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Cognitive Changes in Aging

PTP 783 Jennifer Blackwood. Cognitive Changes in Aging. Cognitive Changes. Cognition: defined as awareness by perception, reasoning, judgment, intuition, memory, and knowledge 25% of the population 65+ have a cognitive impairment Increases with advanced age

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Cognitive Changes in Aging

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  1. PTP 783 Jennifer Blackwood Cognitive Changes in Aging

  2. Cognitive Changes • Cognition: defined as awareness by perception, reasoning, judgment, intuition, memory, and knowledge • 25% of the population 65+ have a cognitive impairment • Increases with advanced age • Elderly maintainthe ability to understand new experience & situations • Changes in this should NOT be dismissed as normal aging Personalities remain stable with aging: if it changes possible psychiatric dysfunction

  3. Changes in cognition are linked to • Cardiovascular disease • DM • HTN • Atherosclerosis • Low blood pressure • Dehydration, nutritional deficits • Infection • Genetic link: APOE, total cholesterol (Panza et al, 2007)

  4. Intelligence & Learning Capacity • No age related decline in spatial learning abilities • A minimal amount of absent-mindedness is considered normal • No decrease in information processing in the absence of disease or mental dysfunction • Learning progresses slower with age, affected by sensory changes (vision) • Declines difficult to research

  5. Intelligence • Performance on IQ tests diminishes after a LONG period of time (55-70 yrs) • Fluid Intelligence: capacity to use unique ways of thinking to solve unfamiliar problems • declines with age • Crystallized Intelligence: through education and acculturation • remains stable through age 70

  6. Executive Function • Combines memory, intellectual capacity, and cognitive planning • Correlated with ADLs • PTs are concerned- decline in EF= decline in balance and increased fall risk

  7. Benign Senescent Forgetfulness • Memory loss with the normal older person • Functional decline isnot present with this • as opposed to it being present with dementia • PTs can play a role with assisting in dx

  8. Age Associated Cognitive Decline • 27% of those 68-78 have AACD • Gradual cognitive decline over 6 mo • 1 SD below the normal for neuropsychological testing • All areas of cognitive performance are limited: memory, learning, attention, concentration, thinking, language, & visuospatial functioning.

  9. Mild Cognitive Impairment • Deterioration of cognitive function greater than expected for a person’s age and education level, does not meet criteria for dementia, and does not affect ADLs • Amnestic or multiple domain • Increased risk with CV diseases or risk factors • 12-28% progress to AD • Difficult to detect with MMSE as it is not sensitive • Difficult to detect objectively as patient’s behavior’s change

  10. The 3 D’s • Delirium • Depression • Dementia

  11. Delirium • Acuteconfusional state (aka acute brain syndrome) • Inattention, distractibility, drowsiness • Often accompanied by agitation • Sundowners: worse in evening & night • More agitated in afternoon, therefore see in morning. • Hallucinations • STM very significantly affected: immediate recall, attention, and retention of new info

  12. Depression • Episode: sub acute onset • 1 in 4 women and 1 in 10 men experience this • 90% can be treated • Symptoms: recent onset, flat affect, decreased communication, feelings of sadness, helplessness, or despair, physical pains, suicidal thoughts, guilt, loss of interest or pleasure • Somatic concerns in 60%

  13. Screening for Depression • GDS • Beck’s Inventory • USPSTF- • ‘Over the past 2 weeks, have you felt down, depressed, or hopeless?’ • ‘Have you felt little interest or pleasure in doing things?’ • As effective as longer screening tools for risk for depression

  14. Meds for Depression • SSRIs- favored…. Why? • Zoloft, Paxil, Prozac • Tricyclic Antidepressants • Serotonin/Norepinephrine Reuptake Inhibitors • MAO Inhibitors

  15. Dementia • More frequently in adults age 75+, women • Defined as: Global impairment of intellect, memory and personality in the absence of impaired consciousness (WHO, 1993) • Amnesia, aphasia, agnosia, apraxia, decreased executive functioning • Chronic, non-reversible, slow onset of STM loss. • Don’t confuse confusion with dementia • Causes: Alzheimer’s, alcoholism, NPH, cerebral infarct, pernicious anemia, vit B12deficiency, vascular origin, Lewy body disease

  16. Vascular Dementia • AKA Multi-Infarct Dementia (multi-TIA-”mini stoke”) • Organic mental disorder with cerebrovascular disease • Cognitive decline is due to multiple infarcts that produces a loss of brain tissue • In addition to memory impairments personality changes occur

