categories is the identified target of intervention (e.g. specific symptoms versus underlying brain pathology).
Restorative cognitive training refers to interventions involving structured and repeated practice of specific cognitive tasks and mental exercises to improve specific cognitive abilities and underlying neural connections. Examples of restorative cognitive training include repetitive auditory processing training exercises or use of commercially available ‘brain training’ products. The purported target of such interventions is the neural systems underlying the cognitive domain of interest. Two assumptions underlie restorative cognitive training. The first is that practice in the given task/exercise will improve or at least maintain function in the targeted cognitive domain by way of strengthening or maintaining connectivity of underlying neural circuits. Second, it is assumed that benefits obtained from the task/exercise will generalize to behaviour outside of the training context.
Compensatory cognitive training refers to interventions that teach patients and caregivers to use specific techniques and strategies to compensate for the functional impact of cognitive deficits in daily life. The target of these interventions is improving the individual's functional ability but not necessarily underlying neural function. The primary assumption underlying this approach is that the patient, despite having cognitive deficit, can still use residual cognitive ability in impaired and unimpaired domains to learn and implement compensatory techniques. A wide variety of compensatory cognitive techniques have been described and can be subdivided into internal strategies (e.g. spaced retrieval, method of loci), external strategies (e.g. day planners, pill boxes, smartphone applications), and environmental strategies (e.g. quiet workspace, eliminating unnecessary distractions).
Lifestyle interventions refer to efforts designed to educate and promote healthy lifestyle habits that have been shown to benefit cognitive function in older adults. These interventions often target cerebrovascular health but can also target mood symptoms. Examples include education about the neuroprotective effects of regular aerobic exercise, a healthy diet, and participation in cognitively stimulating activities. Education can also focus on the detrimental effects of specific lifestyle habits, such as smoking and heavy alcohol consumption. Lifestyle interventions sometimes go beyond education and enrol individuals in exercise programs and use motivational interviewing techniques to facilitate behaviour change.
Finally, psychotherapeutic interventions refer to traditional psychotherapy approaches to target neuropsychiatric symptoms that can occur with or independent of cognitive dysfunction in older adults (e.g. depression, anxiety, sleep problems). Individuals with depression often have a greater subjective experience of cognitive symptoms than non‐depressed individuals. Treatment of mood symptoms with psychotherapy can result in improved self‐perception of cognitive and daily function. Common examples of psychotherapeutic interventions include cognitive behavioural therapy, mindfulness training, and relaxation techniques.
There is now a broad literature on the efficacy of non‐pharmacologic interventions for cognitive and functional decline in late life, and recent reviews and meta‐analytic studies have outlined the main findings of this work to date. These summaries have generally concluded that restorative cognitive training, compensatory cognitive training, and lifestyle interventions (e.g. regular aerobic exercise, dietary changes) are effective for improving cognitive function on objective neuropsychological testing as well as for improving subjective cognitive appraisal and daily function (Chandler, Parks, Marsiske, Rotblatt, & Smith, 2016); (Huckans, et al., 2013); (Sherman, Mauser, Nuno, & Sherzai, 2017). Given the broad support for these interventions, some clinics have combined these non‐pharmacologic methods with traditional pharmacologic approaches in comprehensive multidisciplinary treatment programs. One such example is the Healthy Action to Benefit Independence & Thinking (HABIT) program hosted at the Mayo Clinic.
Implications for practice
1 Normal psychological and cognitive changes occur in older adulthood. Knowledge of these changes can inform patient care by contextualizing the individual against the typical changes and challenges that occur with ageing.
2 Abnormal cognitive ageing is common enough to be encountered by most physicians treating older adults. Pharmacologic and several non‐pharmacologic interventions are available and effective for slowing decline, compensating for weakness, and/or maximizing functional independence.
3 Psychopathology is common in older adulthood, most often in the form of depression and anxiety. Early identification is key to preventing comorbid medical conditions and overall quality of life and functional status.
4 The US Preventive Services Task Force released detailed recommendations for depression screening for adults, which can be implemented during routine office visits. The final recommendation statement and guidelines can be accessed at https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression‐in‐adults‐screening.
5 Successful treatment for medical diseases must allow for the impact of psychological issues. Impaired cognition can interfere with a person’s understanding of their health and prognosis. The treatment plan design should consider a person’s ability to understand and follow through with recommendations.
6 The International Association of Gerontology and Geriatrics (IAGG) recommends all people age 70 and older have their cognition evaluated by their healthcare provider. Cognitive screening tools such as the Saint Louis University Mental Status Exam (SLUMS) and Rapid Geriatric Assessment (RGA) are open source tools that can assist with in‐office screening and can be accessed at https://www.slu.edu/medicine/internal‐medicine/geriatric‐medicine/aging‐successfully/assessment‐tools/index.php.
7 There is a need for psychologists to assist in addressing the mental and behavioural health needs of the older adult population. A review of psychology’s role in addressing these needs presented by the American Psychological Association can be found at https://www.apa.org/pi/aging/resources/psychologist‐role‐geriatric.pdf.
Key points
Psychological growth continues in older adulthood, with greater emphasis on reflecting on past accomplishments to find a sense of meaning.
Abnormal behavioural and mental health conditions are commonly encountered in the ageing population, with depression and anxiety being most common.
Behavioural and mental health conditions adversely impact comorbid medical conditions, medication adherence, and quality of life and may accelerate morbidity and mortality.
Psychological interventions have proven successful in older adults, and older adults tend to prefer psychotherapy intervention versus medication for mental health problems.
Mild cognitive change and dementia are increasingly encountered with advancing age. The presence of cognitive impairments needs to be considered when developing a treatment plan to optimize patient health and safety.
Pharmacological and non‐pharmacological interventions for age‐related cognitive declines are available and may reduce the rate of decline and/or functional status.
References
1 1. Alexopoulos GS, Kiosses DN, Sirey JA, et al. Personalised intervention for people with
