COGNITIVE DECLINE IN THE ELDERLY -FROM UNDERSTANDING TO MAKING A PLAN-1

Abstract

Longevity is a success. Cognitive decline appears in the context of ageing. Physiological cognitive decline must be differentiated from pathological degradation which leads to disease, the final form being dementia. The current pharmaceutical therapeutic possibilities for neurocognitive disorders are limited; succeeding only in slowing down the evolution of the disease and in lessening some behavioural disorders, yet in more than 10 years there has been no improvement in the field. Other methods, using communication means, such as physical exercise, therapy through dancing, music and painting seem to be more efficient at certain levels. We can say that communication is a key element in the diagnosis and current treatment of neurocognitive disorders, offering new perspectives for the future.

Headnote

ABSTRACT: Longevity is a success. Cognitive decline appears in the context of ageing. Physiological cognitive decline must be differentiated from pathological degradation which leads to disease, the final form being dementia. The current pharmaceutical therapeutic possibilities for neurocognitive disorders are limited; succeeding only in slowing down the evolution of the disease and in lessening some behavioural disorders, yet in more than 10 years there has been no improvement in the field. Other methods, using communication means, such as physical exercise, therapy through dancing, music and painting seem to be more efficient at certain levels. We can say that communication is a key element in the diagnosis and current treatment of neurocognitive disorders, offering new perspectives for the future.

KEYWORDS: ageing, cognitive decline, dementia, communication

Population ageing. Physiological and pathological ageing.

We are witnessing the rise of life expectancy, and this fact is a success at the social level because it is due to some social and economic factors, such as improved and safer living conditions, appropriate resources and the development of medical sciences. Mortality has considerably decreased once antibiotics were discovered, allowing for infectious diseases to be cured. Due to modern treatments some diseases which once were lethal have become chronic diseases. The rise of life expectancy, simultaneously with the decrease of births, causes population ageing2 which is a global phenomenon currently unfolding. In this context, Ana Aslan's recommendation "Let's make years matter!" for a meaningful ageing, becomes the most important purpose. If we wish to talk about "successful ageing", it must be done in the context of "active ageing", meaning that the elderly must be independent, active participants in the social and cultural life, effectively contributing to society. In the traditional family the elderly had a well defined role, a respected role, they were provided with the safety of the home and they could render valuable their experience and time in the middle of the family, thus feeling useful. In the modern society the elderly do not often have this role, as the independence acquired by the young family also comprises the lack of involvement of the elderly in daily matters. In some cultures a way to render the elderly valuable is to introduce volunteering in their midst3.

The ageing process is irreversible, continuous and gradual. The rhythm of ageing is individual and it can be slow or increased. That is why we talk about chronological age (the number of years) and physiological age. In a slowed rhythm of ageing, the person has a smaller physiological age than the chronological one, in other words he" looks younger than one thought". Age related physiological changes involve most of the functions. Ageing also implies cognitive decline which, if it observes "the ageing slope" represented in the general population, may be considered physiological. When the slope suddenly modifies, the cognitive parameters abruptly deteriorate, the context changes from the physiological domain to the pathological one, namely to the disease, neurocognitive disorder.

It is very important that generally speaking the population should get informed and advised on the changes of memory representing cognitive decline in order to send the affected person towards the medical specialists. It is equally important to know the signs and the evolution of the disease. Generally speaking, the family members are the first to notice and signal the cognitive decline. There are also cases in which the person lives alone and does not have close relatives to assume the responsibility and support for the person's needs. It is advisable in all situations, especially in these, to make a correct, realistic planning, regarding different legal issues, managing the financial problems of the person, the way he wants his resources to be managed, choosing the type of nursing and treatment, to make clearly expressed specifications, regarding all the wishes of the elderly person.

The number of the persons diagnosed with neurocognitive disorders is increasing4. On the one hand, the population grows and at the same time the number of the elderly grows, age being the main risk factor for the incidence of memory diseases. Taking into account the age groups, we can notice that at every 5 years the prevalence of neurocognitive disorders doubles5. There are also cases of neurocognitive disorders at a young age, but these are rare, most of them being genetically determined. Many persons are not diagnosed with cognitive decline because of the lack of access to medical services. Many people go to a specialist only in late stages, being highly affected by behavioural troubles. The main cause is the lack of education of the population, the family does not know how to understand the initial symptoms or they think wrongly as changes in the context of normal aging. As we presented above, it is important to make the difference between normal and pathological in cognitive decline in order to provide the patient with the appropriate medical therapy and counselling as soon as possible.

