This document summarizes age-related changes in memory and other cognitive abilities. It finds that normal aging is associated with declines in processing speed and attention that mediate declines in episodic memory performance. Verbal abilities remain largely intact with aging, though confrontation naming and verbal fluency decline after age 70. Executive functions that rely on the prefrontal cortex also show age-related declines, with more pronounced changes emerging after age 75 on tasks like the Wisconsin Card Sorting Test. Overall, the text suggests that cognitive slowing and reduced attention help explain memory and executive function changes in older adults.
This document summarizes age-related changes in memory and other cognitive abilities. It finds that normal aging is associated with declines in processing speed and attention that mediate declines in episodic memory performance. Verbal abilities remain largely intact with aging, though confrontation naming and verbal fluency decline after age 70. Executive functions that rely on the prefrontal cortex also show age-related declines, with more pronounced changes emerging after age 75 on tasks like the Wisconsin Card Sorting Test. Overall, the text suggests that cognitive slowing and reduced attention help explain memory and executive function changes in older adults.
This document summarizes age-related changes in memory and other cognitive abilities. It finds that normal aging is associated with declines in processing speed and attention that mediate declines in episodic memory performance. Verbal abilities remain largely intact with aging, though confrontation naming and verbal fluency decline after age 70. Executive functions that rely on the prefrontal cortex also show age-related declines, with more pronounced changes emerging after age 75 on tasks like the Wisconsin Card Sorting Test. Overall, the text suggests that cognitive slowing and reduced attention help explain memory and executive function changes in older adults.
Retrieval of information is an important part of daily functioning.
With normal aging, memory deficits are associated primarily with the storage of long-term episodic memories. Information that places little demand on attention, such as implicit memory tasks, results in very little age-related changes in performance. The advantage that older adults experience on recognition tasks indicates that their memory storage and retrieval may be much less efficient than that of younger adults. A processing speed perspective illustrates that normal aging is accompanied by a slowing in overall cognitive processing and it is accepted that older adults process information at a slower rate compared with younger adults. Salthouse19 found that after statistically controlling for processing speed, age was only weakly related to memory. Memory functioning in normal aging is thus mediated by processing speed. The reduced attentional resources concept18,40 suggests that a limited amount of cognitive resources are available for a given task and consequently, a more complex task requires more attentional capacity than a simpler task. It follows that because the amount of attentional resources is reduced with aging, the processes of encoding and retrieval of information use a larger proportion of available resources for older adults than for younger adults. In sum, research suggests that overall cognitive slowing and changes in attentional ability account for much of the change in memory functioning as we age. Verbal Abilities Most verbal abilities remain intact with normal aging.41 Therefore vocabulary and verbal reasoning scores remain relatively constant in normal aging and may even show minor improvements. The two main areas of verbal abilities that are frequently discussed in terms of aging are verbal fluency (semantic and phonemic) and confrontation naming. Verbal fluency is the ability to retrieve words based on their meaning or their sounds. Confrontation naming describes the ability to identify an object by its name. Two common tests used to assess verbal fluency are the Controlled Oral Word Association Test (COWAT)42 and the semantic fluency test.31 The COWAT is perhaps the most widely used test of phonemic fluency. The COWA task requires an individual to generate as many words that begin with a specific letter as quickly as they can. The semantic fluency task is a timed-test that requires the individual to generate examples in a specific category (e.g., animal naming test). The Boston Naming Test32 is a commonly used test to measure confrontation naming ability as individuals are required to name the object in the presented picture. Confrontation naming is composed of several different processes; an individual must perceive the object in the picture correctly, identify the semantic concept of the picture, and retrieve and express the appropriate name for the object.43 Confrontation naming ability is associated with the tip-of-the-tongue (TOT) phenomenon. The TOT phenomenon occurs when an individual knows the name of a person or object and is able to retrieve the semantic information about the object, but cannot retrieve the name of the object.44 Although an individual is unable to retrieve the target word, he or she will often try to describe the term using other words.45 Throughout all of adulthood, proper nouns comprise the majority of TOT experiences. However, the increase in TOT phenomenon among older adults is due to their greater difficulty in retrieving proper nouns.44 There is not a significant age difference in the frequency of TOT episodes for simple words. However, older adults have significantly more TOT experiences than younger adults for difficult words.45 Thus, wordfinding difficulty and TOT moments are the most common cognitive complaints of older adults. The majority of cross-sectional studies have found that older adults have lower scores on the Boston Naming Test compared with younger individuals. It should be noted that while subjective complaints of word-finding difficulties increase with age, significantly lower performance on tasks of confrontation naming only emerges after age 70.44 Zec et al46 found that confrontation naming ability as measured by the Boston