Cognition and Dementia

Defining Cognition: Cognition encompasses various mental processes including critical thinking, which is highlighted as an important organized task and domain.
Factors Supporting Cognition:
- Education: Higher levels of education are associated with experiencing less cognitive decline related to aging, suggesting that the processes involved in learning provide some "insulation" against decline. It's not a guarantee against conditions like dementia, but it can make diagnosis more challenging in highly articulate individuals.
- Social Interaction: Being in a social environment is suggested to support cognition, based on retrospective studies analyzing qualities of supportive environments.
Impaired Cognition: This refers to a decline in cognitive functions. Individuals may have background support that masks or compensates for early signs of impairment.

It is crucial to differentiate between three common causes of cognitive impairment, especially in geriatrics:
- Depression: Can present with cognitive symptoms that mimic dementia.
- Delirium: An acute, fluctuating state of confusion. It is often misdiagnosed as dementia, but it is typically reversible when the underlying cause is addressed. Patients with delirium may experience significant cognitive dysfunction, then return to their baseline.
- Dementia: A chronic, progressive decline in cognitive function. Unlike delirium, it is generally not reversible in most common forms.
Accurate differentiation is critical for appropriate intervention and management.

These terms describe specific cognitive changes often observed in conditions like dementia:
- Agnosia: The inability to recognize objects, people, sounds, shapes, or smells despite intact sensory function. For example, a person with dementia might not recognize a toilet as a toilet and therefore not use it appropriately.
- Apraxia: The inability to perform purposeful movements despite having the physical capacity and desire to do so.
- Aphasia: Difficulty with language, including expressing oneself or understanding language. This is a common symptom in individuals with dementia, leading to trouble communicating.
Healthcare professionals, particularly OTs, are not usually experts in diagnosing these conditions but are vital in recognizing behaviors associated with them and collaborating with other specialists for diagnosis.

Comprehensive Workup: Diagnosing cognitive impairment, especially dementia, requires a thorough medical workup. It is often a diagnosis of exclusion, meaning other potential causes of cognitive symptoms must be ruled out (e.g., metabolic imbalances, infections, medication side effects).
Screening Tests: Various tests are used to screen for cognitive changes:
- Mini-Mental State Exam (MMSE): A widely used test for assessing cognitive function. While common, newer tests offer advantages.
- Montreal Cognitive Assessment (MoCA): This test is noted for its ability to assess cognitive changes at an earlier stage than the MMSE, making it valuable for detecting subtle declines.
Baseline Information: Establishing a patient's baseline cognitive function and orientation is essential. For example, knowing if a patient normally knows their location can help identify confusion when they state they are "at home" while in a care facility.
Observational Cues: Nurses and other healthcare professionals play a critical role in observation. Changes from a patient's baseline (e.g., disorientation, decreased alertness) serve as cues for further investigation. This continuous monitoring is an important aspect of skilled nursing in long-term care.
Dementia vs. Stroke: Unlike the immediate, definite deficits often seen immediately after a stroke, cognitive decline in dementia is typically insidious and not as sudden.

Alzheimer's Type Dementia: The most common form of dementia, accounting for a significant portion of cases. Changes associated with dementia are mostly described through this type.
Mixed Dementia: Occurs when a person has more than one type of dementia simultaneously, such as Alzheimer's disease and vascular dementia.
Lewy Body Dementia: Characterized by fluctuating cognition, recurrent visual hallucinations, and motor features of parkinsonism. Patients may describe vivid hallucinations, such as seeing people (e.g., their daughter) in their room and interacting with them.
Frontotemporal Dementia (FTD): A type of dementia that primarily affects the frontal and temporal lobes of the brain. It often leads to changes in personality, behavior, and social interaction, which can manifest even at a relatively young age. These are often described as very sad cases.