  17. Pseudodementia • Dementia like behavior is actually the result of a major depressive episode • Flat affect, disinterest in events • Depressed persons respond in a slow, labored manner but provide accurate responses • Patients with dementia are unable to produce the correct response • ‘Don’t know’ study

  18. Lewy Body Dementia • Carotid sinus hypersensitivity (as high as 50%) • Symptoms of both AD and Parkinson’s Disease type Dementia • Cognitive decline and motor symptoms • Fluctuating levels of cognition throughout the day • Motor changes similar to PD • Hallucinations

  19. Changes in cognition relate to • Increased fall risk (1.5-3 x the risk of cognitively normal fallers) • Study by Tinetti found 67% with MCI fell over a year • Decreases on the MMSE relate to a reduction in survival probability • Every point decrease on MMSE: adjusted odds ratio for mortality was .95 (95% CI: .93-.97) and for institutionalization: .91 (95% CI: .90-.94)

  20. Alzheimer’s Disease • 60% of those with dementia • Diagnosed post morbidly • Inclusionary criteria: memory loss, aphasia, apraxia, and disturbance in executive functioning • Severe enough to impair social or occupational function • Difficult to diagnose in the early stages • Masked by those with more education • Affects 25-30% those 65 y.o; • Older than 85 y.o.: 50% incidence

  21. AD • Genetic risk factors: APOE e4 (apolipoprotein E allele) • Average life span: 8-10 yrs from symptom onset • Physical changes in the brain:

  22. FAST scale for Alzheimer's Disease • Stage 1: no change in function • Stage 2: deficits with word finding or recall of objects • Stage 3: difficulty in unfamiliar environments, missed appts. Hides it well. • Stage 4: needs help with complex community or domestic tasks (finances/shopping) • Stage 5: not able to live alone, decreased safety awareness, simple tasks affected (changes in gait speed, tone, reaction time) • Stage 6: assistance nec for most basic ADLs (eating, grooming, toileting) • Stage 7: dependence for all care, incoherent speech, disorientation of time, place, person

  23. Medications: are they effective • Anticholinergics • Can only be used for certain levels of dementia • Psychotropic meds (antipsychotics, benzodiazepines, tricyclic antidepressants, and hypnotics): increase fall risk in those with dementia by 2x

  24. Gait changes with AD • Compared to age and sex matched controls: • Shorter step length • Slower gait speed • Lower step frequency • Increased step to step variability • Greater double support ratio • Greater sway path *Peripheral impairments less likely as a source, but more central processing and integration of perceptual information (Franssen et al, 1999)

  25. Evaluate Cognition with: • MMSE • Mini-Cog • SLUMS • MOCA • Trail Making Test A, Trail Making Test B • Others Folstein et al, 1975, Galantino et al, 2006

  26. Evaluate Cognition: MMSE & the Mini-Cog • MMSE: 30 total points • Assesses orientation, attention, calculation, recall, and language • Mini- Cog: • 3 minute instrument to screen for cognitive impairment: • 3 item recall test • Clock drawing test • Folstein et al, 1975; Borson, 2000

  27. MMSE • AKA: Folstein • 0-30, median score for those 80+ is 25 • 24-30: Minimal cognitive impairment • 18-23: Mild to Moderate cognitive Impairment • 0-17: Severe impairment • Median score for those who completed 4th grade: 22 or less • Ceiling effect with MCI • Sensitivity: 82% and Specificity: 99% in detecting dementia

  28. SLUMS Test • St. Louis University Mental Status Examination • Created because MMSE not good at detecting MCD, MCI, or MNCD • Maximum score of 30 • Addresses attention, recall, calculation, and executive function (clock drawing) • Addresses the difference between those who have more education versus less • Sensitivity & Specificity: 100% in detecting dementia

  29. SLUMS norms:

  30. MoCA • Montreal Cognition Assessment • MCI • Assesses executive function, visuospatial abilities, memory, attention, concentration, working memory, language, & orientations • Scores range from 0-30 • Adjusts for education level • Sensitivity (100%) & Specificity: 87% in detecting MCI in the general population using a cutoff score of 26 • Less than 24: MCI (sensitivity: 83.3%, specificity: 29.6% in those with CV disease)

  31. Evaluate Cognition: Trail Making Tests A & B • TMT A- Assesses processing speed • Paper/pencil, timed test to connect a trail of numbers in ascending order • TMT B- Assesses Executive Function • Paper/pencil, timed test to connect a trail of alternating numbers/letters in ascending order • Norms stratified by age and education • See Tombaugh 2004 article for norms

