Neuro-Cognitive Function and Aging

Cognitive Function

The process by which a person:

-Perceives, Recognizes, Registers, Stores, Uses information

Brain maintains the ability to change in positive ways

-Mental skills that improve with age include: use of common sense, conflict resolution, emotional regulation, etc.

Age-related changes have a negative impact on cognition

Age-related changes that affect cognition associated with negative functional consequences

-Minor loss of recent memory

-Delayed response time to stimuli: may not be able to drive

-Gradual decline in abstraction, calculation, verbal fluency, spatial orientation

-Diminished ability to learn complex informations

-Decreased ability to accomplish complex tasks especially those that require multiple steps (e.g., navigating through a new city’s subway system)

Functional Consequences of Age-related changes

-Healthy older adults have no significant cognitive impairments but minor deficits may be noted

-Cognitive functions dependent on experience and well-practiced tasks do not decrease in health older adults

-Earliest age-related changes result from decrease perceptual speed. It is important to allow for more time in all tasks

-Age-related cognitive changes occur at a slow linear rate. Rapid changes likely pathological

-Note: Health promotion interventions involving social engagement and cognitive stimulation are protective

Risk factors that affect cognitive wellness

-Personal, social, and attitudinal influences: Low SES, sensory deficits, ageism, decreased expectations in society negatively affect cognitive function

-Health factors and health behaviors

• Nutritional factors: low levels of beta-Carotene and vitamin B, C, D

• Lifestyle: Smoking, physical inactivity, inadequate sleep

• Chronic conditions: decreased sensory ability (i.e., diabetes, HTN)

-Medications effects: Anticholinergic effects, hypoglycemia, decrease cerebral flow

-Environmental factors: 2nd hand smoking, occupational/environmental exposure to toxins like lead and mercury

Assessment of Cognitive Function

-Crucial for the early detection of risks, pathological conditions and monitoring effectiveness of interventions

-Routine history and standard examination fail to evaluate cognitive function; made sure to encourage routine history and seeing their PCP, especially if they have a concern or a family member is worried 

-Early detection of cognitive impairment possible only when cognitive function is assessed

Pathological conditions are often un(der)diagnosed and individuals face much greater, accelerated, and long-term cognitive and functional decline, as well as death

Methods for Assessing Cognitive Function: 3 step process

-1st step: screening for impairments affecting day to day activities (nursing); Briefly evaluate presence/absence of impairment

-2nd step: full evaluation: neuropsychological testing

-3rd step: If impairment is diagnosed, ensure treatment and reassessment for monitoring

-dementia is not a normal age related change; Make sure what we are doing is helping by reassessing 

-Note: mental status assessment is an organized approach to collecting date on psychosocial function

Folstein’s Mini-Mental State Examination

-11 items assessing orientation, attention, memory, concentration, language, and constructional ability

-Each question scored as either correct or incorrect

-Total score ranges from 0 to 30

-Score <24 often considered impaired cognition

-Score influenced by education, language (English speaking), verbal ability, and age

The mini-Cog

-Three item recall and a clock-drawing item

Scoring:

-1 point per word

-2 points for correct clock

-Scores <3 indicate high risk

-Valid in all social strata

Montreal Cognitive Assessment

-Assessments: attention, memory, concentration, executive functions, language, visual-constructional skills, conceptual thinking, calculations and orientation

-Has improved ability to screen for MCI and dementia

-Score greater than or equal to 26 considered normal

When to Assess Cognitive Function

-Routine basis (once a year)

-New care environment

-Change in physical or mental status

-Before important decision making

-Concerns about changes in memory or thinking

Strategies for Cognitive Function Assessment

-Check environment: comfort, privacy, well lit room

0No extraneous noise or distractions

-Emotionally favorable environment to reduce anxiety; Don’t call assessment “simple”, silly, or “stupid” questions

-Avoid assessment in presence of others

-Make sure the resident can hear and see (allow use of hearing aid and glasses/lens)

-Avoid assessment on awakening from sleep, acute pain, immediate pre/post prandial or medical procedures (wait at least 30 minutes)

-Let older adult set pace of the assessment

Cognitive Testing Anxiety

-Older adults are especially sensitive to any insinuation that they may have some (memory problem)

-Stress the importance of the assessment without increasing the individual’s anxiety

-Individuals may consider the assessment intrusive, intimidating, fatiguing, and offensive, which can seriously and negatively affect performance

-Positioning the individual to use the assessor’s nonverbal communication and read the assessor’s lips

Cautions for Assessing Cognitive Function

-Even in perfect circumstances and in the absence of pathological conditions that affect cognition, individuals may perform poorly on cognitive, screening tests

Reasons include:

-Acute illness

-Sleep deprivation

-Cultural issues

Nursing Interventions to promote cognitive wellness (EBP)

