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cognitive impairment in the elderly

Also see: - subjective memory problems in the elderly - prevention of Alzheimer's disease - prevention of cognitive impairment - dementia - Alzheimer's disease - minimal cognitive impairment - psychosis & agitation in the elderly - plasma factors associated with cognitive function Etiology: - dementia - delirium - psychosis - nightmares in middle-age & older adults [55] - intracranial atherosclerosis [38] - retinopathy may be risk factor [40] - chronic systolic hypertension in middle-age [11] - late life systolic hypertension not associated with cognitive decline [11] - lowering of blood pressure in the elderly may adversely affect cognitive function [18] - higher BP is associated with better cognitive function in the oldest old (>= 85 years of age) [25] - daytime systolic blood pressure < 130 mm Hg may be associated with faster cognitive decline in cognitively impaired elderly treated with antihypertensives [17] - systolic blood pressure variability is associated with cognitive impairment in the elderly [31] - hospitalization of community-dwelling elderly is associated with accelerated cognitive impairment [3] - executive dysfunction & diminished ventricular size after hospitalization of older adults - frailty increases risk for mild cognitive impairment & dementia [46] - regional adiposity accumulating in skeletal muscle [61] - most (59%) of the determining factors for cognitive decline are idiopathic [8] - depression worsens cognitive decline in the elderly [12,28] - social isolation & loneliness contribute higher risk of cognitive impairment & nursing home placement [32,51] - perceived psychosocial stress is associated with both prevalent & incident cognitive impairment (RR=1.4-1.6) [59] - orthostatic hypotension renders elderly with mild cognitive impairment twice as likely to become demented [26] - low levels of leisure-time physical activity associated with greater decline in cognitive performance (executive function, semantic memory, & processing speed scores) [30] - sleep disordered breathing [34] - sensory impairment: - hearing impairment, visual impairment [52], anosmia - olfactory impairment is an independent risk factor for cognitive impairment in the elderly [21] - anxiety & beta-amyloid may amplify risk of cognitive impairment [48] - personality traits associated with risk of cognitive impairment & demenia [37] - neuroticism - being less agreeable - being less conscientious - exposure to lead-contaminated drinking water in childhood is associated with cognitive impairment in later life (age 72 years) [56] - general anesthesia may increase risk of cognitive impairment in the elderly [62,63] * personal education important predictor (25%), followed by race, household wealth & income, parental education, occupation, & depression - contributions of sedentary lifestyle, chronic diseases, obesity, smoking, vigorous activity, childhood health, nutrition, gender, marital status, & religion < 5% [58] Epidemiology: - 13% of adults > 60 years of age report memory problems or confusion during preceding year [6] - women may have greater cognitive reserve but faster cognitive decline than men [47] Pathology: - cognitive aging distinct from Alzheimer's disease & other neurodegenerative disorders is proposed [19] - in animal models, cognitive aging is associated with synaptic dysfunction rather than neuronal loss, particulary in the prefrontal cortex [19] - deficits in dopaminergic systems for reward prediction may make it difficult to appreciate the potential negative consequences of a choice [5] - plasma contains factors that affect cognitive function - hypoxia, hypoglycemia & ischemia may be common factors Genetics: - apoE4 allele worsens negative effect of depression on cognitive decline in the elderly [12] Clinical manifestations: Cognitive changes with normal aging: 1) attention: diminished attention, divided & sustained 2) language: a) diminished fluency, word finding & confrontation naming b) vocabulary largely unchanged - vocabulary may increase with advanced age, provided there is opportunity & exposure to new words - increased vocabulary is accompanied by enhanced comprehension [32] 3) memory: a) diminished episodic memory b) diminished working memory [32] c) remote memory generally remains intact [32] - thus decline in remote recall suggest abnormal cognition* d) no change in ability to retain learned information 4) visuospatial function: diminished visuospatial skills 5) executive function a) cognitive processing speed decreases b) abstractions become more concrete - memory impairments are pathological if they interfere with activities of daily living (ADL) (i.e. forgetting to pay bills) [32] - best indicator of pathologic neurologic decline - executive dysfunction contributory [32] - getting lost in familiar places is pathological & consistent with dementia [32] - difficulty following conversations & understanding instructions is pathological in the absence of hearing impairment [32] - difficulty remembering names is common, a cue may be helpful in normal aging but not with pathologic cognitive impairment [32] - ability to learn & remember a list of words may be diminished in normal aging [32] - taking longer to complete routine tasks may be a decline in the speed of processing that may occur with normal aging [32]** - anxiety can be a prodromal manifestation of cognitive impairment & dementia [32] - subtle declines in various activities of daily living are associated with cognitive impairment in the elderly [45] - stages of objective memory impairment predict mild cognitive impairment [60] * distinguishes abnormal cogntition from normal age-related cognitive decline [32] ** seems more like a pathololgic effect of myelination changes Laboratory: - basic chemistry panel - complete blood count (CBC) - vitamin B12 in serum - TSH in serum Special laboratory: - assess for hearing impairment [27] - audiology as needed - vision assessment - CSF analysis not part of routine evaluation - indications: - rapidly progressive dementia - age < 60 years - malignancy or paraneoplastic syndrome - suspicion of acute or subacute infection - immunosuppresion - positive syphilis serology or Lyme serology - autoimmune disease or suspected CNS inflammation [27] - electroencephalography (EEG) - subacute decline in cognitive function with new onset incontinence [32] - actigraphy demonstrate changes in circadian rhythms, decreased & delayed activity associated with increased risk of cognitive impairment - University of Pennsylvania Smell Identification Test (UPSIT) - olfactory impairment is an independent risk factor for cognitive impairment in the elderly [21] Radiology: - neuroimaging (all patients) [27] - MRI neuroimaging or non-contrast CT of brain [27] - PET scan for uncertain diagnosis or atypical presentation in consultation with neurologist [27] Complications: - cognitive impairment in the elderly predicts mortality [2] - increased risk of stroke (RR=1.4), & fatal stroke, especially ischemic stroke [13] - may be increased risk of parkinsonism & Parkinson's disease [39] - vulnerability to scams in older patients is associated with cognitive impairment & Alzheimer dementia [44] - memory problems & problems with executive function that interfere with activities of daily living such as making mistakes in finances, forgetting to pay bills is best indicator of pathologic neurologic decline [32] Management: - Institute of Medicine guidelines include: [20] - conduct a formal cognitive assessment at primary care visit - consider screening for: - cardiovascular risk factors - alcohol use - smoking history - diet - exercise - depression - chronic diseases - hearing impairment [27] - hearing aids & cochlear implants may attenuate cognitive decline [57] - encourage patients to - get regular physical activity - reduce their cardiovascular risk factors - maintain social engagement & learning - get sufficient sleep. - minimize use of psychoactive medications & inappropriate medications, including anticholinergic drugs - identify patients who could be at high risk for delirium before or at the time of hospital admission - caution patients about the use of so-called "brain games" & nutraceuticals, which have little proven benefit [20] - multicomponent strategy may help slow cognitive decline in elderly [14,36] - nutrition, exercise, cognitive training, cardiovascular risk reduction - higher cognitive activity associated with better cognitive performance [54] - exercise improves cognition in the elderly [4] - moderate-intensity exercise of no benefit for cognition in sedentary elderly [24] - insufficient evidence to assess benefit of physical activity [35] - exercise may reduce beta-amyloid burden in men [54] - an intensive program of exercise & functional activity training did not improve activities of daily living, physical activity, or quality of life; reduce falls; or improve any other secondary health outcomes in elderly (80 years) with mild cognitive impairment or early dementia, despite good compliance [64] - adequate sleep & good sleep hygiene may improve cognition in the elderly [19] - cognitive training (Tai-chi) improves iADL* in the elderly [9] - cognitive training with benefits in domain of training - midlife & late-life social & cognitive activities diminish likelihood of late-life cognitive decline [16] - intellectual engagement helps to maintain cognitive function in the elderly but does not change the downward trajectory [42] - treat depression - see prevention of cognitive impairment - see prevention of Alzheimer's disease - USPSTF recommends against routine screening - no evidence of improved outcomes [6] - no benefit of antihypertensive treatment vs placebo or intensive vs standard treatment [35] - intensive blood pressure control & intensive lowering of lipids with combination of simvastatin plus fenofibrate does not slow the rate of cognitive decline in elderly with diabetes mellitus type 2 [10] - rosuvastatin (10 mg) &/or candesartan/hydrochlorothiazide (16 mg/12.5 mg) ineffective in slowing cognitive decline in the elderly (> 70 years) [43] - intensive glycemic control in elderly with type 2 diabetes of no benefit [35] - no evidence of benefit for statins [35] - no benefit of cholinesterase inhibitors in minimal cognitive impairment [35] - neither omega-3 fatty acids, lutein/zeaxanthin or both improves cognition in elderly with macular degeneration [24] - no benefit in omega-3 fatty acids or gingko biloba in reducing incidence of Alzheimer's disease or improving cognition in normal elderly [35] - DHA-rich fish oil does not improve age-related cognitive decline in the elderly [41] - no strong evidence supports benefit of any vitamin [35] - multivitamin for 3 years is associated with a 60% slowing of cognitive aging in older adults [49] - no benefit for NSAIDs or aspirin [35] * instrumental activities of daily living Notes: - Affordable Care Act requires a cognitive assessment for Medicare recipients during their annual wellness visit [29] - cognitive assessment by general practitioners is more specific than sensitive [53] - false negatives more likely in elderly with less severe impairment - false positives may occur in those with depression [53] Comparative biology: - plasma beta2 microglobulin (B2M) negatively regulates age-associated cognitive function in hippocampus of mice [22] - age-associated increase in B2M in plasma levels in humans & mice [22] - increased plasma eotaxin may inhibit learning, memory, & neurogenesis during aging in mice [23] - age-associated increase in eotaxin in plasma levels in humans & mice [23] - blocking FSH in ovariectomized mice protects against cognitive decline [50]

Related

Alzheimer's disease (AD) cognitive resilience dementia; Alzheimer's disease & related dementias (ADRD) depression in the elderly mild cognitive impairment (MCI); benign senile forgetfulness; age-associated memory impairment (AAMI) pre-mild cognitive impairment (preMCI) prevention of Alzheimer's disease/dementia prevention of cognitive impairment psychosis, agitation & difficult behavior in the elderly subjective memory problems in the elderly SuperAger (exceptional cognition in the elderly)

General

cognitive impairment geriatric disorder; disease of old age; geriatric syndrome

References

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