Neurocognitive Disorders PDF

Neurocognitive Disorders Although most older people think and remember quite well, nonetheless age is the main risk factor for every neurocognitive disorder (NCD). About 9 percent of the world’s population over age 65 (less than 1 percent of the total population) experiences an NCD. Rates are lowest...

Neurocognitive Disorders Although most older people think and remember quite well, nonetheless age is the main risk factor for every neurocognitive disorder (NCD). About 9 percent of the world’s population over age 65 (less than 1 percent of the total population) experiences an NCD. Rates are lowest in nations where most people die before age 60. In wealthy nations such as the United States, brain diseases are unusual for people in their 60s but become more common with every decade. For example, almost half of the people in Sweden who are age 95 or older have an NCD (Mathillas et al., 2011). Ageism and Words Because ageism distorts our perception, we need to use words carefully when referring to neurocognitive disorders. Senile simply means “old.” Do not use senility to mean “severe mental impairment,” because that implies that old age brings intellectual failure — an ageist myth. Dementia (used in DSM-IV) is a more precise term than senility for irreversible, pathological loss of brain functioning. However, the roots of that word include demon: People once thought that dementia occurred because a person was possessed. Accordingly, the DSM-5 has scrapped the word dementia. In the fifth diagnostic manual, “neurocognitive disorders” is a major category, subdivided into major (previously called dementia) or mild. Mild neurocognitive disorder has replaced the term mild cognitive impairment (MCI), to emphasize that cognitive losses discussed in this section originate in the neurons of the brain, hence neurocognitive. THINK CRITICALLY: The terms MCI and dementia are still used. Should they be? Diagnosis is complicated. The line between typical age-related changes, mild disorder, and major disorder is not clear. Symptoms and criteria vary from one culture to another, and from one doctor, diagnostician, and impaired individual to another. Many scientists seek biomarkers, which are biological measures (such as in the blood, in cerebrospinal fluid, or in brain scans) to provide diagnosis or guide treatment (Jeromin & Bowser, 2017). None are definitive, however. Combining several biomarkers works better than any single measure, but even that is not always right (Zetterberg & Blennow, 2021). Both the hope and the problems are summarized thus: biomarkers are invaluable [but].… caution must be exercised to ensure appropriate interpretation.… there continues to be a grave need for novel biomarkers, improved development of existing tools, standardization, and improved accessibility. [Ehrenberg et al., 2020] In VIDEO ACTIVITY: Alzheimer’s Disease, experts and family members discuss the progression of the disease. Alzheimer’s Disease In the past century, millions of people in every large nation have been diagnosed with Alzheimer’s disease (AD) (called major NCD due to Alzheimer’s disease in DSM-5). Severe and worsening memory loss is the main symptom of AD, which proceeds stage by stage. Definitive diagnosis occurs on autopsy, with extensive plaques and tangles in the cerebral cortex (see Table 14.3). TABLE 14.3 Stages of Alzheimer’s Disease Stage 1. People in the first stage forget recent events or new information, particularly names and places. For example, they might forget the name of a famous film star or how to get home from a familiar place. This first stage is similar to mild neurocognitive disorder — even experts cannot always tell the difference. In retrospect, it seems clear that President Ronald Reagan had early AD while in office, but no doctor diagnosed it. Stage 2. Generalized confusion develops, with deficits in concentration and short-term memory. Speech becomes aimless and repetitious, vocabulary is limited, words get mixed up. Personality traits are not curbed by rational thought. For example, suspicious people may decide that others have stolen the things that they themselves have mislaid. Stage 3. Memory loss becomes dangerous. Although people at stage 3 can care for themselves, they might leave a lit stove or hot iron on or might forget whether they took essential medicine and thus take it twice — or not at all. Stage 4. At this stage, full-time care is needed. People cannot communicate well. They might not recognize their closest loved ones. Stage 5. Finally, people with AD become unresponsive. Identity and personality have disappeared. When former president Ronald Reagan was at this stage, a longtime friend who visited him was asked, “Did he recognize you?” The friend answered, “Worse than that — I didn’t recognize him.” Death comes 10 to 15 years after the first signs appear. Plaques are clumps of a protein called beta-amyloid in the tissues surrounding the neurons; tangles are twisted threads of a protein called tau within the neurons. Every brain contains some beta-amyloid and tau, but plaques and tangles proliferate in brains