Cognitive Development in Late Adulthood

There are numerous stereotypes regarding older adults as being forgetful and confused, but what does the research on memory and cognition in late adulthood actually reveal? In this section, we will focus upon the impact of aging on memory, how age impacts cognitive functioning, and abnormal memory loss due to Alzheimer’s disease, delirium, and dementia.^[1]

How does aging affect memory?

The Sensory Register

Aging may create small decrements in the sensitivity of the senses. And, to the extent that a person has a more difficult time hearing or seeing, that information will not be stored in memory. This is an important point, because many older people assume that if they cannot remember something, it is because their memory is poor. In fact, it may be that the information was never seen or heard.

The Working Memory

Older people have more difficulty using memory strategies to recall details.^[2] Working memory is a cognitive system with a limited capacity responsible for temporarily holding information available for processing . As we age, the working memory loses some of its capacity. This makes it more difficult to concentrate on more than one thing at a time or to remember details of an event.  However, people often compensate for this by writing down information and avoiding situations where there is too much going on at once to focus on a particular cognitive task.

When an elderly person demonstrates difficulty with multi-step verbal information presented quickly, the person is exhibiting problems with working memory. Working memory is among the cognitive functions most sensitive to decline in old age. Several explanations have been offered for this decline in memory functioning; one is the processing speed theory of cognitive aging by Tim Salthouse. Drawing on the findings of general slowing of cognitive processes as people grow older, Salthouse argues that slower processing causes working-memory contents to decay, thus reducing effective capacity.^[3] For example, if an elderly person is watching a complicated action movie, they may not process the events quickly enough before the scene changes, or they may processing the events of the second scene, which causes them to forget the first scene. The decline of working-memory capacity cannot be entirely attributed to cognitive slowing, however, because capacity declines more in old age than speed.

Another proposal is the inhibition hypothesis advanced by Lynn Hasher and Rose Zacks^[4]. This theory assumes a general deficit in old age in the ability to inhibit irrelevant, or no-longer relevant, information. Therefore, working memory tends to be cluttered with irrelevant contents which reduce the effective capacity for relevant content. The assumption of an inhibition deficit in old age has received much empirical support but, so far, it is not clear whether the decline in inhibitory ability fully explains the decline of working-memory capacity.

An explanation on the neural level of the decline of working memory and other cognitive functions in old age was been proposed by Robert West. He argued that working memory depends to a large degree on the pre-frontal cortex, which deteriorates more than other brain regions as we grow old.^[5] Age related decline in working memory can be briefly reversed using low intensity transcranial stimulation, synchronizing rhythms in bilateral frontal and left temporal lobe areas.

The Long-Term Memory

Long-term memory involves the storage of information for long periods of time. Retrieving such information depends on how well it was learned in the first place rather than how long it has been stored. If information is stored effectively, an older person may remember facts, events, names and other types of information stored in long-term memory throughout life. The memory of adults of all ages seems to be similar when they are asked to recall names of teachers or classmates. And older adults remember more about their early adulthood and adolescence than about middle adulthood.^[6] Older adults retain semantic memory or the ability to remember vocabulary.

Younger adults rely more on mental rehearsal strategies to store and retrieve information. Older adults focus rely more on external cues such as familiarity and context to recall information.^[7] And they are more likely to report the main idea of a story rather than all of the details.^[8]

A positive attitude about being able to learn and remember plays an important role in memory. When people are under stress (perhaps feeling stressed about memory loss), they have a more difficult time taking in information because they are preoccupied with anxieties. Many of the laboratory memory tests require comparing the performance of older and younger adults on timed memory tests in which older adults do not perform as well. However, few real life situations require speedy responses to memory tasks. Older adults rely on more meaningful cues to remember facts and events without any impairment to everyday living.

