COGNITION- ORIENTATION,

ATTENTION, MEMORY, DELIRIUM

AND LEARNING
Presenter: Roja Rani. M
Faculty: Dr. Priya M.B
“Old age takes away from us what we have
inherited and gives us what we earned.”
Gerald Brennan
 According to Coffey et al (2002) the age-specific changes in cerebral size
were associated with poorer performance on the cognitive test measures.

Cerebral atrophy (as measured by both decreased

cerebral hemisphere volume and by increased
peripheral CSF volume) and lateral ventricular
enlargement were each associated with poorer
performance on measure of attention,
psychomotor speed, and working memory.
Enlargement of the lateral ventricles and the third ventricle was
associated with poorer visual delayed memory.

In the course of standardization of the original Wechsler-Bellevue

Intelligence Scale (1955), cross-sectional studies of large samples of
the population indicated that there was a steady decline in cognitive
function starting at 30 years of age and progressing into old age.
Similar results were found by Peterson and colleagues in 161
normal, community-dwelling individuals 62 to 100 years of age.
The most definite effects of age were in learning and memory
and in problem solving

Cognitive impairments probably attributable to a progressive

reduction in the speed of processing information.
MEMORY
 Working memory

Older adults exhibit significant deficits in tasks that involve active

manipulation, reorganization, or integration of the contents of
working memory.

Complex everyday tasks such as decision-making, problem-solving,

and the planning of goal-directed behaviours require the integration
and reorganization of information from a variety of sources.

Attention, speed of information processing, and the ability to inhibit

irrelevant information are important functions for effective
performance of these higher-level cognitive tasks.
 Long term memory

The cognitive domain that has probably received the most attention in normal
aging is memory.

Of all the types of LTM, episodic and semantic memory remains to be stable.
(Johnson et al, 2002).

Age related changes in LTM are common, however the magnitude and presence
of these changes depends on the type of processing required by the task.

Many older adults complain of increased memory lapses as they age

Memory declines attributable to normal aging differs from those that are
indicative of pathological aging, particularly Alzheimer’s disease.
 EPISODIC MEMORY

Episodic memory refers to memory for personally experienced events that

occurred in a particular place and at a particular time.

Jennings and Jacoby (1997) have demonstrated that recollection, which

requires effortful retrieval of episodic detail, is impaired with age, whereas
the more automatic judgments of familiarity are intact.

Evidence from functional neuro imaging and neuropsychological studies

suggests that these more strategic retrieval processes depend on the
prefrontal cortex, as well as the hippocampus
 SEMANTIC MEMORY

Normally aging older adults do not have significant impairments in semantic memory

In fact, their knowledge of the world often exceeds that of young people.

In addition, although access to information may be somewhat slower (particularly for

words and names), the organization of the knowledge system seems unchanged
with age.

Semantic memories are believed to be stored in a variety of regions in posterior

neocortex.
 SEMANTIC MEMORY (contd.)

Memory decline in aging arises from multiple, distinct age-associated

processes. While the constellation of factors that influence memory in
advanced aging eludes a simple, parsimonious explanation ( [West 1996],
Bäckman et al. 2000a, Greenwood 2000, Raz 2000, Park et al. 2001, Della-
Maggiore et al. 2002 and Hedden and Gabrieli 2004])

There is a recurring distinction between cognitive decline associated with

executive and attention difficulties and that associated with long-term,
declarative memory.
 AUTOBIOGRAPHICAL MEMORY

Autobiographical memory involves memory for one’s personal past and

includes memories that are both episodic and semantic in nature.

Events that occurred between the ages of 15 and 25 are recalled at a higher
rate — what is referred to as the reminiscence bump — a finding that has
usually been attributed to the greater salience or emotionality of the memories
during this time period.

This general pattern holds across all ages, suggesting that autobiographical
memory is largely preserved with age (Rubin, 2000)
 PROCEDURAL MEMORY

Procedural memory refers to knowledge of skills and procedures such as

riding a bicycle, playing the piano, or reading a book..

Once acquired, procedural memories are expressed rather

automatically in performance .

In general, older adults show normal acquisition of procedural skills in

both motor and cognitive domains and retain them across the lifespan

Procedural memory depends on several brain regions, including the

basal ganglia and the cerebellum
 IMPICIT MEMORY

Implicit memory refers to a change in behaviour that occurs as a result of prior

experience, although one has no conscious or explicit recollection of that prior
experience.

