An understanding of age-related cognitive deficits, cognitive reserve, and neuroplasticity is important for gerontological nurses to provide support to older patients. Although some degree of age-related cognitive decline is a part of normal aging, this does not mean that it is necessarily inevitable for everyone to experience cognitive deficits that impair everyday functioning. There are individual differences in cognitive decline, with some people aging very well cognitively while others are more susceptible to cognitive deficits. Fortunately, evidence now demonstrates that interventions and strategies such as cognitive remediation therapy and lifestyle choices can actually improve and maintain cognitive health in older adults.
Cognitive remediation therapies continue to be developed in order to improve global cognition and particular cognitive domains such speed of processing and memory. For example, to improve visual speed of processing, Edwards and colleagues (2005)
randomly assigned 126 community-dwelling older adults to either a visual speed of processing condition or a social-contact control Internet training condition. In the active experimental condition, 10 hours of visual speed of processing exercises were administered on the computer. During these exercises participants had to quickly absorb visual information presented within 17 to 500 ms and respond with the correct answer. If they did not respond correctly, the presentation time was slowed; if they responded correctly, the presentation time was faster. This forced participants to reach their visual speed of processing threshold in order to improve their ability. In the control condition, participants received 10 hours of social contact and computer exposure while they were taught how to use the Internet, send e-mails, “surf” the web, and so forth. Using a pre-post experimental design, researchers found that, in comparison to the control group, those in the visual speed of processing group improved on a measure of visual speed of processing (i.e., Useful Field of View®
) and a functional measure (the Timed IADL test). Interestingly, subsequent studies also show that improving the Useful Field of View®
using this training technique improves driving performance, health-related quality of life, and locus of control (Ball et al., 2007
Other training approaches to improve memory have been tested, but with limited success. For example, in a sample of 265 community-dwelling older adults, McDougall and colleagues (2010)
assigned participants (Mage
= 75) to either a memory training intervention or a health promotion training comparison (control) group for a 24-month period. At baseline, participants could not have Hodgkin’s disease, neuroblastoma, Alzheimer’s disease or related dementias, or lung, brain, or liver disease; also participants had to have adequate vision and hearing and function within a normal cognitive range as judged by a the Mini-Mental Status Exam (23 or higher). The memory training consisted of a small group format in which internal and external memory strategies and exercises were performed; educational lectures about memory were also provided. The researchers found that those assigned to the memory training condition improved on measures of memory complaints and global cognition; however, measures on objective memory performance and IADLs did not improve. Regardless, such cognitive remediation techniques show promise in ameliorating cognitive deficits in lieu of age-related cognitive changes. Many cognitive remediation therapies are now being administered via computer with very good results; however, not all of these programs are evidence-based. Recommendations for use of a particular computer-based remediation program should only be made with caution after examining the literature as to which ones are effective (Vance, McNees, & Meneses, 2009
Healthy lifestyle choices have also been found to promote cognitive health (Milgram et al., 2006
). Numerous studies have shown that moderate exercise, a balanced diet including higher levels of antioxidants and omega 3 fatty acids, stimulating activities such as playing a musical instrument, intellectually challenging work, low to moderate alcohol use, and stress reduction contribute to cognitive health (Milgram et al., 2006
; Vance et al., 2010
). In fact, Vance, Eagerton, and colleagues (in press)
proposed a simple method of incorporating healthy lifestyle choices into a behaviorally-oriented cognitive prescription. Using motivational interviewing techniques, nurses can help patients set individualized exercise goals, dietary goals, intellectual goals, and other such goals in order to develop a cognitive prescription. The purpose of the cognitive prescription is to not only promote cognitive health over the lifespan, but to improve general quality of life as well. However, cognitive prescriptions focusing on lifestyle choices are not a quick fix for subjective memory loss; cognitive prescriptions may achieve the benefits of being neuroprotective against age-related cognitive deficits only after a course of years.
Despite our best efforts, many patients will still develop age-related cognitive deficits. Therefore, it is important to develop compensatory strategies for coping with such deficits. Some patients who are less satisfied with their memory may resort to using external mnemonics such as calendars, making lists, or posting “to be remembered” items on their refrigerator. In our technological age, numerous gadgets, cell phones, and so forth can be used to help compensate for memory problems. Other, more basic, mnemonic techniques can also be used to help memorize information (e.g., method of loci, chunking, levels of processing, and spaced-retrieval method) (see Vance, Webb et al., 2008
). These mnemonic techniques are inexpensive, easy to use, and do no not require any special training. Many of these are already used informally. For example, the method of loci is one that has been used by students for decades. For example, if one needed to learn the date of a historical event such as when the Treaty of Versailles was signed, one can visualize the numbers of the date along the sequence of a familiar path (e.g., 28 at the beginning of the path, 6 next to the big tree, and 19 at the end of the path); thus, one would have the numbers 28-6-19 or 28th
of June 1919. Such compensatory strategies do not have to be overly complex and can be applied to a number of everyday situations.
When patients present cognitive complaints, it is reasonable to be instructive about how to compensate for such normal age-related cognitive deficits and assuage concerns that such deficits are normal; however, it is also important to document such complaints and observe whether the deficits become more severe over time. Many patients will develop amnestic Mild Cognitive Impairment (MCI) which is considered to be a preclinical stage of dementia, with 23% eventually developing Alzheimer’s disease within two years of the MCI diagnosis (Nordlund et al., 2010
). Vance, Farr, and Struzick (2008)
proposed a nursing framework of how to document and track such cognitive problems through the use of asking patients or family members about such deficits, observing if patients forget appointments, and more objectively through the use of brief cognitive screeners such as the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975
). For example, the MMSE is a widely used screener to examine global cognition. It takes approximately 5-10 minutes to administer; during this test, items are scored on orientation (e.g., Where are you? What is it today?), reading, comprehension, spatial orientation and drawing, and following directions. Scores range from 0 to 30; scores less than 24 are indicative of those developing dementia or already have dementia. Since many older patients have excellent social skills which can hide their cognitive deficits; such cognitive screeners can help reveal whether such cognitive deficits are progressive. If evidence indicates that patients are performing progressively worse, then the medical team can make the appropriate referral to a neurologist or psychologist.