Aleksandra Kudlicka and Linda Clare
The number of people living with dementia is growing, and with limited pharmacological treatment options the importance of psychosocial interventions is increasingly recognized. Cognitive rehabilitation is particularly well placed to address the needs of people living with mild and moderate dementia and their family supporters, as it offers a range of tools to tackle the complexity of the condition. It utilizes powerful approaches of problem solving and goal setting combined with evidence-based rehabilitative techniques for managing cognitive impairments. It also incorporates strategies to address emotional and motivational aspects of dementia that may affect a person’s well-being. It is provided on an individual basis, usually in people’s homes, making it directly applicable to everyday life. It is also genuinely person-centered and flexible as the therapy goals are agreed in a collaborative process between the therapist, person with dementia, and family members. Cognitive rehabilitation does not claim to address underlying pathology, but instead focuses on a person’s functional ability and enjoyment of life.
Evidence for effectiveness of cognitive rehabilitation in the context of mild and moderate dementia, mostly Alzheimer’s disease (AD), is gradually accumulating with a number of randomized control trials demonstrating that people with mild and moderate dementia can significantly improve their functioning in targeted areas. For example, the GREAT trial with 475 people with mild to moderate Alzheimer’s, vascular, and mixed dementia completed in 2017 in the United Kingdom demonstrated that cognitive rehabilitation improves everyday functioning in relation to individual therapy goals.
There is a growing interest in cognitive rehabilitation and the focus shifts to extending evidence to less-common forms of dementia, particularly in people with non-amnestic presentation. Future efforts need to concentrate on promoting the approach and optimizing application in real-life settings with the aim of maximizing benefits for people living with dementia and their families.
Patrick D. Gajewski and Michael Falkenstein
Healthy aging is associated with changes in sensory, motor, cognitive, and emotional functions. Such changes depend on various factors. In particular, physical activity not only improves physical and motor but also cognitive and emotional functions. Observational (i.e., associations) and cross-sectional studies generally show a positive effect of regular physical exercise on cognition in older adults. Most longitudinal randomized controlled intervention studies also show positive effects, but the results are inconsistent due to large heterogeneity of methodological setups. Positive changes accompanying physical activity mainly impact executive functions, memory functions, and processing speed. Several factors influence the impact of physical activity on cognition, mainly the type and format of the activity. Strength training and aerobic training yield comparable but also differential benefits, and all should be used in physical activities. Also, a combination of physical activity with cognitive activity appears to enhance its effect on cognition in older age. Hence, such combined training approaches are preferable to homogeneous trainings. Studies of brain physiology changes due to physical activity show general as well as specific effects on certain brain structures and functions, particularly in the frontal cortex and the hippocampus, which are those areas most affected by advanced age. Physical activity also appears to improve cognition in patients with mild cognitive dysfunction and dementia and often ameliorates the disease symptoms. This makes physical training an important intervention for those groups of older people.
Apart from cognition, physical activity leads to improvement of emotional functions. Exercise can lead to improvement of psychological well-being in older adults. Most importantly, exercise appears to reduce symptoms of depression in seniors. In future intervention studies it should be clarified who profits most from physical activity. Further, the conditions that influence the cognitive and emotional benefits older people derive from physical activity should be investigated in more detail. Finally, measures of brain activity that can be easily applied should be included as far as possible.
Theoretical Perspectives on Age Differences in Brain Activation: HAROLD, PASA, CRUNCH—How Do They STAC Up?
Sara B. Festini, Laura Zahodne, and Patricia A. Reuter-Lorenz
Cognitive neuroimaging studies often report that older adults display more activation of neural networks relative to younger adults, referred to as overactivation. Greater or more widespread activity frequently involves bilateral recruitment of both cerebral hemispheres, especially the frontal cortex. In many reports, overactivation has been associated with superior cognitive performance, suggesting that this activity may reflect compensatory processes that offset age-related decline and maintain behavior. Several theories have been proposed to account for age differences in brain activation, including the Hemispheric Asymmetry Reduction in Older Adults (HAROLD) model, the Posterior-Anterior Shift in Aging (PASA) theory, the Compensation-Related Utilization of Neural Circuits Hypothesis (CRUNCH), and the Scaffolding Theory of Aging and Cognition (STAC and STAC-r). Each model has a different explanatory scope with regard to compensatory processes, and each has been highly influential in the field. HAROLD contrasts the general pattern of bilateral prefrontal activation in older adults with that of more unilateral activation in younger adults. PASA describes both anterior (e.g., frontal) overactivation and posterior (e.g., occipital) underactivation in older adults relative to younger adults. CRUNCH emphasizes that the level or extent of brain activity can change in response to the level of task demand at any age. Finally, STAC and STAC-r take the broadest perspective to incorporate individual differences in brain structure, the capacity to implement functional scaffolding, and life-course neural enrichment and depletion factors to predict cognition and cognitive change across the lifespan. Extant empirical work has documented that compensatory overactivation can be observed in regions beyond the prefrontal cortex, that variations in task difficulty influence the degree of brain activation, and that younger adults can show compensatory overactivation under high mental demands. Additional research utilizing experimental designs (e.g., transcranial magnetic stimulation), longitudinal assessments, greater regional precision, both verbal and nonverbal material, and measures of individual difference factors will continue to refine our understanding of age-related activation differences and adjudicate among these various accounts of neurocognitive aging.