-Nutrition

-Mental exercise

-Physical exercise

-Sleep hygiene

-Maintain healthy weight

-Challenging leisure activities

-Strong social networks

-Adapting health education materials

-Activities that foster sense of control and mastery

-right left brain connection for cognitive wellness; activities that you need to use both sides of your brain for 

Pathological changes that affect cognition

Prevalent with aging but are not normal

-Mild cognitive impairment

-Delirium

-Dementia

-Depression

Differential tests for cognitive impairment

-In addition to cognitive assessment tools, parallel use of additional instruments can determine the nature of impairment

-The confusion Assessment Method (CAM)- delirium

-The Geriatric Depression Scale (GDS)- depression

Delirium

-Develops over a short period of time (hrs. to days)

-Fluctuates over course of day

-Can persist for months

-Changes in mental status: Attention, Consciousness, Altered sleep-wake patterns

-Can not be explained by preexisting neurocognitive disorders, but may be supra-imposed with dementia

-May present with hyperactive, hypoactive, or mixed motoric subtypes of delirium

Risk factors for delirium

-Dementia, Old age

-Comorbid illness, Severity of illness, infection

-High risk meds, Polypharmcy

-Sleep deprivation

-Elevated BUN/Creatinine ratio, Malnutrition (low albumin level), Electrolyte imbalance

-Decreased ADLs, Immobility, Sensory impairment

-Urinary catherterization

-Length of hospital stay, Physical restraints

-Anemia

Delirium Sequelae

-Longer hospital stays

-Increase mortality

-Increase dependency

-Short/long-term functional impairment

-Increased rates of permanent residency in long-term facilities

-22% to 89% of hospitalized older adults with dementia have delirium superimposed on the dementia, or they are at increased risk for developing delirium and have worse outcomes when they do

Delirium Prediction Rule

Clinical Feature	Measurement	Points
Cognitive Impairment	MMSE < 24	1
Acute Illness	APACHE II > 16	1
Visual Impairment	Corrected vision < 20/70	1
Dehydration	BUN: creatinine ratio > 18	1

-The points are added. The incidence of delirium for 0 points is 3%-9%, 1-2 points is 16%-23%, and for ≥3 points is 32%-83%.

-MMSE = Mini Mental State Examination; APACHE = Acute physiology and chronic health evaluation; BUN = blood urea nitrogen.

Delirium vs. Dementia

-Acute vs. Insidious

-Fluctuating vs. Gradual deterioration

-Impaired vs. Often clear until advanced stages

-Disturbed vs. Often good until advanced stages

-Poor working memory and immediate recall vs. Poor short-term memory

-Often short-lived or changing vs. more fixed

-Fragmented sleep vs. sleep-wake reversal

Tools to assess if delirium is present: CAM screening tool

◦The Confusion Assessment Method is a diagnostic tool used to identify delirium based off the four cardinal signs of delirium

1.Acute onset and fluctuating course

2.Inattention

3.Disorganized thinking

4.Altered level of consciousness

*If there is presence of features of 1, 2, and/or 3 and 4 a diagnosis of delirium will be confirmed

Tools to assess if delirium is present: UB-2

◦The Ultra-Brief 2 item screener (UB-2) is a clinician administered two item interview designed for large-scale delirium case identification

◦Typically performed on admission and with any significant changes

Workup of Delirium

-History and physical examination

•Collateral information from family, nursing teams

•Neurological examination

-Review of medications

•Esp. benzodiazepines, anticholinergics & antipsychotics

•Drugs that were recently stopped and may cause withdrawal syndrome (opioids, antidepressants, alcohol)

-Basic laboratory tests for electrolytes, kidney function, workup of suspected infection

-Identify and treat underlying cause that precipitated delirium

Treatment of Delirium

-Prevention, early detection and treatment strategy

•Aggressive mobilization (PT and OT), assessment

-Identify & treat underlying cause

•Treat infections, address sensory deficits

-Provide supportive and restorative care

•Orientation interventions, nutritional interventions, family

-Control dangerous and disruptive behaviors to avoid harm to the patient or others

•Environmental modification, presence of familiar sitter

-Pharmacologic interventions

•Avoid aggravating factors such as use of benzodiazepines

•Use small dose haloperidol if agitation severe

The role of family member at the bedside

-Reorienting stimulus for patient

◦10-20 staff may see patient daily, facilitating disorientation

-Source of cognitive stimulation

-Participate in care of patient to
the extent possible

Take-home Points on Delirium

-Delirium, an acute change in cognition and attention, is common, morbid, and costly

-In the inpatient setting, all new changes in mental status should be assumed to be delirium until proven otherwise

-The treatment of delirium is to identify and remedy the underlying causes

-Elements of the hospital environment can contribute to delirium and expose patients to safety risk

-Family members and caregivers are crucial to the diagnosis and management of delirium; incorporating them into the plan of care is strongly recommended