with AD, especially in the hippocampus, where memories are made. The Alzheimer’s Brain This computer graphic shows a vertical slice through a brain ravaged by Alzheimer’s disease (left) compared with a similar slice of a typical brain (right). The diseased brain is shrunken because neurons have degenerated. The red indicates plaques and tangles. If Alzheimer’s develops in middle age, the cause is genetic: Affected people have either trisomy-21 (Down syndrome) or one of three genes: amyloid precursor protein (APP), presenilin 1, or presenilin 2. Early-onset AD progresses quickly, reaching the last phase and death within three to five years. Most cases of Alzheimer’s are late-onset, beginning after age 70. Many genes have some impact, but health habits also matter. People, on average, die 10 years after the first symptoms. Vascular Disease The second most common cause of neurocognitive disorder is vascular disease (VD), caused by a stroke (a temporary obstruction of a blood vessel in the brain) or a series of strokes, called transient ischemic attacks (TIAs, or ministrokes) (Burhan et al., 2018). The interruption in blood flow reduces oxygen, destroying part of the brain. Symptoms (blurred vision, weak or paralyzed limbs, slurred speech, and mental confusion) suddenly appear. Vascular Disease The second most common cause of neurocognitive disorder is vascular disease (VD), caused by a stroke (a temporary obstruction of a blood vessel in the brain) or a series of strokes, called transient ischemic attacks (TIAs, or ministrokes) (Burhan et al., 2018). The interruption in blood flow reduces oxygen, destroying part of the brain. Symptoms (blurred vision, weak or paralyzed limbs, slurred speech, and mental confusion) suddenly appear. In a TIA, symptoms may vanish quickly, unnoticed. However, unless recognized and prevented, another TIA is likely, eventually causing vascular or multi-infarct dementia (Kalaria, 2018). Executive functioning is reduced, which means that poor decisions and uncontrolled impulses are as prevalent as memory problems. Symptoms vary, depending on which part of the brain has been affected. FIGURE 14.4 The Progression of Alzheimer’s Disease and Vascular Disease Cognitive decline is apparent in both Alzheimer’s disease and vascular disease. However, the pattern of decline for each disease is different. Individuals with Alzheimer’s show steady, gradual decline, while those with vascular disease get suddenly much worse, improve somewhat, and then experience another serious loss. Vascular disease correlates with the genes and health risks of AD (Vittner et al., 2018), as well as with surgery that requires general anesthesia. It is difficult to know how often surgery is the direct cause, however, since postoperative delirium and dementia may be the manifestation of previously undiagnosed VD (Houghton et al., 2021). Frontotemporal Disorders Several types of neurocognitive disorders affect the frontal lobes and thus are called frontotemporal NCDs, or frontotemporal lobar degeneration. This is a diverse collection of disorders: Pick’s disease is the most common form (Neumann & Mackenzie, 2019). These disorders cause perhaps 15 percent of all cases of NCDs in the United States. In frontotemporal NCDs, parts of the brain that regulate emotions and social behavior (especially the amygdala and prefrontal cortex) deteriorate. Emotional and personality changes are the main symptoms. Frontotemporal NCDs usually occur before age 70, unlike Alzheimer’s or vascular disease. The diagnosis is difficult partly because the symptoms appear at younger ages and partly because memory loss is not the primary symptom. One woman, Ruth French, was furious because her husband threw away tax documents, got a ticket for trying to pass an ambulance and bought stock in companies that were obviously in trouble. Once a good cook, he burned every pot in the house. He became withdrawn and silent, and no longer spoke to his wife over dinner. That same failure to communicate got him fired from his job. [D. Grady, 2012] Finally, he was diagnosed with a frontotemporal NCD. Ruth asked him to forgive her fury. It is not clear that he understood either her anger or her apology. Other Disorders Many other brain diseases begin with impaired motor control (shaking when picking up a cup of coffee, falling when trying to walk), not with impaired thinking. The most common of these is Parkinson’s disease. Parkinson’s starts with rigidity or tremor of the muscles as dopamine-producing neurons degenerate, affecting movement long before cognition (Jankovic, 2018). Middle-aged adults usually have sufficient cognitive reserve to avoid major intellectual loss (Darweesh et al., 2017). When this disorder appears in late adulthood, cognitive problems are soon apparent. Why? Many people wonder why actor and comedian Robin Williams died by suicide at age 63. One explanation: He was in the early stages of a serious neurocognitive disorder. Williams was diagnosed with Parkinson’s disease a few months before he died, but an autopsy revealed Lewy body disease, whose symptoms include loss of inhibition, severe