit. ries of gains and losses. Cognitive people with cognitive impair - decline in normal aging refers to ment. the slower processing of complex

American Nurse Today Volume 12, Number 11 AmericanNurseToday.com 14 issues and difficulty retrieving infor - was 22%. Many clinicians and scien - mation from long-term memory. tists believe that MCI is the prodro - Memory may improve with age, but mal phase of AD and other demen - many individuals experience mem - tias and that its diagnosis depends ory complaints. For example, for - on differentiating between objective getting the location of car keys in and subjective memory perform - the house is not cognitive impair - ance. The NIA-AA established these ment, but typically a lack of organi - criteria for assessing MCI: zational strategy or divided atten - • subjective memory complaints tion. Cognitive impairment refers to reported by the patient, caregiv - a dysfunction in one of the do - er, or clinician mains noted above and is quantifi - • objective memory loss measured able on a test of cognitive function. using a validated instrument, such In the past 30 years, thousands of as the WMS-R Logical Memory Test research studies have expanded our pairment to Alzheimer’s disease • a global Clinical Dementia Rating knowledge of cognitive decline and (AD) and severe dementia. Individ - score impairment and its assessment. New ual aspects along the continuum • general cognitive and functional terminology has been adopted and may include tasks involved with performance that prevents a di - refined with evidence to include cognitive function, such as lan - agnosis of dementia at the time sub jective evaluations such as meta- guage, thought, memory, executive of screening. memory (attitudes and opinions) function, judgment, attention, per - Subjective memory complaints, and memory self-efficacy (prediction ception, remembered skills (for ex - defined as everyday memory prob - and confidence). An individual may ample, driving), and the ability to lems that may motivate older adults have extensive and accurate knowl - live a purposeful life. to seek care, are the diagnostic edge about how his or her memory window into MCI. They’re robust functions, but also may believe that AD or mild cognitive predictors of cognitive decline and the ability to remember is poor. In a impairment? conversion to dementia. Rather large multistate sample of communi - The prevalence of AD is expected than relying on the patient’s per - ty-residing older adults (N = 686), a to increase to 13.2 million by 2050, ception of their cognitive function significant finding was that memory making large-scale preventive inter - to subjectively evaluate everyday self-efficacy was inversely related ventions a priority. The National In - memory function, which empha - to age, with self-efficacy scores de - stitute on Aging and the Alzheimer’s sizes the decremental view of cog - creasing in each decade after 70 Association (NIA-AA) proposed a nitive aging (predicting that as ag - years of age. Memory self-efficacy is framework for defining preclinical ing progresses, predictable and directly related to actual memory AD based on three stages. The mod - quantifiable cognitive losses occur), performance and is therefore rele - el postulates that first abnormal amy - these individuals should be evaluat - vant in evaluations of older adults. loid beta plaques are deposited in ed using psychometrically sound Screening instruments, such as the brain, but the patient is still cog - measures, such as the WMS-R and the Mini-Mental State Exam and nitively normal. Next, a lag period Clinical Dementia Rating. the Saint Louis University Mental occurs, followed by neuronal dys - The relationship between sub - Status exam are considered reliable function, which presents as cognitive jective memory impairment and and valid ways to determine if fur - symptoms. The severity of symptoms ob jective memory performance is ther evaluation and referral are re - is regulated by , a not universally supported. Subjec - quired, even though they don’t destructive process in which neurons tive evaluation of memory must be measure all the cognitive areas list - lose structure or function, and may systematically assessed with a ed above. While screening meas - result in their death. The NIA-AA known measure, and more work is ures have become more sensitive, suggested that memory dysfunction needed to identify the most impor - in-depth memory testing is essen - may be a key element in this tran - tant factors of subjective cognitive tial for the early detection of mem - sition or lag period. decline to aid clinical evaluation. Ra - ory impairment and a comprehen - Some older adults experiencing bin and colleagues evaluated 34 sive evaluation of an individual’s cognitive impairment don’t have AD, cognitive self-report measures with cognitive status. but rather a diagnosable syndrome 640 items that were used in 19 inter - Cognitive function can be viewed called mild cognitive impairment national studies. The authors found along a continuum—from optimal (MCI). The prevalence rate of MCI that the self-report instruments were functioning to mild cognitive im - in a nationally representative sample used inconsistently, with only 25%