Naming Test improves when individuals are in their 50s, remain the same in their 60s, and decline in the 70s and 80s; it should be noted that the magnitude of these agerelated changes is relatively small. It was found that there was an approximate one word improvement in the 50s age group and a 1.3 word decline in the 70s age group. There is some indication that there is an accelerated rate of decline in confrontation naming ability with age.44 Normal aging is associated with a decline in verbal fluency. It is important to note that the normal age-related decline seen in verbal fluency performance may be partially mediated by reduced psychomotor speed rather than true deficits in verbal ability. Slowed handwriting and reading speed in the elderly was predictive of poorer performance on verbal fluency tests.47 Rodriguez-Aranda and Martinussen48 found a decline in verbal fluency as measured by the COWAT after age 60. The ability to generate words beginning with a particular letter improves until the third decade of life and remains constant through the 40s. Subsequently, a significant decline occurs in phonemic naming ability and continues to worsen gradually until the late 60s. Phonemic verbal fluency ability continues to decline rapidly through the late 80s. Gender and education may impact ones phonemic verbal fluency across the lifespan. Women may slightly outperform men on tasks of phonemic verbal fluency. Individuals with higher levels of education (beyond high school) show greater verbal fluency ability as measured by the COWAT compared with individuals with lower levels of education (12 years or less).49 Executive Functions Executive functions describe a wide range of abilities that relate to the capacity to respond to a novel situation.16 Executive functions include abilities such as mental flexibility, response inhibition, planning, organization, abstraction, and decision-making.50,51 Executive function can be thought of as having four distinct components: volition, planning, purposive action, and effective performance.3 Volition is a complex process that refers to the ability to act intentionally. Planning is the process and the steps involved in achieving the goal. Purposive action refers to the productive activity required to execute a plan. Effective performance is the ability to self-correct and monitor ones behavior while working. All of the components of executive functioning are necessary for problem solving and appropriate social behavior. Another term for executive functions is frontal lobe functions because these abilities are localized in the prefrontal cortex.52 The frontal aging hypothesis refers to the idea that normal aging leads to deterioration of the frontal lobes. Deterioration is due to a loss of volume in the prefrontal cortex and is associated with cognitive deficits. Prefrontal deterioration plays a key role in many of the age-related changes in cognitive processes, such as memory, attention, and executive function.53 Like many cognitive processes, it is difficult to assess pure executive function as many of the measures used in its assessment rely on other cognitive processes such as working memory, processing speed, attention, and visual spatial abilities. The Wisconsin Card Sorting Test (WCST)54 is a popular test used to measure executive function. The WCST requires an individual to sort a set of cards based on different categories. Individuals are not informed about how to sort the cards and must deduce the correct sorting strategies through the limited feedback that is provided. After a particular category is achieved (i.e., a set number of correct responses) based on a particular characteristic (e.g., color or shape), the sorting strategy changes and the individual must shift strategies accordingly. Once the test is completed, the examiner is provided with several measures related to executive function, for example, categories and perseverative errors. A category is achieved when a specific number of cards have been sorted correctly based on the particular criterion such as color. Perseverative errors occur when an individual continues to give the wrong response when provided the feedback that the strategy is not or is no longer correct, thus demonstrating a lack of cognitive flexibility. On the WCST older adults achieve significantly fewer categories than younger adults.52 The most significant decline in performance on this test is seen in adults age 75 and older. Individuals of this age group achieve significantly fewer categories and more perseverative errors compared with younger individuals. However, changes in executive functioning as measured by neuropsychological assessments, such as the WCST, can be seen in adults aged 53 to 64, but adults ages 53 to 64 do not show deficits on more real-world executive tasks.55 Thus although individuals in midadulthood may show a decline in executive functioning on structured neuropsychological tests, their real-world executive skills remain intact. Other measures used in the assessment of executive functioning included Trail Making Test, Part B5 and the WAIS-III subtests,4 Matrix Reasoning and Similarities. Trail Making, Part B, is a timed visual-spatial sequencing task requiring an individual to draw connecting lines alternating between numbers and letters in numerical and alphabetical order. Matrix Reasoning is an untimed task that measures ones nonverbal analytic thinking abilities. The Matrix Reasoning task requires an individual to identify the missing element of an abstract pattern from a variety of choices. Wechslers Similarities subtest measures an individuals verbal abstract reasoning skills by asking an individual to describe how two different objects/concepts are alike. Normal aging is generally associated with a decline in executive functioning.56 When reasoning and problem-solving involve material that is novel, complex, or requires the ability to distinguish relevant from irrelevant information, the performance of older adults suffers because they tend to think in more concrete terms and the mental flexibility required to form new abstractions and concepts declines.3 Compared with younger adults, older adults also show a decreased capacity to form conceptual