The most extensively studied form of implicit memory is perceptual priming, which
occurs in response to a perceptual cue.

Perceptual priming is modality specific and depends on sensory processing areas

of the brain (e.g., in the visual domain, priming involves extra-striate regions of the
visual cortex).

Conceptual priming, which requires semantic processing and is observed in

response to a conceptual cue, is also preserved in many older adults, and has
been associated with left frontal and left temporal cortical regions.
 PROSPECTIVE MEMORY

Everyday life involves prospective memory — remembering to do

things in the future, such as keep appointments, return a book to the
library, or pay bills on time (west,2005).

Older adults do quite well on these daily tasks, using a variety of

external aids such as calendars and appointment books to remind
themselves of these activities.

Prospective memory may also rely on some aspect of working

memory to maintain future intentions over time and likely also involves
divided attention, both functions that show age-related deficits.
 DECISION MAKING
The geriatrics tend to rely more on prior knowledge about the problem
domain and less on new information, whereas young people tend to sample
and evaluate more current information and consider more alternatives
before making their decisions (Sanfey, 2000).

Because of working memory limitations, older persons tend to rely on expert

opinion to a greater degree than young adults.

Poor decision-making may also be a result of episodic memory decline,

particularly the loss of memory for details or source.
EXECUTIVE FUNCTIONS
Executive control is a multi-component construct that
consists of different processes that are involved in the
planning, organization, coordination, implementation, and
evaluation of many of our non-routine activities.
According to (Baddely,2002) this central executive
plays a key role in virtually all aspects of cognition,
allocating attentional resources among stimuli or tasks,
inhibiting distracting or irrelevant information in working
memory, formulating strategies for encoding and
retrieval, and directing all manner of problem-solving,
decision-making, and other goal-directed activities.
In support of the frontal lobe hypothesis of aging both
structural and functional neuroimaging studies have
revealed a preferential decline in older adults in volume
and function of prefrontal brain regions (Raz, 2000).
It is important to note that this age-related shrinkage is
region specific. For instance, Haug and coworkers have
shown that areas 7 and 17 (parietal and occipital cortex)
exhibited no shrinkage in aged brains, while >15%
atrophy was found in areas 6 and 11 (extrapyramidal
and orbital cortex).
 Higher level cognitive function: speech and
language
Speech and language processing are largely intact in older adults under normal
conditions, although processing time may slower than in young adults

They usually have more extensive vocabularies; and although they exhibit the occasional
word-finding difficulty, older adults are easily able to provide circumlocutions to mask the
problem.

Deficits that occur under difficult processing conditions seem primarily attributable to
sensory loss or working memory limitations, not to impairments in basic language
capacities (WingField, 200).

Older people often use well-structured elaborate narratives that are judged by others to
be more interesting than those told by young (Kemper, 2000).
 BADDLEY’S MODEL, (Baddley
and Hitch, 1974, 2000)

This temporary system also served

 In ‘The Organization of Behavior’, Hebb (1949) suggested a distinction
as
abetween
working memory,
long-term memory, a
which involved workspace
durable changes in the
nervous system, and short-term memory, which he attributed to temporary
necessary
electrical activity
not only for long-term
 The controversial two-component model was that of Atkinson and Shiffrin
learning,
(1968), who proposedbutthat also for
information camemany other
in from the environment
a temporary short-term storage system which served as an antechamber to
into

complex activities such as reasoning

the more durable LTM.

and comprehension.
 From a study of neuropsychological patients, it was shown that damage to
the medial temporal lobes could lead to grossly impaired capacity for new
learning, while leaving performance on STM tasks unaffected (Baddeley &
Warrington, 1970, Milner, 1966)
 Baddeley and Hitch (1974), required normal subjects to hold sequences of
digits ranging in length from zero to eight items, while at the same time
performing a range of tasks that were assumed to depend on working
memory.
 Their data indicated that there was indeed progressive impairment as the
concurrent digit load was increased.
They proposed to divide the unitary STM into
three separable components

Fig. 1. The three component model of working memory proposed

by Baddeley and Hitch (1974). An attentional control system, the central
executive, is supported by subsidiary storage systems for phonological
and visuospatial information.
 PHONOLOGICAL LOOP

