Executive functioning is the term most frequently used to describe higher cognitive processing skills. Executive skills include initiation, execution, organization, sequencing, judgment, and safety, and are at least partially dependent on fluid intelligence (Roca et al., 2010). IADLs often require the more complex cognitive resources of fluid intelligence; shopping, home management, cooking, and driving are activities with multiple steps that may require complex decision-making skills and safety awareness. When a novel procedure or a new directive is introduced to a common or familiar ADL task, these too can become activities now dependent on fluid intelligence. Delirium and dementia As longevity increases, there is a corresponding increase in disease affecting cognition in later life (Zarit & Zarit, 2007). Mild cognitive impairment (MCI) is the term used to describe impairment of typical memory or “thinking skills” that is considered more severe than the amount of decline expected as a result of aging (Albert et al., 2011). While not all people who have MCI experience progressive loss, it can often be the precursor and first step to a more significant decline in function. Millions of older Americans are afflicted with two major cognitive disorders: delirium (Witlox et al., 2010) and dementia (Plassman et al., 2007). Despite their prevalence and impact, cognitive disorders among older adults are frequently misdiagnosed and untreated by healthcare providers (Press et al., 2008). Delirium is a disorder characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior, with an acute onset – typically developing and fluctuating over a short period of time (American Psychiatric Association [APA], 2013). Generally, delirium is a transient state. However, as Flinn and colleagues stated, “Characterized by perceptual disturbances and a reduced ability to focus, sustain, or shift attention, delirium can be difficult to recognize, and may be confused with other conditions common among the elderly such as dementia or depression” (Flinn, Diehl, Seyfried, & Malani, 2009, p. 261). People with delirium may also experience a change in cognition that affects memory – causing disorientation – and that disturbs language. They may also develop perceptual problems, such as misinterpretations, illusions, or hallucinations. Consequently, persons with delirium are commonly unable to communicate appropriately even when responding to simple questions; they may instead perseverate with answers to previous questions and may be easily distracted by stimuli in the environment. Delirium can present with a hyperalert state, in which the person attends to all environmental stimuli simultaneously, or a hypoactive state, in which the person seemingly retreats into abnormal inner thoughts and experiences. Delirium can also have a mixed presentation, with the person displaying hyperalert and hypoactive symptoms at different times (Huber, 2012). Delirium can be caused by medication, by the aftereffects of a medical procedure (e.g., anesthesia), or by an illness. The primary risk factors for developing delirium are advanced age, cognitive impairment, alcohol abuse, dehydration, and chronic medical illness (Flinn et al., 2009; Huber, 2012; Robinson et al., 2009). Given the amount of one-on-one time spent with clients during rehabilitation service delivery, therapists may be the first to recognize changes in function as a result of a developing onset of delirium. Cognitive functioning before the onset of impairment influences the severity of most of the symptoms of delirium, particularly attention, orientation, thought organization, and memory (Henderson, 2008). The coexistence of delirium and dementia is a commonly recognized occurrence, often magnifying functional decline (APA, 2013; Martins & Fernandes, 2012). Unlike many other cognitive disorders common to older adults, delirium is often reversible in that the condition subsides after the underlying cause is recognized and treated (Martins & Fernandes, 2012). Physical therapists (among other healthcare professionals) should also educate family about delirium, the difference between delirium and dementia, and the fact that delirium’s effects are often temporary.
ADL and 12% required assistance with at least one IADL (AoA, 2017). Managing IADL needs – such as shopping, medication management, and community mobility – is a necessity for older adults living alone in the community. While ADLs and IADLs may be of primary importance in determining older adults’ level of independence, additional areas play a critical role in influencing the well-being and overall quality of life for older adults. These areas include contextual factors, as shown in the ICF model. These include personal factors and environmental factors, which will be described in the following sections. The influence of these personal factors on an older adult’s overall health and quality of life must be taken into account during assessment and during the development of a plan of care. Personal factors An individual’s perception of his or her health is strongly influenced by past experiences, beliefs, and societal influences. An individual’s personal factors are components that make a person unique, such as age, gender, social background, education, and character. This section highlights some personal factors that may affect the overall health and well-being of an older adult. Cognitive Although musculoskeletal and sensory functions may dictate how we physically move and interpret the environment, cognition organizes and drives all planned and purposeful activities in our daily lives. Physical therapists must recognize the importance of a patient’s cognitive status to offer the best possible outcomes. Age-related changes in cognition While research supports the idea that a certain level of cognitive decline is a typical process of aging, the amount of expected change is often hotly debated and varies broadly over the heterogeneous population of older adults (Deary et al., 2009). Areas of cognition most frequently affected by the aging process include attention and memory (Glisky, 2007). Divided attention and attention to complex tasks often become more difficult with each decade of age. Age-associated memory impairment (AAMI) is the term used to describe the age-related decline in memory (Lee et al., 2012). In the absence of disease, long- term memory remains largely intact, with the greatest changes observed in short-term working memory functions (Robnett, 2008). Perceptual changes may also appear with age; however, most research suggests that these changes are primarily due to age-related decline in sensory systems rather than to cognitive declines (Glisky, 2007). Even today, common age-related cognitive changes are frequently categorized using Raymond Cattell’s 1963 model of crystallized and fluid intelligence (Cattell, 1963; Riley, 2009). Crystallized intelligence refers to knowledge and practical skills, including verbal and numerical abilities that have been learned over time (Deary et al., 2009; Riley, 2009). Orientation is largely considered a form of crystallized intelligence (Robnett, 2008). Skills falling into this category are often overlearned and show little to no change as a result of the aging process alone. Reciting the Pledge of Allegiance or performing day- to-day work in a long-held job, for example, would be a demonstration of crystallized intelligence. Many ADLs represent activities that older adults have completed for many years (e.g., feeding, bathing, dressing, toileting). In familiar surroundings or circumstances, completion of daily tasks such as grooming, bathing, and dressing require little cognitive effort and draw upon the strengths of crystallized intelligence. In contrast to more static cognitive stores, fluid intelligence demonstrates a slow decline through middle age and then a more marked decline in older adults as a result of the aging process (Deary et al., 2009). Fluid intelligence reflects the capacity to learn new information and to reason and problem- solve in challenging or novel situations (Tranter & Koutstaal, 2008). Finding the way to a new doctor’s office in an unfamiliar building is an example of the use of fluid intelligence.
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