New Research on Aging and Cognition

Can the brain be trained in order to build cognitive reserve to reduce the effects of normal aging? ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), a study conducted between 1999 and 2001 in which 2,802 individuals age 65 to 94, suggests that the answer is “yes.” These participants received 10 group training sessions and 4 follow up sessions to work on tasks of memory, reasoning, and speed of processing. These mental workouts improved cognitive functioning even 5 years later. Many of the participants believed that this improvement could be seen in everyday tasks as well.^[9] Learning new things, engaging in activities that are considered challenging, and being physically active at any age may build a reserve to minimize the effects of primary aging of the brain.

Changes in Attention in Late Adulthood

Divided attention has usually been associated with significant age-related declines in performing complex tasks. For example, older adults show significant impairments on attentional tasks such as looking at a visual cue at the same time as listening to an auditory cue because it requires dividing or switching of attention among multiple inputs. Deficits found in many tasks, such as the Stroop task which measures selective attention, can be largely attributed to a general slowing of information processing in older adults rather than to selective attention deficits per se. They also are able to maintain concentration for an extended period of time. In general, older adults are not impaired on tasks that test sustained attention, such as watching a screen for an infrequent beep or symbol.

The tasks on which older adults show impairments tend to be those that require flexible control of attention, a cognitive function associated with the frontal lobes. Importantly, these types of tasks appear to improve with training and can be strengthened.^[10]

An important conclusion from research on changes in cognitive function as we age is that attentional deficits can have a significant impact on an older person’s ability to function adequately and independently in everyday life. One important aspect of daily functioning impacted by attentional problems is driving. This is an activity that, for many older people, is essential to independence. Driving requires a constant switching of attention in response to environmental contingencies. Attention must be divided between driving, monitoring the environment, and sorting out relevant from irrelevant stimuli in a cluttered visual array. Research has shown that divided attention impairments are significantly associated with increased automobile accidents in older adults ^[11] Therefore, practice and extended training on driving simulators under divided attention conditions may be an important remedial activity for older people.^[12]

Problem Solving

Problem solving tasks that require processing non-meaningful information quickly (a kind of task which might be part of a laboratory experiment on mental processes) declines with age. However, real life challenges facing older adults do not rely on speed of processing or making choices on one’s own. Older adults are able to resolve everyday problems by relying on input from others such as family and friends. They are also less likely than younger adults to delay making decisions on important matters such as medical care.^[13][14]

Brain Functioning

Research has demonstrated that the brain loses 5% to 10% of its weight between 20 and 90 years of age.^[15] This decrease in brain volume appears to be due to the shrinkage of neurons, lower number of synapses, and shorter length of axons. According to Garrett,^[16] the normal decline in cognitive ability throughout the lifespan has been associated with brain changes, including reduced activity of genes involved in memory storage, synaptic pruning, plasticity, and glutamate and GABA (neurotransmitters) receptors. There is also a loss in white matter connections between brain areas. Without myelin, neurons demonstrate slower conduction and impede each other’s actions. A loss of synapses occurs in specific brain areas, including the hippocampus (involved in memory) and the basal forebrain region. Older individuals also activate larger regions of their attentional and executive networks, located in the parietal and prefrontal cortex, when they perform complex tasks. This increased activation correlates with a reduced performance on both executive tasks and tests of working memory when compared to those younger.^[17]

Despite these changes the brain exhibits considerable plasticity, and through practice and training, the brain can be modified to compensate for age-related changes.^[18] Park and Reuter-Lorenz^[19] proposed the Scaffolding Theory of Aging and Cognition which states that the brain adapts to neural atrophy (dying of brain cells) by building alternative connections, referred to as scaffolding. This scaffolding allows older brains to retain high levels of performance. Brain compensation is especially noted in the additional neural effort demonstrated by those individuals who are aging well. For example, older adults who performed just as well as younger adults on a memory task used both prefrontal areas, while only the right prefrontal cortex was used in younger participants.^[20] Consequently, this decrease in brain lateralization appears to assist older adults with their cognitive skills.