Alzheimer's Disease International estimated for 2017 a number of 50 million people suffering from dementia in the world7. Since there are no efficient methods of prevention, the estimates are worrying, the prevalence of the disease doubling at every 20 years: 75 millions in 2030 and 131.5 millions in 2050 respectively. A large amount will be in the low and middle income states, as a percentage of 58% of people living in such states are diagnosed with forms of dementia.

Cognitive decline, mild cognitive impairment, neurocognitive disorder, dementia, Alzheimer's disease. The gerontologist's perspective

One of the first significant books which describes memory was published by Delay and it talks about three kinds of memory: sensitive and motor (common), social (instrumental) and autistic6, the author also approaching memory disorders, such as "senile" amnesia7. The pathologic degradation of the cognitive function in time can be represented as a continuum: cognitive decline, mild cognitive decline, dementia in a low, moderate and eventually severe degree8.

Commonly said, dementia is a term having negative connotations; etymologically speaking, it comes from the Latin word de - separated, mens, tis= spirit (being identified with madness). It is an old term which refers to the diminishing, sometimes irrevocable, of the psychological functions linked to an organic alteration of the brain cells9. In this context, redefining dementia as a neurocognitive disorder accordingly to the new classification DSM V (May 2013) has the role to reduce both the stigmatizing of the patients and the underlying of the importance to etiologically classification of these diseases.

Alzheimer's disease (AD) is the most frequent form of dementia, representing 60-70% of the total cases of dementia10. In AD symptoms are progressive: the decrease of the cognitive function, the decrease of functional autonomy, and then the decrease of mobility. The evolution can be connected with affective disorders, the most frequent being depression, which can precede the cognitive dysfunction, and in the end behavioural disorders might appear11. Cognitive deficits represent a decline from the previous functional level and cause a significant degradation of social and professional work.

Starting with the diagnosis of AD determined by Alois Alzheimer in 1906 until recently, the diagnosis certainty was provided only by the anatomic-pathological exam. There currently exist highly performing imagistic techniques and laboratory analyses which support the diagnosis.

The cardiovascular risk factors, such as obesity, diabetes, arterial high tension, hypercholesterolemia and atherosclerosis were associated with an increased risk of having both vascular dementia and AD.

Cognitive decline is usually closely connected to depression, this relationship being in both ways: repeated depressive states at adult age are a risk factor for the appearance of cognitive degradation with the elderly or vice versa: cognitive degradation causes an emotional apathy manifested through depression. Having a previous depression increases with up to 2.5 the risk of AD, this connection being independent of the cardio and cerebral-vascular risk factors. The highest risk, up to four times more serious, is found in the case of the persons having depression before being 60 years old12.

There are studies demonstrating that there is a link between the risk of having AD and other potentially protective modifying factors, such as education, intellectual activities, recreational activities, physical exercise or healthy diet13. In the specialized literature it is shown that dementia risk was decreased with 46% in persons with important cognitive reserves who deployed complex cognitive activities14.

There are reversible and irreversible forms of dementia. When assessing cognitive decline we must exclude some reversible medical causes, such as dysfunctions of the thyroid, troubles of some electrolytes, and that is why the "somatic" medical control constitutes the first stage in assessing this disease.

The diagnostic methods include psychological tests of memory. The quickest one is the 5 word test during which the person is asked to reproduce 5 words after a few minutes interval (the number of reproduced words is noted). The verbal fluency test refers to the enumeration of some words in a given domain (the number of words in a time lapse is noted). The clock drawing test, Sunderland15, assesses especially the temporal - spatial orientation and consists in drawing a clock dial and the correct writing of the figures on the dial, then indicating with the clock hands a certain time-line. Another standard test is, Mini Mental State Examination16 (MMSE) which can be applied quite quickly, collecting information from several domains: orientation, recording information, attention and calculus, reproducing information, language. The score allows diagnose in low, moderate or severe cognitive deficit. Psychological evaluation is linked to the clinical and paraclinical medical examination (laboratory exams or imagistic ones, like computerised tomography and nuclear magnetic resonance.)

Therapeutic means in cognitive decline

Prevention is the first and most important method of fighting against all diseases. Modern medicine makes more and more efforts in this domain as benefits have proved to be very significant. For cognitive decline prevention should be made in young adults, the most important being the control of the cardio vascular risk factors. This means maintaining the values of arterial pressure in normal ranges (targets being under 140 mmHg, sometimes even under 130 mmHg, according to new guidelines), the control of the blood sugar level (values under 120mg/dl), the control of triglyceride values, the total cholesterol, the LDL- cholesterol (lower and lower target values for the "bad" cholesterol), reaching some protective values of HDL cholesterol (higher values for the "good" cholesterol). These figures can be influenced by what we call today "life style": Mediterranean type diets (involving an increased consuming of vegetables, fruit and fish, a moderate consuming of meat), frequent physical exercise, avoiding stress. It should be noted that in modern medicine stress has become a wellestablished risk factor for cardio-cerebral-vascular diseases and not only.