Megan S. Barker, Emily C. Gibson, and Gail A. Robinson
The term “acquired brain injury” refers to any type of brain damage that occurs after birth. Two main types of acquired brain injury are stroke and traumatic brain injury (TBI). A stroke occurs when there is a blockage or bleed in the vascular system of the brain, while a TBI results from an external force to the head. Older adults are at a higher risk of both stroke and TBI; thus, overall incidence is increasing as the proportion of older adults in the population is growing. Stroke and TBI result in immediate and long-term cognitive changes. Impairments in the domains of language, attention, memory, executive functions, perception, and social cognition have been documented following stroke and TBI. However, strokes tend to cause focal or selective cognitive disorders, while cognitive deficits following TBI are widespread and can be generalized. Individuals who have suffered a stroke or TBI may also experience psychosocial changes; for example, symptoms of depression and anxiety are common. Functional outcomes, including independence in activities, are varied and are associated with a range of factors including age, injury severity, cognitive disorders, and psychosocial factors. To achieve optimal outcomes for individuals following stroke and TBI, and to reduce the impact of the injury on everyday functioning, a multidisciplinary rehabilitation process is recommended.
Ye In (Jane) Hwang and Julian Trollor
Autism spectrum disorder (ASD), or autism, is a neurodevelopmental disorder that is typically recognized and diagnosed in childhood. There is no established biological marker for autism; rather, the diagnosis is made based on observation of behavioral traits, including (a) persistent deficits in social interaction and communication, and (b) restricted, repetitive patterns of behavior, interests, or activities. Because autism is a spectrum disorder, autistic individuals are a highly heterogeneous group and differ widely in the presentation and severity of their symptoms. The established prevalence of ASD is approximately 1% of the population.
Information about autism in adulthood is limited; most of the literature examines childhood and adolescence. While the term “later life” has traditionally been associated with those over the age of 65, a dire lack of understanding exists for those on the autism spectrum beyond early adulthood.
Individuals remain on the spectrum into later life, though some mild improvements in symptoms are observed over time. Autistic adults experience high levels of physical and mental health comorbidities. Rates of participation in employment and education are also lower than that of the general population. Quality of life is reportedly poorer for autistic adults than for nonautistic peers, though this is not affected by age. More robust studies of the health, well-being, and needs of autistic adults are needed, especially qualitative investigations of adulthood and aging and longitudinal studies of development over the lifespan.
Nicole D. Anderson
Healthy aging is accompanied by decrements in episodic memory and working memory. Significant efforts have therefore been made to augment episodic and working memory in healthy older adults. Two principal approaches toward memory rehabilitation adults are restorative approaches and compensatory approaches. Restorative approaches aim to repair the affected memory processes by repeated, adaptive practice (i.e., the trained task becomes more difficult as participants improve), and have focused on recollection training, associative memory training, object-location memory training, and working memory training. The majority of these restorative approaches have been proved to be efficacious, that is, participants improve on the trained task, and there is considerable evidence for maintenance of training effects weeks or months after the intervention is discontinued. Transfer of restorative training approaches has been more elusive and appears limited to other tasks relying on the same domains or processes. Compensatory approaches to memory strive to bypass the impairment by teaching people mnemonic and lifestyle strategies to bolster memory performance. Specific mnemonic strategy training approaches as well as multimodal compensatory approaches that combine strategy training with counseling about other factors that affect memory (e.g., memory self-efficacy, relaxation, exercise, and cognitive and social engagement) have demonstrated that older adults can learn new mnemonics and implement them to the benefit of memory performance, and can adjust their views and expectations about their memory to better cope with the changes that occur during healthy aging. Future work should focus on identifying the personal characteristics that predict who will benefit from training and on developing objective measures of the impact of memory rehabilitation on older adults’ everyday functioning.
Working memory as a temporary buffer for cognitive processing is an essential part of the cognitive system. Its capacity and select aspects of its functioning are age sensitive, more so for spatial than verbal material. Assumed causes for this decline include a decline in cognitive resources (such as speed of processing), and/or a breakdown in basic control processes (resistance to interference, task coordination, memory updating, binding, and/or top-down control as inferred from neuroimaging data). Meta-analyses suggest that a decline in cognitive resources explains much more of the age-related variance in true working memory tasks than a breakdown in basic control processes, although the latter is highly implicated in tasks of passive storage. The age-related decline in working memory capacity has downstream effects on more complex aspects of cognition (episodic memory, spatial cognition, and reasoning ability). Working memory remains plastic in old age, and training in working memory and cognitive control processes yields near transfer effects, but little evidence for strong far transfer.