Can we improve brain functioning? Many training programs have been created to improve brain functioning. ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), a study conducted between 1999 and 2001 in which 2,802 individuals age 65 to 94, suggests that the answer is “yes”. These racially diverse participants received 10 group training sessions and 4 follow up sessions to work on tasks of memory, reasoning, and speed of processing. These mental workouts improved cognitive functioning even 5 years later. Many of the participants believed that this improvement could be seen in everyday tasks as well.^[21] However, programs for the elderly on memory, reading, and processing speed training demonstrate that there is improvement on the specific tasks trained, but there is no generalization to other abilities.^[22] Further, these programs have not been shown to delay or slow the progression of Alzheimer’s disease. Although these programs are not harmful, “physical exercise, learning new skills, and socializing remain the most effective ways to train your brain” (p. 207). These activities appear to build a reserve to minimize the effects of primary aging of the brain.

Parkinson’s disease

Parkinson’s disease is characterized by motor tremors, loss of balance, poor coordination, rigidity, and difficulty moving.^[23] Parkinson’s affects approximately 1% of those over the age of 60, and it appears more frequently in family members in a little less than 10% of cases. Twenty-eight chromosomal areas have been implicated in Parkinson’s disease, but environmental factors have also been identified and include brain injury. Being knocked unconscious once increases the risk by 32%, and being knocked out several times increases the risk by 174%.^[24] Other environmental influences include toxins, industrial chemicals, carbon monoxide, herbicides and pesticides.^[25] The symptoms are due to the deterioration of the substantia nigra, an area in the midbrain whose neurons send dopamine-releasing axons to the basal ganglia which affects motor activity. Treatment typically includes the medication levodopa (L-dopa), which crosses the blood-brain barrier and is converted into dopamine in the brain. Deep brain stimulation, which involves inserting an electrode into the brain that provides electrical stimulation, has resulted in improved motor functioning.^[26]

Sleep

Similar to other adults, older adults need between 7 to 9 hours of sleep per night, but they tend to go to sleep earlier and get up earlier than those younger. This pattern is called advanced sleep phase syndrome and is based on changes in circadian rhythms.^[27] There are sleep problems in older adults, and insomnia is the most common problem in those 60 and older.^[28] People with insomnia have trouble falling asleep and staying asleep. There are many reasons why older people may have insomnia, including certain medications, being in pain, having a medical or psychiatric condition, and even worrying before bedtime about not being able to sleep. Using over the counter sleep aids or medication may only work when used for a short time. Consequently, sleep problems should be discussed with a health care professional.

Also, common in older adults are sleep disorders, including sleep apnea, restless legs syndrome, periodic limb movement disorder, and rapid eye movement sleep behavior disorder.^[29] Sleep apnea refers to repeated short pauses in breathing, while an individual sleeps, that can lead to reduced oxygen in the blood. Snoring is a common symptom of sleep apnea and it often worsens with age. Untreated sleep apnea can lead to impaired daytime functioning, high blood pressure, headaches, stroke, and memory loss. Restless legs syndrome feels like there is tingling, crawling, or pins and needles in one or both legs, and this feeling is worse at night. Periodic limb movement disorder causes people to jerk and kick their legs every 20 to 40 seconds during sleep. Rapid eye movement sleep behavior disorder occurs when one’s muscles can move during REM sleep and sleep is disrupted. 

According to the National Sleep Foundation,^[30] there are many medical conditions that affect sleep and include gastroesophageal reflux disease, diabetes mellitus, renal failure, respiratory diseases such as asthma, and immune disorders. Diseases such as Parkinson’s disease and multiple sclerosis also commonly cause problems sleeping. Lastly, Alzheimer’s disease can interfere with sleeping patterns. Individuals may wake up many times during the night, wander when up, and yell which can alter the amount of time they sleep. Both minor and significant sleep problems in older adults can lead to increased risk of accidents, falls, chronic fatigue, decreased quality of life, cognitive decline, reduced immune function, and depression.^[31]