anxiety, tremors, and difficulty reasoning. Another 3 percent of people with NCD in the United States suffer from Lewy body disease: excessive deposits of a particular kind of protein in their brains. Lewy bodies are also present in Parkinson’s disease, but in Lewy body disease they are more numerous and dispersed throughout the brain, interfering with communication between neurons. The main symptom of Lewy body dementia is loss of inhibition: A person might gamble or become hypersexual. In many ways, symptoms are similar to Parkinson’s, but brain impairments are more comprehensive and begin sooner (Walker et al., 2019). Some other types of NCDs begin in middle age or even earlier, caused by Huntington’s disease, multiple sclerosis, a severe head injury, a virus such as ZIKA, or the last stages of syphilis, AIDS, or bovine spongiform encephalopathy (BSE, or mad cow disease). Repeated blows to the head (traumatic brain injury), even without concussions, can cause chronic traumatic encephalopathy (CTE), which causes memory loss and emotional changes. Differentiating CTE from other neurocognitive disorders is complex, as is distinguishing brain disease from other problems. One “other problem” is terminal decline, the drop in function that occurs in the months before death. The entire body — heart, lungs, digestive system, and so on — often slows down in the final months of life; the brain does, too. A study of 30,064 nursing home residents, already impaired, found that most of them functioned quite well cognitively before experiencing a notable drop in the months before dying (Hülür et al., 2019). The only group who did not experience terminal decline were those who already suffered from a severe neurocognitive disorder. Their intellectual losses continued, but the rate did not accelerate in the final months. Preventing Impairment Severe brain damage cannot be reversed. However, education, exercise, and good health not only ameliorate mild losses but may prevent worse ones. According to the World Health Organization approximately 40% of dementia cases worldwide could be attributable to 12 modifiable risk factors: low education; midlife hypertension and obesity; diabetes, smoking, excessive alcohol use, physical inactivity, depression, low social contact, hearing loss, traumatic brain injury and air pollution indicating clear prevention potential. [Lisko et al., 2021] Of these, activity may be most important. Because brain plasticity is lifelong, exercise that improves blood circulation not only prevents cognitive loss but also builds capacity and repairs damage. The benefits of exercise have been repeatedly cited in this text. Now we simply reiterate that physical movement — even more than nutrition and mental exercise — prevents, postpones, and slows cognitive loss of all kinds. Exercise for Elders In every nation, those who exercise have healthier hearts, lungs, brains, and lives than those who do not. Two contrasting examples are the exercise class in a Michigan Senior Center led by Diane Evans and the stepper machine on a beach in Greece. Avoiding specific pathogens is also critical. For example, beef can be tested to ensure that it does not have BSE; condoms can protect against HIV/AIDS; sprays, screens, and bed nets can protect against ZIKA; face masks and vaccines can protect against COVID-19 (see A Case to Study). A Case To Study COVID-19 and the Brain Longitudinal data on cognitive impairment caused by COVID-19 are not yet available, but it is already apparent that at least a third of those diagnosed with the virus have neurological symptoms, such as headaches and extreme tiredness (Zangbar et al., 2021). Early in the pandemic, the sick were hospitalized only if their fever was above 101 and their blood oxygen was below 70 (these numbers are from one district; other places varied but neurological symptoms were never sufficient). That ignorance of brain symptoms may have been one reason for the deaths of over half a million people in the United States, because “delayed and misdiagnosed … [cases] led to inappropriate management. These patients then become silent contagious sources or ‘virus spreaders’” (Jin et al., 2020). Now we know that high fevers and low oxygen are not the main problems when people fall ill and recover. Some people suffer “long-haul COVID” (the name for the condition of those no longer at risk of death but not yet back to normal). Chills and fever may be gone, but neurological symptoms continue. Consider one case, a 26-year-old teacher who was considered recovered. She was no longer at risk of hospitalization, but My chest hurts and head pounds. The body aches and heart races. I can hardly move, it’s extreme fatigue. Brain’s in a fog, can’t remember the name of my dog. Lost my sleep and my appetite. Feet are tingling and ears are ringing. It’s the Long-Haul COVID. [Nath quoted in Ballard, 2021] Few survivors are as impaired as this woman. Scientists have yet to determine how often neurological symptoms occur, how severe they usually are, or how long they will last. But it is evident that the brain is often affected before and after the rest of the