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Cognitive Impairment in the Elderly a Look at the Research Into Cognitive Impairment

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Cognitive Impairment in the Elderly a Look at the Research Into Cognitive Impairment 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 dementia. 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 - • attention 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, • problem solving 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 brain 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 cognition. 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 neurodegeneration, 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,
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