The Older Adult Learner and Cognitive Aging

Cognitive Aging

• Cognitive aging occurs over time and varies among individuals

• Changes in cognitive functioning are not specifically caused by aging, factors such as general health, education, life-style, genetics, socioeconomics, and socialization can cause changes in individuals

• The stereotype that older adults have fewer cognitive skills can lead to assumptions in relationships that could be less than ideal

Factors that Impact Cognitive Health

• Lifestyle

• Education

• Socioeconomic status

• Access to health care

Cognitive Processes Include

• Attention

• Memory

• Problem-solving

• Decision-making

• Reasoning

• Judgment

• Language

• Speed of processing

Attention

• The ability to focus on stimuli for the purpose of processing information

• Requires effort and the ability to filter relevant and irrelevant stimuli

• The ability to successfully make decisions, problem-solve, or think through an issue requires attentional resources

Sustained (or focused) Attention

• The ability to direct attentional resources to a single task or activity

• Example: Concentrating on reading a book

Selective Attention

• The ability to direct attentional resources to a task or activity while simultaneously directing attention resources to ignore distracting information

• Example: Listening to a story someone is telling while others are talking around you

Alternating Attention

• The ability to direct or switch attentional resources between two or more tasks or activities

• It is conceptually distinct from divided attention because tasks are performed one at a time with attentional resources switching back and forth between tasks

• Example: When cooking, a person attends to stirring on item and then letting it cook, while they work on chopping and prepping another item; the person then shifts back and forth depending on the instructions.

Tips for practice

1. Minimize all distractions; remove unneeded equipment, ensure privacy

2. Consider speed of processing. Slow the instruction if client needs more time to process

3. Know the client’s sensory processing abilities to ensure the client is understanding and seeing what you are doing; asking the client for feedback is one way of checking their understanding

4. Explain to the client your goal for the session and ask what they would like to get from the session; this can build meaning and set expectations

5. Actively engage the client in the treatment; this can emphasize the meaning and relevance to the client

6. Use a “teach-back” method of instruction, asking the client to explain what was said and ask their opinion

7. Repetition. Engage in problem-solving for the client’s learning

8. Once the occupation has been performed safely, you may introduce distractions to challenge the client and simulate a realworld environment, such as a busy home

9. Review the session, address questions and concerns, and ask the client if the session met their expectations and what more is needed

10. Handouts can be helpful to enhance learning

What factors can impact a person’s attention while performing a task?

• environmental factors/distractions

• medication (e.g., drowsiness)

• stress

• fatigue

• relevance to the task (e.g., is it meaningful?)

• motivation (e.g., depression)

Memory

A generic term used to describe type of memory including

• Sensory memory

• Short-term memory

• Working memory

• Several long-term memory systems (including declarative and procedural long-term memory)

Sensory memory

The processing of information through the vestibular, visual, auditory, and tactile systems

Short-term memory

2 Forms

• 1. new information is stored based on sensory inputs

• 2. memories that have been stored and retrieved through cueing such as smelling an odor and recalling a feeling or conversation

Working memory

• Demands attention and requires the intentional use of strategies to manipulate, store, and maintain information

• Serves a vital role in facilitating higher-order cognitive processes such as language production and comprehension, decisionmaking, problem-solving, and learning

Procedural or Non-Declarative Memory

• Nonverbal-based memory system that stores information for motor-based skills and behaviors (e.g. muscle memory), habits, emotional associations, priming, and classical conditioning

• Retrieval of nondeclarative memories can occur with little effort or even conscious awareness

• Examples: how to play a musical instrument, ride a bike, or perform a habitual task, such as brushing your teeth

Prospective memory

• Enables individuals to remember future-oriented or scheduled tasks without the use of external memory aides (e.g. a written note or list)

• Examples: remembering to take medications twice daily, wearing a brace to bed, stopping at the grocery store, or buying a birthday card for a friend

Semantic memory

• The knowledge of language including words, phrases, definitions, and grammar

• Understanding language and memory for facts is considered crystalized intelligence and remain relatively stable with aging