Because of sleep problems experienced by those in late adulthood, research has looked into whether exercise can improve their quality of sleep. Results show that 150 minutes per week of exercise can improve sleep quality.^[32] This amount of exercise is also recommended to improve other health areas including lowering the risk for heart disease, diabetes, and some cancers. Aerobic activity, weight training, and balance programs are all recommended. For those who live in assisted living facilities even light exercise, such as stretching and short walks, can improve sleep. High intensity activity is not necessary to see improvements. Overall, the effects of exercise on sleep may actually be even larger for older adults since their sleep quality may not be ideal to start.

Intelligence and Wisdom

When looking at scores on traditional intelligence tests, tasks measuring verbal skills show minimal or no age-related declines, while scores on performance tests, which measure solving problems quickly decline with age.^[33] This profile mirrors crystalized and fluid intelligence. As you recall from last chapter, crystallized intelligence encompasses abilities that draw upon experience and knowledge. Measures of crystallized intelligence include vocabulary tests, solving number problems, and understanding texts. Fluid intelligence refers to information processing abilities, such as logical reasoning, remembering lists, spatial ability, and reaction time. Baltes^[34] introduced two additional types of intelligence to reflect cognitive changes in aging. Pragmatics of intelligence are cultural exposure to facts and procedures that are maintained as one ages and are similar to crystalized intelligence. Mechanics of intelligence are dependent on brain functioning and decline with age, similar to fluid intelligence. Baltes indicated that pragmatics of intelligence show little decline and typically increase with age. Additionally, pragmatics of intelligence may compensate for the declines that occur with mechanics of intelligence. In summary, global cognitive declines are not typical as one ages, and individuals compensate for some cognitive declines, especially processing speed.

Wisdom is the ability to use the accumulated knowledge about practical matters that allows for sound judgment and decision making. A wise person is insightful and has knowledge that can be used to overcome obstacles in living. Does aging bring wisdom? While living longer brings experience, it does not always bring wisdom. Paul Baltes and his colleagues^[35][36]  suggest that wisdom is rare. In addition, the emergence of wisdom can be seen in late adolescence and young adulthood, with there being few gains in wisdom over the course of adulthood.^[37] This would suggest that factors other than age are stronger determinants of wisdom. Occupations and experiences that emphasize others rather than self, along with personality characteristics, such as openness to experience and generativity, are more likely to provide the building blocks of wisdom.^[38] Age combined with a certain types of experience and/or personality brings wisdom.

Attention and Problem Solving

Changes in Attention in Late Adulthood

Changes in sensory functioning and speed of processing information in late adulthood often translates into changes in attention.^[39] Research has shown that older adults are less able to selectively focus on information while ignoring distractors,^[40][41] although Jefferies and her colleagues found that when given double time, older adults could perform at young adult levels. Other studies have also found that older adults have greater difficulty shifting their attention between objects or locations.^[42] Consider the implication of these attentional changes for older adults.

How do changes or maintenance of cognitive ability affect older adults’ everyday lives? Researchers have studied cognition in the context of several different everyday activities. One example is driving. Although older adults often have more years of driving experience, cognitive declines related to reaction time or attentional processes may pose limitations under certain circumstances.^[43] In contrast, research on interpersonal problem solving suggested that older adults use more effective strategies than younger adults to navigate through social and emotional problems.^[44] In the context of work, researchers rarely find that older individuals perform poorer on the job.^[45] Similar to everyday problem solving, older workers may develop more efficient strategies and rely on expertise to compensate for cognitive decline.