The first type of treatment which we recommend to those having cognitive decline is cognitive stimulus: reading, crosswords, figure games (Sudoku), memory and attention games (classical or on electronic platforms of the e-gamming type). Socializing is also very important, interacting with other persons being a precious stimulus with multiple consequences, both affective and cognitive. We must keep in mind that humans are social beings and that they accomplish themselves only in relationship with other people.

In the case of the mild cognitive decline the pharmaceutical treatment recommendations are: cerebral vascular dilatators, nootropics, others neuro-regenerating drugs. In the case of more advanced disease, we use for about 20 years, two classes of anti-dementia drugs which act at the level of neuronal synapses. The benefits of these treatments consist in slowing down the evolution of the disease and controlling behavioural disorders which frequently associate with cognitive decline. Medical research, regarding the discovery of new pharmaceutical therapies in dementia, has been unsuccessful for the last 10 years17. All the newly tested therapeutic lines were stopped either because of the lack of benefits or because of highly dangerous adverse effects. There are many discussions linked to the cost -benefit report of the anti-dementia drugs which are now being used.

Given this context, it is worth underlying that there are other nonpharmaceutical treatment means which seem to have superior benefits, such as physical exercise (kinetotherapy or adapted physical activity), dancing, music and painting for which there are specialized therapists.

Adapted physical activity is a quite new technique; it is performed individually or in a group of 10-12 persons, twice a week: the meetings last 1 hour and 15 minutes. The patients are placed in real life situations and the work is adapted to their needs: balance, movement ability, strength, the main purpose being to prevent dependency. The consequences are increased autonomy, stimulating the desire to live, the growth of self-esteem. The therapy has effects ranging from cognitive and memory stimulation, social stimulation, regaining the pleasure of movement through games. In France this type of therapy18 is refunded by the insurance company, while for pharmaceutical antidementive therapy the funding has been stopped a year ago. There is a new orientation of the treatment towards occupational therapy, language stimulation, socializing and movement therapy. These treatments are sometimes cheaper than pharmaceutical therapy. They are maybe more difficult to be quantified on an efficiency scale, they need to devote more time to the affected persons, it is not a simple pill which can be administered in a few minutes, but it provides the patients with a stimulus in the most profound domain, emotion. These techniques imply using efficient methods of communication, in most cases communication being achieved through emotion.

Some recommendations instead of conclusions

As it is a domain of interest in the geriatric field, we met many patients, each with their own story. Each patient perceives differently cognitive decline, according to the level of education, personality or stage of the disease.

Memory disorders as perceived by an individual are firstly considered as "subjective memory impairment". Many of these symptoms are denied by the applied tests, as in many cases, especially with the young, it is only overworking, oblivion being a physiological method of cleaning the memory in order to provide free space for the new information. Other memory disorders in the same field are those appearing due to a lack of attention without being forms of pathology linked to memory disorders, as they are due to a lack of motivation. The lack of attention can also be part of a depressive disorder which implies that the depression must be diagnosed and treated.

When symptoms and diagnostic tools indicate a pathologic cognitive decline, it is very important how the diagnosis is being communicated to the patient and how he and the family are advised concerning the treatment and the prognosis of the disease.

In the beginning of the disease there predominates denial, non acceptance, drama. Sometimes even usual talks during which the patient notices his memory disorders or his logic, or even the test that we apply to evaluate the cognitive impairment makes the person face the perspective of the disease, creating feelings of frustration, confusion, aggressive behaviour. A very important role is played at this stage by the doctorpsychologist-patient communication.