  • However, age-related differences can be found in the production of speech

External Memory Aids

• • Alarms/Timers

• Notebooks/Datebooks

• Calendars

• Audio messages

• Pillboxes

Internal Memory Aids

• Association

  • e.g., “everytime i cook dinner, I will also have to give my son his medication”

• Organization

  • knowing where things are meant to be

• Visualization

• Imagination

Executive Functioning

• Refers to higher-order cognitive processes such as reasoning, decision-making, problem-solving, judgment, abstract thought, cognitive flexibility, initiation (i.e., beginning a task), and inhibition (e.g., having no filter)

• Underlies a person’s ability to engage in everyday activities

Intelligence Abilities

• Fluid Intelligence:

  • the ability to use abstract reasoning, flexibility to shift one’s mental set, and initiate and complete purposeful action

  • it includes creative and flexible thinking required in novel situations and can be directly affected by physiological structure changes

• Crystallized intelligence:

  • the accumulation of knowledge, experience, and acculturation that is highly representative of individual differences

    • older adults can learn new things stil!!- just may take more time

  • knowledge of facts, rules, and verbal skills rely on crystallized intelligence

Implicit and Explicit Processing

Two types of cognitive processes used to learn (or transfer) information from short-term to long-term memory and to retrieve information from long-term to short-term memory

• Implicit: unintentional, occurs without awareness, and is effortless, requiring minimal cognitive resources

  • e.g., remembering a song from just listening to it a lot

• Explicit: intentional, occurs with awareness, and is effortful, requiring moderate to substantial cognitive resources

  • e.g,. remembering a song b/c you practice reading the lyrics

Functional Cognition

• The cognitive ability to perform B(basic)ADLs and IADLs, incorporating the cognitive processes previously discussed

• Should be assessed in the natural, real-world context in which the task is performed, rather than a laboratory setting using standardized measures

  • performance-based assessments (^ tasks being performed in a natural, real-world context) have much better psychometrics than self-report measures

Performance-based Executive Function Assessments (specific to OT)

• Assessment of Motor and Performance Skills (AMPS; Fisher, 1995)

• Cognitive Performance Test (CPT; Burns et al., 1994)

• Complex Task Performance Assessment (CTPA; Wolf et al., 2008)

• Multiple Errand Test (MET; Shallice & Burgess, 1991)

• Performed Direct Assessment of Functional Status (modified) (PDADS; Rankin & Keefover, 1998)

• Executive Functional Performance Test (EFPT; Baum, 2011)

• The Kitchen Task Assessment (KTA; Baum & Edwards, 1993)

• Large Allen’s Cognitive Screen-5 (LACLS-5; Allen et al., 2007)

• Menu Task (Edwards et al., 2019) • Performance Assessment of Self-Care Skills (PASS; Holm & Rogers, 2008)

• Weekly Planning Calendar Activity (WPCA; Toglia, 2015)

Need for Functional Cognitive Screening

Neuropathologies and Impact on Cognitive Functioning in Older Adults

• Delirium

• Mild Cognitive Deficits

• Dementia

• CVA

• TBI

• Mental disorders

Delirium

• A syndrome with an acute onset of changes in attention, awareness, and cognitive functioning

• Onset is rapid as 1 or 2 hours and can last for day to months

• Can be caused by a medical condition not related to a preexisting neurocognitive disorder

• Causative factors include

• Frailty, infections (e.g. urinary tract infections), prolonged illness, low sodium, medication reactions, alcohol, and surgery with anesthesia

  • UTIs are very big in causing cognitive deficits!!

• Often presents during daytime and worsens at night

• Being in an unfamiliar environment can exacerbate delirium

• Treatment: discovering the cause and intervening

  • UTI —> treatable but you must catch in time or they’ll become septic (full-body infection)

• Multi-intervention approaches including OT and PT have been effective in reducing the number of days with delirium

D.E.L.I.R.I.U.M. Mnemonic

Encompasses the key elements of current best practice in managing delirium

• Drugs

  • removing drugs that might make people, e.g., narcotic

• Environment

  • make sure it’s safe

• Light

  • natural light appropriate for day vs night (e.g., limiting light at nighttime)

• Initiate Cognitive Tasks

  • practice meaningful, stimulating tasks in therapy

• Routine

  • using clocks, schedules (24-hr method), etc.

