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Cognitive Changes in Aging

PTP 783 Jennifer Blackwood

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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 maintain the ability to understand new experience & situations Changes in this should NOT be dismissed as

normal agingPersonalities remain stable with aging: if it

changes possible psychiatric dysfunction

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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)

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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

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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

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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

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Benign Senescent Forgetfulness

Memory loss with the normal older person

Functional decline is not present with this as opposed to it being present with

dementia

PTs can play a role with assisting in dx

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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.

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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

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The 3 D’s

Delirium

Depression

Dementia

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Delirium

Acute confusional 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

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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%

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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

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Meds for Depression

SSRIs- favored…. Why? Zoloft, Paxil, Prozac

Tricyclic Antidepressants Serotonin/Norepinephrine Reuptake

Inhibitors MAO Inhibitors

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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 B12 deficiency, vascular origin, Lewy body disease

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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

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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

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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

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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)

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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

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AD

Genetic risk factors: APOE e4 (apolipoprotein E allele)

Average life span: 8-10 yrs from symptom onset

Physical changes in the brain:

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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

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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

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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)

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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

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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

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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

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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

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SLUMS norms:

High School Education Less Than High School

Normal functioning 27 to 30

25 to 30

MNCD 21 to 26 20 to 24

Dementia 1 to 20 1 to 19

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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)

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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

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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)

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TMT A TMT B

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TMT A

Norm:29 seconds

Deficit: > 78 seconds

Most in 90 seconds

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TMT B: Norm: 75 seconds

Deficit:> 273 seconds

Most in 3 minutes

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2 things proven to slow Cognitive decline:

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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

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Allen Levels 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

High

Low

Cognition

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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.

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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

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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

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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.

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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

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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

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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.

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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.

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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

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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

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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

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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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Level 2 Treatment Considerations

Teach caregivers proper cues for HEP completion with appropriate amount of time for processing

Responds better to tactile cues than verbal instructions

Prevent falls, contractures, wounds, and positioning issues (wedge cushions, lap tray)

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