This involves two sub-components

 A temporary storage system
 held memory traces over a matter of second

 A sub-vocal rehearsal system

 maintained information within the store,
 also served the function of registering visual information within the store, provided the
items can be named
 For example,

 if a subject is shown a sequence of letters for immediate recall, then despite

their visual presentation, subjects will subvocalize them, and hence their
retention will depend crucially on their acoustic or phonological
characteristics.
 Thus, while subjects can readily recall a sequence of letters such
as B, W, Y, K, R, X, they are likely to have considerable difficulty in retaining
sequences of letters with similar sounding names, such
as T, C, V, D, B, G (Conrad & Hull, 1964).
EVIDENCES

 Evidence for the rehearsal system is provided by the word length effect.
 It involves presenting subjects with a sequence of items and requiring
immediate serial recall.
 Here, memory for a five-word sequence drops from 90% when these are
monosyllables to about 50% when five syllable words are used, such
as university, opportunity, international, constitutional, auditorium(Baddeley,
Thomson, & Buchanan, 1975).
 EVIDENCES (contd.)

 The process of subvocal rehearsal does not appear to depend on the capacity for
overt articulation.
 Baddeley and Wilson (1985) showed that dysarthric patients who have lost the
capacity to articulate can show clear evidence of subvocal rehearsal as reflected in
the word length effect.

 In contrast, dyspraxic patients whose problems stem from a loss of capacity to

assemble speech-motor control programs show no sign of rehearsal (Caplan &
Waters, 1995).
NEUROLOGICAL BASIS OF
PHONOLOGICAL LOOP
 Supporting the concept of two components, the separable storage and
rehearsal systems,
 Brodmann area 44 is the cortical area associated with storage,
 subvocal rehearsal appears to be associated with Broca’s area (Brodmann
areas 6 and 40).
A proposed structure for the
phonological loop.
Auditory information is analyzed (A) and
fed into a short-term store (STS) (B).
Information from this system can pass into
a phonological output system (C) which
can result in spoken output, or in
rehearsal. This in turn may recycle
information, both subvocally into the STS,
and when rehearsal is overt, into the
ears. Visually-presented material (D) may
be transferred from an orthographic to a
phonological code (E) and thereby
registered within the phonological output
buffer. Based on Vallar and Papagno
(2002).
REACTION TIME
automated movements are less affected by ageing than movement performed
infrequently and that reaction time decrease with repeated trials in aged.
 Peripheral Mechanisms: Small decrease in nerve conduction velocity may be
seen in the elderly, it must be considered a trivial component of elevated
reaction time. Perceptual speed is slower; increasing stimulus intensity can
minimize age related differences in reaction time.
 Central mechanism: Central deficits greatly influence the psychomotor slowness
in the elderly. Welford (1965) presented four changes in CNS which influences the
psychomotor performance with age.
First, reduction in the number of functional neuron cells will reduce signal strength
and processing capacity.

Second, there may be an increase in random neural activity in the older brain
that acts as noise during the processing of certain stimulus-response events.

Third, the aged may evidence longer "aftereffect" of neural activity which
interfere or blur new signals coming to the brain, thereby reducing the ability of
the brain to process these more recent activities.

Fourth, arousal levels may be diminished in the CNS of older persons and optimum
activity level in central neurons or neuron sets are diminished. This would have
overall effect of reducing signal strength and functional capacity.
 THE COMPLEXITY HPOTHESIS

The proposal that all central processes are slowed by approximately

the same degree has been termed the “complexity hypothesis”
(Cerella et al, 1980).

According to this hypothesis, the absolute difference in response time

for old and young persons should vary according to the complexity of
the task.

This hypothesis proposes that through a slowing of central processes in

NS, age differences are seen.
DELIRIUM
 The syndrome of It is complex Despite medical
delirium can be and often progress, delirium
defined as acute multi-factorial, remains a major
brain failure and hence challenge for
associated with continues to health care
autonomic be under workers with the
dysfunction, motor diagnosed increasing burden
dysfunction and and poorly of an ageing
homeostatic failure. managed. population.
 DEFINITION

The Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV-TR) defines delirium as:
"A disturbance of consciousness that is accompanied by
a change in cognition that cannot be better accounted
for by a pre-existing or evolving dementia".
Delirium develops over a short period of time (hours to days)
and fluctuates throughout the course of the day.