Aidan Moran and John Toner
We are constantly bombarded by information. Therefore, during every waking moment of our lives, we face decisions about which stimuli to prioritize and which ones to ignore. To complicate matters, the information that clamors for our attention includes not only events that occur in the world around us but also experiences that originate in the subjective domain of our own thoughts and feelings. The end result is that our minds can consciously attend to only a fraction of the rich kaleidoscope of information and experiences available to us from our senses, thoughts, memories, and imagination. Attentional processes such as “concentration,” or the ability to focus on the task at hand while ignoring distractions, are crucial for success in sport and other domains of skilled performance. To illustrate, Venus Williams, one of the greatest tennis players of all time, proclaimed that “for the players it is complete and pure focus. You don’t see anything or hear anything except the ball and what’s going on in your head.” For psychological scientists, concentration resembles a mental spotlight (like the head-mounted torch that miners and divers wear in dark environments) that illuminates targets located either in the external world around us or in the internal world of our subjective experiences. A major advantage of this spotlight metaphor is that it shows us that concentration is never “lost”—although it can be diverted to targets (whether in the external world or inside our heads) that are irrelevant to the task at hand. Research on attentional processes in sport and performance has been conducted in cognitive psychology (the study of how the mind works), cognitive sport psychology (the study of mental processes in athletes), and cognitive neuroscience (the study of how brain systems give rise to mental processes). From this research, advances have been made both in measuring attentional processes and in understanding their significance in sport and performance settings. For example, pupillometry, or the study of changes in pupil diameter as a function of cognitive processing, has been used as an objective index of attentional effort among skilled performers such as musicians and equestrian athletes. Next, research suggests that a heightened state of concentration (i.e., total absorption in the task at hand) is crucial to the genesis of “flow” states (i.e., rare and elusive moments when everything seems to come together for the performer) and optimal performance in athletes. More recently, studies have shown that brief mindfulness intervention programs, where people are trained to attend non-judgmentally to their own thoughts, feelings, and sensations, offer promise in the quest to enhance attentional skills in elite athletes. By contrast, anxiety has been shown to divert skilled performers’ attention to task-irrelevant information—sometimes triggering “choking” behavior or the sudden and significant deterioration of skilled performance. Finally, concentration strategies such as “trigger words” (i.e., the use of short, vivid, and positively phrased verbal reminders such as “this ball now”) are known to improve athletes’ ability to focus on a specific target or to execute skilled actions successfully.
Alison Chasteen, Maria Iankilevitch, Jordana Schiralli, and Veronica Bergstrom
In 2016, Statistics Canada released the results of the most recent census. For the first time ever, the proportion of Canadians aged 65-plus years surpassed the proportion aged 15 and under. The increase in the proportion of older adults was viewed as further evidence of the faster rate of aging of Canada’s population. Such demographic shifts are not unique to Canada; many industrialized nations around the world are experiencing similar changes in their populations. Increases in the older adult population in many countries might produce beneficial outcomes by increasing the potential for intergenerational contact and exposure to exemplars of successful aging. Such positive intergenerational contact could counter prevailing age stereotypes and improve intergenerational relations. On the other hand, such increases in the number of older adults could be viewed as a strain and potential threat to resources shared with younger age groups. The possibility of increased intergenerational conflict makes it more important than ever before to understand how older adults are stereotyped, how those stereotypes can produce different kinds of biased behavior toward them, and what the impact of those stereotypes are on older adults themselves.
Social-cognitive age representations are complex and multifaceted. A common stereotype applied to older people is one of warmth but incompetence, often resulting in paternalistic prejudice toward them. However, such benevolent prejudice, characterized by warm overtones, can change to hostile bias if older adults are perceived to violate prescriptive norms about age-appropriate behavior. In addition to coping with age prejudice, older adults also have to deal with the deleterious effects of negative age stereotypes on their day-to-day function. Exposure to negative aging stereotypes can worsen older adults’ cognitive performance in a number of contexts. As well, age stereotypes can be incorporated into older adults’ own views of aging, also leading to poorer outcomes for them in a variety of domains. A number of interventions to counteract the effects of negative aging stereotypes appear promising, but more work remains to be done to reduce the impact of negative aging stereotypes on daily function in later life.
Markus Wettstein, Hans-Werner Wahl, and Michael Schwenk
When referring to life space, researchers usually mean the area in which individuals move in their everyday lives. Life space can be measured based on different approaches, by means of self-reports (i.e., questionnaires or diaries) or by more recent approaches of technology-based objective assessment (e.g., via Global Positioning System [GPS] devices or smartphones). Life space is an important indicator of older adults’ out-of-home mobility and is meaningfully associated with autonomy, well-being, and quality of life. Substantial relationships between life space and socio-demographic indicators, health, and cognitive abilities have been reported in previous research. Future research on life space in old age will benefit from a more comprehensive and stronger interdisciplinary perspective, from taking into account different time scales (i.e., short- and long-term variability), and from considering life space as a multidimensional measure that can be best assessed based on multi-method approaches with multiple indicators.