links as mental flexibility diminishes.3 Executive functions serve as the overseer of brain processing and are essential for purposeful, goal-directed behavior. Deficits in executive functioning can be seen in difficulties with planning and organizing, difficulties implementing strategies, and inappropriate social behavior or poor judgment. Lifestyle Factors Associated with Cognitive Functioning LEISURE ACTIVITIES The mental exercise hypothesis refers to the notion that keeping mentally active will help maintain an individuals cognitive functioning and prevent cognitive decline. Many activities, such as playing bridge, doing crossword puzzles, studying a foreign language, and learning to play an instrument, have been suggested to help in preventing cognitive decline.57 The research regarding the mental exercise hypothesis has been varied and there is currently not a definitive answer regarding the role of leisure activities in preventing cognitive decline. It is suggested that engaging in leisure activities, especially ones that are cognitively demanding, maintains or improves cognitive functioning.58 However, there is also evidence that individuals with high levels of intellectual functioning engage in more cognitively demanding activities, making it difficult to discern the exact role of mental activities in preventing cognitive decline. This line of research suggests that it is not the activity per se that is responsible for maintaining cognitive functioning, but rather specific lifestyles and living conditions.58 Although there is not conclusive evidence regarding the protective factors of leisure activities, several research studies59,60 have shown that leisure activities reduce the risk of dementia in the elderly. Reading, playing board games, learning a musical instrument, visiting friends or relatives, going out (i.e., to movies or a restaurant), walking for pleasure, and dancing are associated with a reduced risk of dementia.59,60 Such leisure activities have been shown to protect against memory decline even after controlling for age, sex, education, ethnicity, baseline cognitive-status, and medical illness. Participation in an activity for 1 day per week was found to reduce the risk of dementia by 7%.59 Individuals who participated in many leisure activities (i.e., six or more activities a month) had a 38% less risk of developing dementia.60 It has been also hypothesized that leisure activities reduce the risk of cognitive decline by enhancing cognitive reserve. A decrease in activity results in reduced cognitive abilities.61 Engaging in leisure activities may also provide structural changes in the brain that protect against cognitive decline given that certain areas of the adult brain are able to generate new neurons (i.e., plasticity). Stimulation, such as engaging in social, intellectual, and physical activities, is suggested to promote increased synaptic density. Enhanced neuronal activation has been proposed to hinder the development of disease processes, such as dementia.60 However, research has also shown that changes in cognitive reserve are more likely to occur early in life; it is primarily the early experiences of education and intellectual activity that increases cognitive reserve the most.11 Despite the varied findings, people should continue to engage in mentally stimulating activities because even if there is not yet evidence that it has beneficial effects in slowing the rate of age-related decline in cognitive functioning, there is no evidence that it has any harmful effects, the activities are often enjoyable and thus may contribute to a higher quality of life, and engagement in cognitively demanding activities serves as an existence proofif you can still do it, then you know that you have not yet lost it.57 PHYSICAL ACTIVITIES It has been hypothesized that engaging in physical activities may enhance cognition and prevent decline in late life as physical activities enhance blood flow to the brain and oxygenation, processes which are known to slow biologic aging.11 Physical activities reduce cardiovascular and cerebrovascular risk factors, which may reduce the risk of vascular dementia and Alzheimer disease.62 There is also evidence that physical activity may directly affect the brain by preserving neurons and increasing synapses.63 Moderate and strenuous physical activity is associated with a decreased risk of cognitive decline. Moderate activity includes playing golf on a weekly basis, playing tennis twice a week, and walking 1.6 m/day. Research has found that long-term regular physical activity, such as walking, is associated with less cognitive decline in women.64 The benefits of walking at least 1.5 hr/wk at a 21 to 30 min/mile pace are similar to being about 3 years younger and are associated with a 20% reduced risk of significant cognitive decline SOCIAL ACTIVITIES Social support has also been suggested to serve as a protective factor in cognitive decline. Social support may serve as a buffer against stress and may lead to decreased cortisol production in the brain. Lower levels of cortisol result in better performance on tests of episodic memory.65 Interacting with others may also prevent cognitive decline by providing an individual with increased mental stimulation66 and may also protect an individual from depression, which has been shown to negatively impact cognition.67 Depression and mood disorders are associated with an accelerated cognitive decline as people age.68 Processing speed, attention, and consequently, memory may all be affected by depression. In addition, a lack of social interaction also impacts an older adults well-being. It has been found that individuals who live alone or have no intimate relationships are at an increased risk of developing dementia; those individuals who are classified as having a poor social network are 60% more likely to develop dementia.69 Individuals in their 70s who report having limited social support at baseline show greater cognitive decline at follow-up assessments.67 On the other hand, individuals with greater emotional supports have better performance on cognitive tests.67 Rowe and Kahn70 proposed a model of successful aging as being composed of three main components: avoidance of disease-related disability, maintenance of physical and cognitive functioning, and active engagement in life. Active engagement with life involves maintaining interpersonal relationships and it has been found that social environment and emotional supports may be protective against cognitive decline and result in a slower decline in functional status. HEALTH FACTORS Several medical conditions are associated with cognitive decline. Hypertension is the most prevalent vascular risk factor in the elderly.71 Chronic hypertension has been shown to result in deficits in brain structure including the reduction of white and gray matter in the prefrontal lobes, atrophy of the hippocampus, and increased white matter hypertensities.72 Research has found that uncontrolled hypertension can lead to cognitive decline that is independent of normal aging,71,73 aside from posing a risk for stroke. Older adults with hypertension have mild but specific cognitive deficits in the areas of executive function, processing speed, episodic memory, and working memory.73 Diabetes mellitus has also been associated with cognitive decline.74,75 Lipids and other metabolic markers may play a role in the relationship between diabetes and cognition.76 Diabetes may also impact cognition through confounding factors such as hypertension, heart disease, depression, and decreased physical activity.76 Individuals with type 1 diabetes display a slower processing speed and a decline in mental flexibility.75 Type 2 diabetes is also associated with cognitive decline; longer duration of type 2 diabetes results in greater cognitive decline.77 Elderly women with type 2 diabetes have a 30% greater risk of cognitive decline compared with those without diabetes, with a 50% greater risk for individuals with a 15-year or greater history of diabetes. Dietary factors and vitamin deficiencies have also been associated with cognitive decline in the elderly population. Individuals with cognitive decline associated with normal aging should be investigated for B12 deficiency. Research has demonstrated that vitamin B12 injections may improve executive and language functions in patients with cognitive decline, but will rarely reverse dementia.78 Low vitamin B levels may be associated with impaired cognitive performance through several possible mechanisms including, multiple central nervous system functions, reactions involving DNA, and the overproduction of homocysteine that could potentially damage neurons and blood vessels.79 Low levels of vitamin B12 and folic acid result in poorer performance on tasks of free recall, attention, processing speed, and verbal fluency.80 Overall, research suggests that the effects of vitamin deficiency are most likely seen on complex cognitive tasks that demand greater executive functions. Conclusion Cognitive decline is a natural part of aging. However, the extent of decline varies across individuals and across the specific cognitive domain being assessed. The cognitive reserve perspective maintains that individual differences with regard to cognitive aging are related to an individuals reserve built upon early life factors (i.e., educational and intellectual experiences).9 Although cognitive reserve can be increased in later life, it is more amenable to change in early life. Although cognitive decline is inevitable, all areas of functioning do not change equally. It is well established that older adults process, store, and encode information less efficiently than younger adults. The cognitive functions related to fluid intelligence, such as the ability to solve novel or complex problems, tend to decline with aging, whereas cognitive functions related to crystallized intelligence, such as school-based knowledge, vocabulary, and reading, generally remain stable throughout life. Processing speed and attentional capacity are particularly vulnerable to aging, especially on more challenging tasks, and mediate multiple areas of cognitive functioning. For example, a memory problem is often, more accurately, a problem with poor attention and/or slowed speed of processing information. KEY POINTS Normal Cognitive Aging Variability exists across individuals in their ability to compensate for cognitive changes as they age. An active, engaged lifestyle, emphasizing mental activity and educational pursuits in early life, has a positive impact on cognitive functioning in later life. In normal aging there is typically a decline in sustained attention and selective attention and an increase in distractibility. Older adults response time is approximately 1.5 times slower than younger adults. Most verbal abilities remain intact with normal aging. Normal aging is generally associated with a decline in executive functioning. Memory deficits associated with normal aging are primarily related to the storage of long-term episodic memories. Implicit memory tasks, results in very little age-related changes in Performance Although research has found cognitive decline in the areas of attention, processing speed, episodic memory, and executive function, research has also shown that older adults have cognitive (or brain) plasticity and may benefit from cognitive training and other mental activities.81 However, the results of cognitive training with normal aging adults has been varied; although improved performance on a specific task can be found, there is a lack of generalizability to daily functioning in the long term.82 Nevertheless, maintaining an engaged and healthy lifestyle (social, physical, and intellectual) improves ones quality of life and may add to successful aging. One problem is the assumption that successful aging means that there is no discernable change in memory and overall cognitive functioning from ones previous level of functioning. Changes in cognition are a normal part of aging and not something that is necessarily a cause for concern or precursor to dementia. Older adults need to adjust their idea of normal aging to a more realistic standard. ACKNOWLEDGMENT Material in this chapter contains contributions from the previous edition, and we are grateful to the previous author for the work done. For a complete list of references, please visit online only at www.expertconsult.com