It is characterized by a reduction in clarity of awareness,

inability to focus, distractibility and change in cognition.

Other terminology used to describe delirium includes ‘acute

confusional state’, ‘acute brain syndrome’, ‘acute organic
reaction’, ‘acute brain failure’ and ‘post-op psychoses
 The DSM-IV classifies delirium according
to etiology, as follows:
1. Delirium due to a general medical condition
2. Substance Intoxication Delirium (drugs of abuse)
3. Substance Withdrawal Delirium
4. Substance Induced Delirium (medications or
toxins)
5. Delirium due to Multiple Etiologies
6. Delirium not otherwise specified.
 Clinically delirium can be divided into the
following three categories:

 Hyperactive Delirium (30%). Patients are agitated and hyper alert

with repetitive behaviors, wandering, hallucinations and aggression.
Although recognized earlier, there is association with increased use
of benzodiazepines, over sedation, use of restraints and falls.

 Hypoactive Delirium (25%). Patients are quiet and withdrawn which is

often missed on a busy medical ward leading to increased length of
stay, increased and more severe complications.

 Mixed Delirium. Fluctuating pattern seen in 45% of cases.

 CLINICAL FEATURES

 Disturbance of consciousness. A reduced ability to focus,

inattention and reduced awareness of the environment.
 A change in cognition or perceptual disturbance including
memory deficits, disorientation and language disturbance.
 The above features develop over hours to days and fluctuate
throughout the day
 PROGNOSIS

Longer term outcomes in these patients are consistently

worse than in those patients who fully recover by point of
discharge, and it is unknown whether these patients will
ever recover.
Education should be provided on what to expect with
regards to the patient’s function and prognosis.
The patient should have regular review every few days in
the community and minimum follow up should be 6
months.
 MOTOR LEARNING
 Kirchner and Schaller, investigated “new” learning of the task “balance and turn a stick” in
a sample of middle-aged and older adults (balancing on a divided bar and at the same
time throwing a stick around 180°; 5 weeks, once per week).
 They investigated older adults being split into three groups (50–59, 60–69, over 70 years).
 Learning improves linearly with practice in all three age groups.
 The 50–59 year olds revealed highest pre-test performance, but also lowest performance
increases with practice.
 On the hand, the learning curves of the groups 60–69 years and over 70 years were a little
steeperother , although the oldest participants performed on a slightly lower level.
 This leads to reduced age-related differences in the post-test as compared to the pre-test.
 Nevertheless, the older groups (60–69 years and >70 years) did not reach the performance
level of the 50–59 year olds.
 ARTICLE

Lesion location matters: The relationships between white matter

hyperintensities on cognition in the healthy elderly

Leonie Lampe, Shahrzad Kharabian-Masouleh, Jana Kynast, et al.

2017

Journal of cerebral blood Flow and metabolism

 White matter hyperintensities (WMH) are associated with cognitive decline.
 The sudy aimed to identify the spatial specificity of WMH impact on cognition in non-
demented, healthy elderly.
 Researchers quantified WMH volume among healthy participants of a community
dwelling cohort (n = 702, age range 60 – 82 years, mean age = 69.5 years, 46% female)
and investigated the effects of WMH on cognition and behavior, specifically for
executive function, memory, and motor speed performance.
 Lesion location influenced their effect on cognition and behavior:
 Frontal WMH in the proximity of the frontal ventricles mainly affected executive function
and parieto-temporal WMH in the proximity of the posterior horns deteriorated memory,
while WMH in the upper deep white matter—including the corticospinal tract—
compromised motor speed performance.
 This study exposes the subtle and subclinical yet detrimental effects of WMH on cognition
in healthy elderly, and strongly suggests a causal influence of WMH on cognition by
demonstrating the spatial specificity of these effects.
 REFERENCES

 Kathryn A. Bayles, A. W. (1987). Communication and Cognition in Normal Aging and

Dementia. U.S.: Pro-Ed.
 Leonie Lampe, S. K.-M. (2017). Lesion location matters: The relationships between white
matter hyperintensities on cognition in the healthy elderly. Journal of Cerebral Blood Flow
and Metaolism.
THANK YOU