• Integrate an Interprofessional Team Approach

  • OT, PT, speech, pharmacology, etc.

• Under hydration/nutrition

  • food and fluid intake is sufficient + incorporate that into a routine

• Mobility

  • incorporate movement into daily routine (e.g., exercise)

Mild Cognitive Impairment (MCI)

• Affects 10-15% of adults over the age of 65

• MCI is a transitional stage between healthy aging and dementia

• The prevalence of MCI in older adults increases with age, lower level of education, and sex (higher in men)

• Diagnoses of MCI include:

  • Client history and cognitive testing

• The progression is defined by the presence of amnesia and the number of areas affected by the amnesia, including attention, language, visuospatial, and executive functioning

• Current medications are shown to only slow progression- doesn’t get rid of it completely

• Persons with MCI benefit from inclusion in

  • Exercise

  • Client-centered activities

  • Cognitive stimulation

  • Socialization

  • Client and family education

  • Memory strategies

Dementia

A syndrome of cognitive impairment affecting cognitive processes and significantly affects a person’s ability to independently perform BADLs and IADLs and participate in meaningful and fulfilling activities

Risk Factors for Dementia

• Less education

• Hypertension

• Hearing impairment

• Smoking

• Obesity

• Depression

• Physical inactivity

• Diabetes

• Excessive alcohol consumption

• TBI

• Air pollution

• Low social contact

Types of Dementia

• Alzheimer Disease

• Vascular Dementia

• Dementia with Lewy Bodies

• Frontotemporal Dementia

Alzheimer Disease

most common type of dementia, accounting for 60% to 70% of cases

Vascular Dementia

• Second most commonly diagnosed form of dementia

• Caused by an overall inefficient supply of oxygenated blood in the brain which may be caused by small transient ischemic attacks, major strokes, or untreated high blood pressure

• Individuals with vascular dementia may not experience progressive cognitive changes across time, but instead will typically experience daily fluctuations in their cognitive abilities, with symptoms becoming worse over the course of the day

• symptoms can be similar to Alzheimer’s, but are more localized

  • also more inconsistency in cognitive processes

• life expectancy: 5 years post-onset of symptoms

Dementia with Lewy Bodies

• A progressive dementia and represents two related diagnoses

  • Dementia with Lewy bodies

  • Parkinsons disease dementia

    • up to 80% of people with Parkinsons disease dementia with also develop Lewy bodies

• Up to 85% of people with dementia with Lewy bodies experience motor difficulties

• Dementia with Lewy bodies is diagnosed as early as 50 years old, and life expectancy is 5 to 7 years after initial onset of symptoms

• Persons present with a range of cognitive changes including

  • Attention

  • Executive functions

  • Visual perceptual symptoms

  • Neuropsychiatric symptoms (hallucinations)

  • Sleep disorders

  • Autonomic symptoms (syncope, dizziness)

• can only truly know this diagnosis from an autopsy after a person dies

Frontotemporal Dementia

• A hereditary neurodegenerative disorder (30% of cases have a strong family history)

• Characteristics include changes in behavior (personality), language (progressive aphasia), and motor function (ALS or PD (parkinson’s disease))

• Characterized by abnormal amounts of forms of tau and TDP-43 proteins accumulating inside neurons in the frontal and temporal lobes

Optimizing Cognitive Functioning in Older Adults

• Cognitive Reserve: the amount of cognitive resources available after an individual engages in a task

  • the more cognitive reserve, the better someone will age

• Factors such as participation in cognitively stimulating activities, physical activity and exercise, and socialization have been linked to facilitating enhanced cognitive reserve

Cognitive and Mental Stimulation

• Participating in mentally stimulating and novel activities can include increasing the difficulty of cognitive tasks during therapy and educating patients to challenge themselves at home with new and unfamiliar tasks, such as learning a new language or activity

• To be considered mentally stimulating, tasks should be novel and mentally challenging, as new learning facilitates neural growth, development, and plasticity

Socialization

Paramount for healthy cognitive aging