AmericanNurseToday.com November 2017 American Nurse Today 15 used in more than one study. Re - Identifying delirium risks and causes sults from a cross-sectional study of Risk factors for delirium fall into four major categories: 221 African American adults with 1. Patient/physiologic factors— age, hypertension, dementia, and coma MCI emphasized that even though 2. Disease factors— metabolic acidosis, organ failure, and multiple traumas no consensus exists about subjective 3. Treatment-related risks— emergency surgery, indwelling catheters, mechani - memory evaluation, a known meas - cal ventilation, I.V. infusions, and use of centrally acting medications that can ure of subjective memory function is cause and intensify delirium preferred over a single question 4. Environmental risks— physical restraints and admission to the intensive care about someone’s perceived memory unit. function. THINK about it The onset of delirium may be precipitated by multiple causes, such as medica - Preventing cognitive decline tions, anesthetics, dehydration, alcohol misuse, pain, sensory impairment, chemi - Little reliable consensus-based diag - cal imbalances, vitamin deficiencies, and infection. The following THINK mnemon - nostic criteria exist for cognitive de - ic can help identify the causes of delirium in patients: cline, MCI, and AD; what does exist Toxic situation, such as heart failure, shock, or organ failure Hypoxemia hasn’t been uniformly applied. This ● ● Infection or immobility has led to insufficient evidence to ● Nonpharmacologic interventions, such as hearing aids, glasses, sleep proto - support the use of pharmaceutical ● cols, music, noise control, and ambulation agents or dietary supplements as K+ (potassium) or other electrolyte problems. preventive measures. However, on - ● going studies, including (but not Source: Render ML, Kim HM, Welsh DE, et al. Automated intensive care unit risk adjustment: Results from a National Veterans Affairs study. Crit Care Med . 2003;31(6):1638-46. limited to) antihypertensive medica - tions, omega-3 fatty acid, physical activity, and cognitive engagement Depression cog nitive decline have been widely may provide new insight into the Depression is a treatable condition studied in aging populations. Studies prevention or delay of cognitive de - that may cause cognitive and exec - have included traditional classroom- cline. The Cochrane panel on cogni - utive function impairment. Older based memory training, somatic tive-based interventions determined adults with depression may have treatment, and technology-driven that firm conclusions can’t be drawn less obvious symptoms, or they may brain-training programs. about the association of modifiable be less likely to admit to feelings of risk factors with cognitive decline or sadness or grief. However, they’re Classroom memory training AD, but researchers continue to test more likely to have medical condi - The Senior WISE ® (Wisdom Is Sim - interventions aimed at improving tions, such as heart disease, that may ply Exploration) study conducted and remediating cognitive function, cause or contribute to depression. by McDougall and colleagues was a including treating causes of cogni - The first step to treating depres - phase III randomized clinical trial tive decline that are reversible, such sion is visiting a mental health with 265 community-dwelling older as delirium and depression. professional. In older adults, ruling adults without dementia. The theo - out other health conditions, such retical framework guiding the study Delirium as cancer or stroke, that may have was based on self-efficacy theory, The prevalence rate for delirium in the same symptoms as depression which explains how people exer - older adults with dementia in the is important. After the patient is cise influence over their own moti - United States ranges from 22% in correctly diagnosed, depression vation and behavior—the amount the community to 89% in the hospi - can be treated with medications, of effort devoted to a task, as well tal. Delirium in patients with de - psychotherapy, or a combination of as the duration of persistence when mentia is frequently unrecognized the two. If these treatments don’t difficulties are encountered. because of overlapping symptoms, reduce symptoms, brain-stimulation The study consisted of eight 90- no mental status baseline, and the therapy may be another option. minute classes and four 90-minute tendency to attribute symptoms of Brain-stimulation therapies are be - booster sessions. Participants were delirium to worsening dementia. ing used more frequently for so - randomized to either memory (n = About 10% to 31% of patients ad - matic disorders. 135) or health training (n = 130) mitted to the hospital have deliri - groups. Memory class topics includ - um, and 14% to 42% of older adults Nonpharmacologic ed memory and health, memory develop delirium while an inpa - interventions functions and mechanisms, factors tient. (See Identifying delirium risks Nonpharmacologic interventions for affecting memory for people of all and causes .) the prevention and treatment of ages, memory beliefs and aging,