  32. Trail Making Tests A & B • Addresses Executive function via: visual-conceptual, visuospatial, and visual-motor tracking, attention, and task alteration • Scores increase with age and education • Performance in the TMT is a strong predictor of: • Mobility impairment • Accelerated decline in LE function • Increased fall risk • Mortality in community dwelling older adults (Vazzana et al, 2010)

  33. TMT A TMT B

  34. TMT A Norm:29 seconds Deficit: > 78 seconds Most in 90 seconds

  35. TMT B: Norm: 75 seconds Deficit:> 273 seconds Most in 3 minutes

  36. 2 things proven to slow Cognitive decline:

  37. The Allen Cognitive Scale • Created by Claudia Allen, OTR • Level determined by how an individual performs on a leather lacing test • Flows from TOP to bottom with regards to cognitive abilities • Has 6 scales with 5 subscales for each identifying criteria

  38. Allen Levels Cognition High • Level 6 Planned Activities • CEO • Level 5 Independent Learning • teenager • Level 4 Goal Directed Activities • Early level dementia **** • Level 3 Manual Actions • Middle level dementia **** • Level 2 Postural Actions • Late level dementia **** • Level 1 Automatic Actions • Semi-comatose Low

  39. We will focus on LEVELS 2 through 4 with regards to dementia and physical therapy practice!Each Level will be broken down in to ‘high’ and ‘low’ portions.

  40. Level 4 Early Dementia • Needs cues to fully complete self care • Poor safety awareness • May wear same clothes or not comb back of head • Can sequence a routine, but not set up or clean up (procedural memory) • May not follow complex commands • All talk but no action • Very social

  41. Level 4 Early Dementia • Low level 4 • Oriented to person, place, and routine • Reads, but not functional • Cues to calendar • Likes structure and schedules • Can potentially learn to use a standard walker • High level 4 • Oriented to person, place, and time • Reads instructions with errors • Can live alone if no stove and becomes a ‘couch potato’ • Able to learn 3-4 steps but without safety • Can learn to use a quad cane • Can follow a list

  42. Level 4 Interventions • Striking visual cues needed to learn new tasks. • Functional exercises needed to prevent boredom • Amb with device, but don’t expect to follow safety precautions. • Gait training with scanning the environment • Practice negotiating corners and other barriers. • Need consistent repetition for HEP/exercise learning.

  43. Level 4 treatment considerations • Needs structure and routine for increased safety and independence • Establish schedules, lists, and other memory aids • Needs cues for any precautions in order to follow • HEP considerations

  44. Level 3 Middle Dementia • Easily distractible • Limited visual field • Follows 1 step directions • Loss of ability to complete basic ADLs (eating/grooming) • Constantly doing something with hands • Confused, wanders

  45. Level 3 Middle Dementia • Low Level 3 • One minute attention span • Visual field 12-14” • Needs constant cueing for participation • Attempts to climb over bed rails • Requires supervision when walking on uneven surfaces • High Level 3 • Learns destination/routine after 3wks of consistency • Performs tasks without completion • Needs verbal cues for sequencing • Can change body position to prevent loss of balance when asked.

  46. Level 3 Interventions • Gait training with various sensory conditions and cues to start/stop. • Closed chain exercises (low level 3) • Supervised stair climbing. • Open chain exercises (high level 3) • Most likely will NOT remember any precautions indicated • Consistent repetition with use of an assistive device for ambulation.

  47. Level 3 Treatment considerations • Shorten activity to decrease risk of combativeness • Use clear concise directions • Reduce distractions by removing extraneous objects from view (mirror, other patients) • Provide a calming environment • Focus on training caregiver for HEP follow through

  48. Level 2 Late Dementia • Postural insecurity with fear of falling (balance issues) • Agitated if hurried • Cognitively processes 2-3 times slower • Disrobes if uncomfortable • Tends to wander, resists confinement • Follows people or goes where pointed to go • Tunnel Vision • No awareness of a physical disability

  49. Level 2 Late Dementia • Low Level 2 • Overcoming gravity (provides 75% effort to move) • Uses one word to initiate communication • Loves reciprocal movement • Avoids barriers above knees, bends at waist • High Level 2 • Fearful • Uses intense grip on railings/grab bars or you • Walks to identified location • Confused by floor contrasts • Likes to push objects

  50. Level 2 Interventions • Sitting activities to work on postural control • Sit<->stand activities with weight shifting (count to 3) • Rhythmic repetitive movements for gait training • Will need supervision with amb with device • Use slow music to encourage ambulation • Use of wide colored tape on stairs/uneven surfaces to increase visibility

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