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Cognitive Changes in Aging

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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
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

changes in cognition are linked to
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)
intelligence learning capacity
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
  • 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
executive function
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
benign senescent forgetfulness
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
age associated cognitive decline
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.
mild cognitive impairment
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
the 3 d s
The 3 D’s
  • Delirium
  • Depression
  • Dementia
  • 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
  • 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%
screening for depression
Screening for Depression
  • GDS
  • Beck’s Inventory
    • ‘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
meds for depression
Meds for Depression
  • SSRIs- favored…. Why?
    • Zoloft, Paxil, Prozac
  • Tricyclic Antidepressants
  • Serotonin/Norepinephrine Reuptake Inhibitors
  • MAO Inhibitors
  • 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
vascular dementia
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
  • 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
lewy body dementia
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
changes in cognition relate to
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)
alzheimer s disease
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
  • Genetic risk factors: APOE e4 (apolipoprotein E allele)
  • Average life span: 8-10 yrs from symptom onset
  • Physical changes in the brain:
fast scale for alzheimer s disease
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
medications are they effective
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
gait changes with ad
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)

evaluate cognition with
Evaluate Cognition with:
  • MMSE
  • Mini-Cog
  • MOCA
  • Trail Making Test A, Trail Making Test B
  • Others

Folstein et al, 1975, Galantino et al, 2006

evaluate cognition mmse the mini cog
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
  • 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
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
  • 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)
evaluate cognition trail making tests a b
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
trail making tests a b
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)
tmt a




Norm:29 seconds

Deficit: > 78 seconds

Most in 90 seconds



Norm: 75 seconds

Deficit:> 273 seconds

Most in 3 minutes

the allen cognitive scale
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
allen levels
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



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.

level 4 early dementia
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
level 4 early dementia1
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
level 4 interventions
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.
level 4 treatment considerations
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
level 3 middle dementia
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
level 3 middle dementia1
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.
level 3 interventions
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.
level 3 treatment considerations
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
level 2 late dementia
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
level 2 late dementia1
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
level 2 interventions
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
level 2 treatment considerations
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)