American Nurse Today Volume 12, Number 11 AmericanNurseToday.com 16 Brain training: Systematic reviews such as strokes, and findings have Few systematic reviews of brain-training studies have been published. Here are proposed mechanisms that may ex - some takeaways from two of them. plain the development of neuro - plasticity. Lampit and colleagues Therapeutic uses of tDCS also Number of studies reviewed: 52 have demonstrated effectiveness in Participants: Community-based older adults without dementia participated in improving memory in healthy brain-training exercises with computer technology software. Total of 4,885 adults. adults. Neurostimulation techniques Conclusions: have resulted in a greater under - • Home-based training wasn’t as effective as group-based. • A minimum of three training sessions per week was most effective. standing of functional anatomic re - • Sessions should be short—less than 30 minutes. lationships, which has led to the • Training was modestly effective and varied across the cognitive domains. development of novel therapeutic interventions, including treatment The results were limited to healthy older adults and did not address the effects for depression and anxiety and for over time. the motor rehabilitation of stroke Lampit A, Hallock H, Valenzuela M. Computerized cognitive training in cognitively healthy older adults: A patients. systematic review and meta-analysis of effect modifiers. PLoS Med . 2014;11(11):e1001756.

Hill and colleagues Technology-driven brain training Number of studies reviewed: 17 Technology has become a preferred platform for delivering brain train - Participants: Adults with mild cognitive impairment (MCI) or dementia partici - pated in delivered computerized cognitive training. ing. It includes participation in nov - Conclusions: el activities, such as learning a new • Effects were small to moderate. language or a new task, to build • Individuals with MCI had improved cognition, attention, , brain capacity and reserve. Some learning, memory, and psychosocial functioning, including a reduction in de - brain-training programs claim they pressive symptoms. will help maintain and enhance • Individuals with dementia experienced changes in cognition and visuospatial memory and other cognitive func - skills. tions. These programs are delivered The evidence for computerized brain training demonstrated real changes in through video games, computer specific areas of cognitive function, but longitudinal benefits haven’t been software, mobile phone apps, and demonstrated. handheld devices.

Hill NT, Mowszowski L, Naismith SL, Chadwick VL, Valenzuela M, Lampit A. Computerized cognitive train - Brain exercises with computer ing in older adults with mild cognitive impairment or dementia: A systematic review and meta-analysis. games were tested by Smith and Am J Psychiatry . 2017;174(4):329-40. colleagues using the Posit Science brain-training software. Participants (N = 487) who were 65 years or and use of internal and external aging, such as alternative medicine, older received 40 hours of memory memory strategies. The classroom exercise, and spirituality. training over multiple sessions and component of the memory training Both groups maintained their weeks. They were randomized to included 30 minutes of practice performance on the other cognitive receive a brain plasticity–based with memory strategies to strength - measures (for example, global cog - computerized cognitive training pro - en enactive mastery experience nition, and episodic, verbal, and vi - gram (experimental group) or a (validation received when success - sual memory) and activities of daily novelty- and intensity-matched gen - fully performing a task after invest - living throughout the 24-month eral cognitive stimulation program ing effort to master a skill), the study period. Black and Hispanic (control group). Significant improve - strongest component of self-effica - participants made greater gains ment in generalized measures of cy. Three months after the interven - than Whites on visual and verbal memory and attention were seen in tion, four booster sessions were de - memory performance measures. the experimental group. livered once per week. Another brain-training study, by The memory training group made Somatic treatment Owen and colleagues, with a sam - greater gains in global cognition and Transcranial direct current stimula - ple of 11,430 adults between ages had fewer memory complaints com - tion (tDCS) has been used as an in - 18 and 60, used a 6-week online pared to the health training group, tervention in over 200 studies. Early course as the intervention. Findings whose curriculum included 18 dif - tDCS studies tested the treatment did not show improvements in cog - ferent health topics on successful on individuals with brain injuries, nition or transfer to everyday tasks,

