Chapter 7 – Cognitive and Psychosocial Wellness

Cognitive decline is not necessarily inevitable

• Cognitive abilities vary from person to person
• Cognitive ability is affected by multiple factors
• Various cognitive abilities of the older adult can vary:
  • Declining ability,
  • Maintenance of ability, and
  • Improvement of ability

Intelligence

• Fluid
  • Integration, reasoning, abstract thinking
  • Allows problem solving and adaptive thinking
• Crystallized
  • Vocabulary, information, verbal comprehension
  • Acquired through culture, education, life experiences

Wisdom

• Crystallized intelligence is associated with wisdom, judgment, and life experiences.
• Wisdom is associated with a person’s sense of well-being
• A resource during times of challenge

Memory

• Short Term
  • Short duration, small capacity
  • Can be transferred to long term storage
• Long Term
  • Greater than seconds or moments
  • Needed for storage and retrieval

Age related changes

• Decreased number of neurons
• Decrease in brain size
• Decreased brain blood flow
• Decrease in short term memory
• Increased pain threshold
• Increased reaction time
• Decreased sensation to touch, pain

Cognitive function in the elderly adult

• Short-term, primary memory remains stable
• Language skills remain intact
• Vocabulary skills improve
• Accumulation of practical experience continues
• Influenced by:
  • Education
  • Pulmonary health
  • General health
  • Activity level
  • Ageism and diminished expectations of older adults

Cognitive wellness in the older adult

• Sociocultural influences
• Nutrition
• Physical activity
• Vision and hearing impairments
• Medication

Other drug effects on mental status

• Antihypertensives, antipsychotics—decreased cerebral blood flow
• Central nervous system depressants—respiratory depression
• Diuretics, alcohol, laxatives—F&E alterations
• Alcohol, psychotropics, narcotics—changes in thermo-regulation
• Diuretics, alcohol, nicotinic acid—acidosis
• Hypoglycemics, alcohol, propranolol—hypoglycemia
• Thyroid extract, corticosteroids—hormonal disturbances

Age related cognitive changes…

• Do not decline in healthy older adults
• Earliest changes that do occur are due to decreased perceptual speed
• Changes occur gradually
• Cognitive reserve develops with intellectual stimulation and higher levels of education

Coping with changes in cognition

• Make lists
• Memory training and techniques
• Playing computer games with hand/eye coordination
• Challenge mind
• Use assistive devices, habit
• Find support from others
• Keep sense of humor

Adjusting to changes

• Most adults adjust successfully
• A life of continuous adjustment makes it easier in the future
• Inability to adjust can be frustrating and/or depressing
• Assess for signs of depression with every life challenge

Rigidity and excess cautiousness

• Not a normal age related change!
• Experiences, values, and expectations no longer congruent with current ideas
• Out of their “comfort zone”
• Method of adjustment influenced by underlying personality

Maladaptation to stress in the elderly

• Sleep problems
• Chronic high anxiety
• Substance use/abuse
• Irritability
• New onset HTN
• Depression
• Chronic fatigue
• Chronic pain, discomfort

Mild cognitive impairment

• A state between normal aging and dementia
• Can remain stable, resolve, or progress
• Increases the risk of developing dementia
• Diagnosis not precise
• Based on:
  • Clinical judgment
  • Functional assessment
  • Neuropsychological testing

Promoting cognitive wellness

• Correct misinformation, myths
• Provide information regarding age-related changes
• Establish positive expectations
• Provide information regarding how to enhance cognitive abilities, such as….

Psychosocial wellness

• Ageism
• Retirement
• Relocation
• Functional Impairment
• Chronic Illness
• Driving decisions
• Widowhood
• Death/Loss

Ageism

• Negative stereotypes of older adults
• Can also be self-imposed attitudes in the elderly

Retirement

• Employment is equated with productivity, contribution
• Retirement brings a change in social status
• Especially difficult if self-esteem is based on work status
• Less negative effect on psychological wellness if
  
  • Person retires voluntarily
  • Participate in volunteer work
  • Transition from work gradually
  • Have established leisure activities

Chronic illness and functional impairment

• Significant cognitive, mobility, or visual impairments associated with:
  • Increased dependence
  • Altered self-esteem, self-concept
  • Lifestyle change
  • Uncertainty of one’s abilities
  • Increased financial burden
  • Frequent health-care visits
  • Adverse medication effects
  • Increased vulnerability to, fear of crime

Adjustment to loss or life events

• Grief lasting up to 2 years is “normal”
• Duration of grief affected by
  • Meaning associated with the person who has died
  • Health of the survivor
  • Survivor’s belief system
  • Existence of substance abuse
  • Cause, suddenness of death

Coping in older adults

• Younger adults tend to cope by modifying events, situations
• Older adults tend to cope by managing thoughts and feelings
• Coping more effective in those with religious support, significant family and friend relationships
• Past effective coping predicts future effective coping
• Due to life experiences, older adults are more adept at doping adaptively

Risk factors affecting psychosocial function

• Poor physical health
• Impaired physical function
• Weak social supports
• Lack of economic stability
• Poor social development
• Limited coping skills
• Unanticipated events
• Complex daily events
• Major life events converging

Personality disorders and psychoses

• Incidence of most personality disorders decline with age
• Schizophrenia rarely occurs initially in old age
• Most common form of psychosis in the elderly is paranoia
  • Hearing loss
  • Social isolation
  • Cognitive impairment
  • Delirium
  • Underlying personality disorder

Alcohol abuse in the elderly

• 7-14% older adults report alcohol abuse, dependence, binge drinking
• Some are long-term users, others are late-onset users

Potential reasons for alcohol abuse in the elderly

• Boredom
• Loneliness
• Stress
• Continuation of long-term patterns
• Pain management
• Sleep problems

Consider alcohol problems if:

• Memory problems
• Frequent falls
• Changes in sleep patterns
• Irritability, sadness, depression
• Trouble concentrating
• Chronic pain
• Smell of alcohol
• Isolation

Nursing diagnoses related to psychosocial function

• Situational low self-esteem
• Social isolation
• Impaired social interaction
• Ineffective coping
• Chronic sorrow
• Grieving
• Relocation stress syndrome
• Spiritual distress
• Stress overload
• Readiness for enhanced spiritual well-being 

A sense of control

• Promotes better physical, cognitive, and psychological health
• Involve the patient in decision making
• Involve the patient in organizing care activities
• Provide the patient information about his plan of care
• Include addressing factors regarding perceived control:
  • Privacy
  • Loss of individuality

Other methods to promote
psychosocial wellness

• Discuss role loss
  • Volunteer work
• Encourage life review, reminiscences
• Promote social support
  • May suggest group settings
  • Referral to community resources
• Discuss spiritual needs openly
  • Offer if patient is receptive
  • Do not be afraid to minister
  • Turn control back to patient and offer to participate