Abnormal Loss of Cognitive Functioning During Late Adulthood

Dementia is the umbrella category used to describe the general long-term and often gradual decrease in the ability to think and remember that affects a person’s daily functioning. The manual used to help classify and diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V, classifies dementia as a “major neurocognitive disorder,” with milder symptoms classified as “mild cognitive impairment,” although the term dementia is still in common use. 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, 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, a baseline intellectual development disorder, 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.^[1]

The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation (including easily getting lost), mood swings, loss of motivation, not managing self-care, and behavioral issues. In the early stages, memory loss is mild, but with late-stage Alzheimer’s, individuals lose the ability to carry on a conversation and respond to their environment.

Figure 1. Alzheimer’s disease is not simply part of the aging process. It is a disease with physiological symptoms and decay in the brain.

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).^[2]

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.