AmericanNurseToday.com November 2017 American Nurse Today 17 although cognitive outcomes were demiological and intervention re - better. (See Brain training: Systematic search supports a three-prong ap - reviews .) proach for successful cognitive ag - Memory training has evolved ing that includes physical activity, over 40 years from a traditional mental stimulation, and social en - classroom learning model to individ - gagement. Brain training comes in ually tailored computerized software many shapes and forms—it can be programs that adjust and adapt as as simple as doing puzzles, reading individuals progress through the a book, or playing cards with training. An ongoing concern is friends. None of these exercises related to the transfer of learned will prevent dementia, but the material from these programs to mental stimulation may help many everyday function. For example, a older adults remain engaged. generalized cognitive training pro - As a nurse, be alert to subtle gram isn’t likely to improve an indi - memory or function changes in vidual’s ability to organize and your patients. In the acute care set - comply with daily medication ad - ting, this may be challenging if you herence, unless that task is a com - have little or no knowledge about ponent of the training program. included three sections: events that the patient. But at your first inter - Nevertheless, brain-training pro - happen at a particular time (for ex - action, establish a baseline and grams help with mental stimulation. ample, appointments), events that then use it to gauge subtle im - can happen anytime (for example, provements or losses. Watch for Remediation of mild cognitive daily to-do items), and important delirium, depression, and other re - impairment events that happened that day, versible conditions that are tran - Researchers have reported mixed recorded in a journaling section. sient and short-term. Use your results for cognitive interventions Each pair of participants received unit’s delirium assessment protocol tested with individuals diagnosed 12 hours of training over 6 weeks. or suggest implementing one. with MCI. A subgroup of memory- Compliance with documenting ac - The need to care for patients impaired participants (N = 193) tivities of daily living and emotional with cognitive impairment, MCI, from the Advanced Cognitive Train - impact were measured throughout and AD is only going to increase. ing for Independent and Vital Eld - the study. Researchers are moving forward erly (ACTIVE) trial conducted by This memory training led to with projects that address diagnosis, Unverzagt and colleagues was eval - posttest improvements in functional intervention, and treatment. In the uated for possible training gains. ability and self-efficacy and a de - future, it may be possible to diag - The ACTIVE trial included three in - crease in depressive symptoms. Re - nose AD at early stages (currently, tervention groups that consisted of searchers are hopeful that MCI can it can be accurately diagnosed only training in memory, reasoning, and be ameliorated or reversed with tar - at autopsy) and to implement inter - processing speed. Each group re - geted brain training, but more in - ventions to slow or halt its progres - ceived a 10-session, 60-minute in - vestigation is still needed. sion. A vaccine may even be devel - tervention delivered over 6 weeks. oped to prevent the disease. But Participants in the reasoning and Nursing care until then, nurses and other health - processing speed groups benefited Cognitive decline and impairment care professionals must use their at multiple times in the study, when isn’t an inevitable consequence of assessment and intervention skills, tested at different times; whereas aging. Many older people in their as well as their knowledge of cur - those in memory training failed to 80s, 90s, and beyond are fully rent best evidence, to care for pa - benefit from the intervention. engaged in their lives. However, tients at risk for or experiencing In another study, by Greenway lifestyle behaviors that impact cognitive impairment and decline. and colleagues, 40 individuals with health and wellness have been single-domain amnestic MCI and shown to influence memory and Visit americannursetoday.com/preventing-cognitive- their partners (spouses, significant cognition. Eating a healthy, bal - impairment for a list of selected references. others, or family members) used anced diet, being physically active Graham J. McDougall Jr. developed and tested Senior the memory support system (MSS), for at least 30 minutes a day, and WISE® (Wisdom Is Simply Exploration), an award- a two-page-per-day calendar and getting plenty of sleep can help winning mental stimulation program. He is an ad - note-taking system small enough to prevent chronic illness and im - junct professor at Florida State University College of fit in a pocket or purse. The MSS prove cognitive function. The epi - Nursing in Tallahassee.

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