In advanced dementia the central role of treatment is taken over by care. In the advanced stage when the patient has moments of lucidity the situation can be very confusing both for him and for the caregiver. Relating to the person with severe dementia can be achieved only by understanding the symptoms of the disease and by very good communication techniques. In many cases the people around perceive only the behaviour of the ill person: agitation, aggression or apathy, but this is only the reflection of a need which the patient cannot explain otherwise such as pain, fear or something else. Of all behavioural disorders the only one that does not bother the caretaker is apathy because in this case the patient is calm. Yet, apathy must be analysed just like the other behavioural disorders in order to find causes and implicitly solutions. The starting point is to try to understand what the ill person feels, to understand that he relates differently with time. He lives in a suspended time, a past mixed with the present and the future, in many cases the past being idealized. The reality of the present is in most cases difficult to accept and the ill persons sometimes prefer a different reality; they do not pretend, they have a conscience of the subconscious. They frequently get stuck at a certain age, in a different time, that is why they do not recognize themselves in photographs or in the mirror. The time they relate to can be linked to a joyful moment or on the contrary a traumatic one. In such a case they often return to the moment, as if trying to mend it in order to get rid of it. Every behavioural act of the ill person has a meaning, but it is not our meaning, it is their meaning, their language. They must not be corrected by us, their behaviour is the consequence of a fact happening in the psyche of the ill person. He must not be brought back to our reality, he cannot change, we must adapt our behaviour and accept the person, accept a different reality and admit that we cannot change their reality. If one tries to bring him back to reality, one creates frustration, confusion, aggressive behaviour, an overall increased degradation.

Actually, communication in such situations must be accomplished by taking into account the three basic needs of any person: the need to be loved (which manifests through attention, affection, tenderness), the need to be useful (to be involved in daily life), the need to express one's emotions. When communicating with such persons it matters to understand the emotion more than the message. Emotion can be fear, joy, disgust; logical arguments have no value. One solution can be to adapt to the needs of the patient, to transmit to him that you are interested and that you try to understand his emotion, in a gentle way, centered on emotion. A reason for denial, agitation or an aggressive behavior can sometimes be pain which he cannot express verbally, but which is the cause of the behavior.

We can say that the patient with dementia lives in a "bubble", a bubble of time and feelings, which should not be removed because it can cause suffering. Therefore, contrary to the laws of logic, we must enter the world of the sick, the vector being emotions, feelings, tenderness. The communication channel, adapted to the elderly patient, must be adapted according to his personality model. Communication is important in any field, but in geriatrics it has therapeutic connotations. Communication is something that is learned actively through emotion and dedication as you care about the other person.

Therefore, the modern approach towards cognitive decline implies efficient methods regarding communication both for the diagnosis and for the treatment and caregiving. Since from the perspective of the current pharmaceutical treatment possibilities research has not come up lately with satisfying results, we can say that the development in the communication domain has practical perspectives in the future.

Footnote

1 Translated by Andreea Maria POPESCU, Associate Professor, PhD., Faculty of Foreign Languages and Literatures, University of Bucharest.

2 National Institute on Aging, Why Population Aging Matters: a Global Perspective. Bethesda: NIH Publ. No 07-6134, 2007.

3 International Volunteer Day, 5th of December, WHO (1985).

4 World Alzheimer Report, The Global Impact of Dementia, 2015.

5 Wimo A., The magnitude of Dementia occurrence in the world, Alzheimer's disease Associated Disorders, 2004, p. 17:63-67.

6 Delay, J., Les trois memoires,. s.l.: Presses Universitaires de France, 1949.

7 Les Maladies de Mémoires, L'amnésié sénile.

8 Budson AE, et al. Practica Neurolo. 2012; 12:88-96.

9 Rusu, V., Medical Dictionary, Bucharest, Medical Publishing House, 2001.

10 Fratiglioni, L., Launger, Lj., Incidence of dementia and major subtypes in Europe: a collaborative study of population- based cohorts, Neurology, 2000, p. 54: S10-S15.

11 Lovestone & Gauthier 2000.

12 Geerlings, M.I., History of depression, depressive symptoms, and medial temporal lobe atrophy and the risk of Alzheimer disease., Neurology, 2008, p. 70:1258-1264.

13 Jedrziewski, M.K., Lee, V.M., Trojanowski, J.Q. Lowering the risk of Alzheimer's disease: evidence- based practices emerge from new research. Alzheimers Dement, 2005, pg. 1:152-160.

14 Valenzuela, M.J., Sachdev, P., Brain reserve and dementia: a systematic review, Psychol Med, 2006, p. 36:441-454.

15 Sunderland T., Hill J.L., Mellow A.M., Lawlor B.A., Gundersheimer J., Newhouse P.A., Grafman J.H., Clock drawing in Alzheimer's disease. A novel measure of dementia severity, J. Am Geriatr Soc 1989; Aug: 37 (8): &25-9.

16 Foltein, M.F., S.E. Lolstein, McHugh, P.R., Mini-mental state: A practical method for garding the mental state of patientsfor the clinician, Journal of Psychiatry Research, 1975, p. 189-198.

17 World Alzheimer Report, The global impact of dementia -, 2015.

18 "Siel Bleu" Group started in France 1997, its objective being a better quality of life for frail people by using adapted physical activities.

References

REFERENCES

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