Counseling Older Adults About Cognitive Decline

The case of Mrs. J captured my interest in a JAMA article regarding diagnosis and management of mild cognitive impairment (Langa & Levine, 2014). Mrs. J was 81, but remained independent in activities of daily living, displayed no personality change, and had no symptoms of a mood disorder. What brought her to a physician's office was a concern about gradually worsening memory, especially for recent conversations and the whereabouts of objects in her home. According to her husband, she also experienced difficulty in managing familiar household tasks such as cooking. Mrs. J was diagnosed with mild cognitive impairment (MCI), which occurs in 10% to 20% of people over age 65 (Langa & Levine, 2014). It does not inevitably lead to Alzheimer's disease (and, in fact, can revert to normal cognition in some people), but it is different from normal cognitive aging.

How is mild cognitive impairment different from cognitive aging, about which the Institute of Medicine (IOM) recently issued an important report (Blazer, Yaffe, & Karlawish, 2015)? According to the IOM report titled Cognitive Aging: Progress in Understanding and Opportunities for Action, cognitive aging is “inherent in humans and animals as they age, only now beginning to be understood biologically” and “is not a clinically defined neurological or psychiatric disease” (Blazer et al., 2015, p. 2121). Although some age-related changes in memory and reaction time do take place as we grow older, some of our cognitive functions may actually improve. We now know that neurons do not automatically die with aging, even though there is some decrease in synaptic function (Blazer et al.) Furthermore, we can compensate for declines by drawing on years of life experience and by simple memory aids such as making lists. The IOM report emphasizes elders’ potential for increased knowledge and wisdom. Its authors call on health care professionals to educate the public (and our patients) regarding actions they can take to improve their cognitive health.

The state of the science regarding effective approaches to mitigate cognitive decline is nascent, compelling the National Institutes of Health to allocate millions for brain resilience research in 2016 (Kuehn, 2015). As we await findings of randomized clinical trials of various interventions to promote cognitive health, what shall we tell our older adult patients when we counsel them? An AARP survey of its members showed that maintaining cognitive function is the primary concern of older Americans (AARP, 2012). They want to know what, if anything, they can do to prevent mild cognitive impairment or the much more severe impairment of Alzheimer's disease. They may be aware that there is currently no medication proven efficacious for women such as Mrs. J who already have MCI, nor is a prophylactic medication available. They may also be aware that there is no proven efficacy of the brain-stimulating puzzles, games, and other such products being offered on the market. Some predisposing factors, such as genetics and medical comorbidities, are not modifiable. Worry and pessimism are widespread.

We can share with elders the encouraging new research showing that behavioral factors can modify the connection between cellular pathology and cognitive functioning. Sense of purpose in life and social interaction appear to be very influential in reducing risk of cognitive decline, even when brain pathology is present (Kuehn, 2015). Social support for older adults increases levels of a protein called brain-derived neurotrophic factor (BDNF), which seems to protect neurons from dying and fosters growth of new neurons and synapses (Seshadri, 2015, cited in Kuehn, 2015). Exercise increases levels of vascular endothelial growth factor (VEGF), a protein that promotes brain development and blood vessel growth (Hofman et al., 2015, cited in Kuehn, 2015). A new diet developed at Rush University slashed Alzheimer's risk by 53% in rigorous adherents and by 35% in moderate adherents (Di Fiore, 2015). The MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay) emphasizes fish, poultry, green vegetables, nuts, whole grains, beans, berries, coffee, dark chocolate, olive oil, and wine, and discourages butter, cheese, and fried or fast food (Di Fiore). Maintaining healthy weight, blood pressure, and cholesterol, and getting adequate sleep can be recommended with confidence to all individuals we counsel, not only for cognitive health but general health and well- being.

Quite impressive are autopsy findings showing that some individuals with extensive neurological pathology had actually remained mentally sharp in their older years, leading Kuehn to proclaim “Pathology is not destiny” (Kuehn, 2015, p. 2492). Drawing upon this new research evidence, we can present a more positive message to elders about cognitive aging, mild cognitive impairment, and prevention or delay of Alzheimer's disease. Psychiatric-mental health nurses can offer to speak at senior centers and other community venues to convey this educational and motivational message to the public. Obviously, we can also continue our vital roles in geriatric clinical practice and research on aging.

I welcome your manuscripts regarding interventions to promote cognitive health in older adults.

Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.