Problem Solving

Problem solving tasks that require processing non-meaningful information quickly (a kind of task that might be part of a laboratory experiment on mental processes) declines with age. However, many real-life challenges facing older adults do not rely on speed of processing or making choices on one’s own. Older adults resolve everyday problems by relying on input from others, such as family and friends. They are also less likely than younger adults to delay making decisions on important matters, such as medical care.^[46][47]

Deficit theories

The processing speed theory, proposed by Salthouse,^[48][49] suggests that as the nervous system slows with advanced age our ability to process information declines. This slowing of processing speed may explain age differences on many different cognitive tasks. For instance, as we age, working memory becomes less efficient.^[50] Older adults also need longer time to complete mental tasks or make decisions. Yet, when given sufficient time older adults perform as competently as do young adults.^[51] Thus, when speed is not imperative to the task healthy older adults do not show cognitive declines.

In contrast, inhibition theory argues that older adults have difficulty with inhibitory functioning, or the ability to focus on certain information while suppressing attention to less pertinent information tasks.^[52] Evidence comes from directed forgetting research. In directed forgetting people are asked to forget or ignore some information, but not other information. For example, you might be asked to memorize a list of words, but are then told that the researcher made a mistake and gave you the wrong list, and asks you to “forget” this list. You are then given a second list to memorize. While most people do well at forgetting the first list, older adults are more likely to recall more words from the “forget-to-recall” list than are younger adults.^[53]

Cognitive losses exaggerated

While there are information processing losses in late adulthood, overall loss has been exaggerated.^[54] One explanation is that the type of tasks that people are tested on tend to be meaningless. For example, older individuals are not motivated to remember a random list of words in a study, but they are motivated for more meaningful material related to their life, and consequently perform better on those tests. Another reason is that the research is often cross-sectional. When age comparisons occur longitudinally, however, the amount of loss diminishes.^[55] A third reason is that the loss may be due to a lack of opportunity in using various skills. When older adults practiced skills, they performed as well as they had previously. Although diminished performance speed is especially noteworthy in the elderly, Schaie^[56] found that statistically removing the effects of speed diminished the individual’s performance declines significantly. In fact, Salthouse and Babcock^[57] demonstrated that processing speed accounted for all but 1% of age-related differences in working memory when testing individuals from 18 to 82. Finally, it is well established that our hearing and vision decline as we age. Longitudinal research has proposed that deficits in sensory functioning explain age differences in a variety of cognitive abilities.^[58]

Abnormal Loss of Cognitive Functioning During Late Adulthood

Dementia

Historically, the term dementia was used to refer to an individual experiencing difficulties with memory, language, abstract thinking, reasoning, decision making, and problem-solving.^[59] While the term dementia is still in common use, in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)^[60] the term dementia has been replaced by neurocognitive disorder. A Major Neurocognitive Disorder is diagnosed as a significant cognitive decline from a previous level of performance in one or more cognitive domains and interferes with independent functioning, while a Minor Neurocognitive Disorder is diagnosed as a modest cognitive decline from a previous level of performance in one of more cognitive domains and does not interfere with independent functioning. There are several different neurocognitive disorders that are typically demonstrated in late adulthood, and determining the exact type can be difficult because the symptoms may overlap with each other. Diagnosis often includes a medical history, physical exam, laboratory tests, and changes noted in behavior.

Common symptoms of dementia include emotional problems, difficulties with language, and a decrease in motivation. A person’s consciousness is usually not affected. Globally, dementia affected about 46 million people in 2015. About 10% of people develop the disorder at some point in their lives, and it becomes more common with age. About 3% of people between the ages of 65–74 have dementia, 19% between 75 and 84, and nearly half of those over 85 years of age. In 2015, dementia resulted in about 1.9 million deaths, up from 0.8 million in 1990. As more people are living longer, dementia is becoming more common in the population as a whole.

Dementia generally refers to severely impaired judgment, memory or problem-solving ability. It can occur before old age and is not an inevitable development even among the very old. Dementia can be caused by numerous diseases and circumstances, all of which result in similar general symptoms of impaired judgment, etc. Alzheimer’s disease is the most common form of dementia and is incurable, but there are also nonorganic causes of dementia which can be prevented. Malnutrition, alcoholism, depression, and mixing medications can also result in symptoms of dementia. If these causes are properly identified, they can be treated. Cerebral vascular disease can also reduce cognitive functioning.

Delirium

Delirium, also known as acute confusional state, is an organically caused decline from a previous baseline level of mental function that develops over a short period of time, typically hours to days. It is more common in older adults, but can easily be confused with a number of psychiatric disorders or chronic organic brain syndromes because of many overlapping signs and symptoms in common with dementia, depression, psychosis, etc. Delirium may manifest from a baseline of existing mental illness, baseline intellectual disability, or dementia, without being due to any of these problems.

Delirium is a syndrome encompassing disturbances in attention, consciousness, and cognition. It may also involve other neurological deficits, such as psychomotor disturbances (e.g. hyperactive, hypoactive, or mixed), impaired sleep-wake cycle, emotional disturbances, and perceptual disturbances (e.g. hallucinations and delusions), although these features are not required for diagnosis. Among older adults, delirium occurs in 15-53% of post-surgical patients, 70-87% of those in the ICU, and up to 60% of those in nursing homes or post-acute care settings. Among those requiring critical care, delirium is a risk for death within the next year.

Alzheimer’s Disease

Alzheimer’s disease (AD), also referred to simply as Alzheimer’s, is the most common cause of dementia, accounting for 60-70% of its cases. Alzheimer’s is a progressive disease causing problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.^[61]

Alzheimer’s disease is probably the most well-known and most common neurocognitive disorder for older individuals. In 2016, an estimated 5.4 million Americans were diagnosed with Alzheimer’s disease,^[62] which was approximately one in nine aged 65 and over. By 2050, the number of people age 65 and older with Alzheimer’s disease is projected to be 13.8 million if there are no medical breakthroughs to prevent or cure the disease. Alzheimer’s disease is the 6th leading cause of death in the United States, but the 5th leading cause for those 65 and older. Among the top 10 causes of death in America, Alzheimer’s disease is the only one that cannot be prevented, cured, or even slowed. Current estimates indicate that Alzheimer disease affects approximately 50% of those identified with a neurocognitive disorder.^[63]

Alzheimer’s disease has a gradual onset with subtle personality changes and memory loss that differs from normal age-related memory problems occurring first. Confusion, difficulty with change, and deterioration in language, problem-solving skills, and personality become evident next. In the later stages, the individual loses physical coordination and is unable to complete everyday tasks, including self-care and personal hygiene.^[64] Lastly, individuals lose the ability to respond to their environment, to carry on a conversation, and eventually to control movement (Alzheimer’s Association, 2016). The disease course often depends on the individual’s age and whether they have other health conditions.

Alzheimer’s is the sixth leading cause of death in the United States. On average, a person with Alzheimer’s lives four to eight years after diagnosis, but can live as long as 20 years, depending on other factors. Alzheimer’s is not a normal part of aging. The greatest known risk factor is increasing age, and the majority of people with Alzheimer’s are 65 and older. But Alzheimer’s is not just a disease of old age. Approximately 200,000 Americans under the age of 65 have younger-onset Alzheimer’s disease (also known as early-onset Alzheimer’s).^[65]

The cause of Alzheimer’s disease is poorly understood. About 70% of the risk is believed to be inherited from a person’s parents with many genes usually involved. Other risk factors include a history of head injuries, depression, and hypertension. The disease process is associated with plaques and neurofibrillary tangles in the brain. A probable diagnosis is based on the history of the illness and cognitive testing with medical imaging and blood tests to rule out other possible causes. Initial symptoms are often mistaken for normal aging, but examination of brain tissue, specifically of structures called plaques and tangles, is needed for a definite diagnosis. Though qualified physicians can be up to 90% certain of a correct diagnosis of Alzheimer’s, currently, the only way to make a 100% definitive diagnosis is by performing an autopsy of the person and examining the brain tissue. In 2015, there were approximately 29.8 million people worldwide with AD. In developed countries, AD is one of the most financially costly diseases.