body, and that neurocognitive disorders caused by COVID may continue for months. One doctor predicted: We will see the patients with brain fog, intermittent dizziness, and cognitive delay. Most likely, we will have to tell those patients that we don’t have the answers — or treatments … post-COVID pathology is shaping up to be just as widespread and uncharted as COVID itself. [Ballard, 2021] Much about the neurological effects of COVID-19 cannot be known until longitudinal studies are published. However, we already know that the effects on the brain may not show up in standard laboratory tests. Some compassion for long haulers, as well as for elders with concerns about their mental capacity, may be forthcoming. One doctor changed his mind about neurocognitive disorders. His COVID-19 was diagnosed as mild. However, months after the diagnosis the impact on him and his family was “anything but mild.” He wrote: As an emergency medicine physician, I am trained to develop a hypothesis and to look for objective evidence in support to quickly identify the cause of a patient’s suffering. In the absence of objective data — laboratory tests, imaging, examination findings — we are often left to reassure patients and discharge them with a recommendation for outpatient follow-up, an outcome that too easily can feel dismissive and unsatisfying for the patient and unfulfilling for the physician. My test results were normal: nasopharyngeal swabs for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), imaging, laboratory results, oxygen saturation were all fine. But I did not feel fine, and still do not. I have had a rotating constellation of symptoms, different each day and worse each evening: fever, headache, dizziness, palpitations, tachycardia, and others. As a result, I have been reminded of the need to listen to the patient first, even in the absence of conclusive testing. The next time I care for someone with vague abdominal pain, or fatigue, or paresthesia, or any of the myriad conditions that are uncomfortable on the inside but look fine on the outside, I will remember that these symptoms are real and impactful for patients. There is a marked difference between tests being within normal limits and a patient being well. [Siegelman, 2020, p. 2031] He wrote that he was “one of the lucky ones” in that he had medical and disability insurance, a fully equipped basement in his home where he quarantined for 40 days, an understanding wife, children, and employer. Even so, he suffered. Reversible Brain Disease? Care improves when everyone knows what disease is undermining intellectual capacity. Accurate diagnosis allows targeted treatment and keeps the caregivers from blaming themselves when they are attacked, accused, frustrated, or exhausted. In developing nations, most people with NCD are not diagnosed: They die prematurely with bewildered relatives. In developed nations, the opposite danger is more likely, a misdiagnosis. Accurate diagnosis is crucial when problems do not arise from a neurocognitive disorder. Brain diseases destroy parts of the brain, but some people are thought to be permanently “losing their minds” when the problem is not an incurable disease but, instead, a reversible condition. EMOTIONAL DISORDERS The most common reversible condition that is mistaken for NCD is depression. Typically, older people are quite happy. However, for those with ongoing depression or crippling anxiety, treatment is available. Without it, the risk of major NCD increases, in that depression makes people shut out other people and intellectual challenges, both of which keep the brain functioning well. Ironically, people with untreated anxiety or depression may exaggerate minor memory losses or refuse to talk. Quite the opposite reaction occurs with early Alzheimer’s disease, when victims are often surprised that they cannot answer questions, or with Lewy body disease or frontotemporal NCDs, when people talk too much without thinking. Talking, or lack of it, provides an important clue. Specifics provide other clues. People with neurocognitive loss might forget what they just said, heard, or did because current brain activity is impaired, but they might repeatedly describe details of something that happened long ago. The opposite may be true for emotional disorders, when memory of the past is impaired but short-term memory is not. MALNUTRITION Malnutrition and dehydration can also cause symptoms that seem like brain disease. The aging digestive system is less efficient but needs more nutrients and fewer calories. This requires new habits, less fast food, and more grocery money (which some do not have). Elders may drink less to avoid frequent urination, yet inadequate fluid in the body impedes cell health. Since homeostasis slows with age, older people may not recognize hunger and thirst and thus may inadvertently impair their cognition. Sudden weight loss is a sign of dementia (Shlisky et al., 2017, p. 21). Beyond the need to drink water, eat vegetables, and strive for a balanced diet (Mediterranean is again recommended) nutritionists find “no consistent evidence exists that nutritional supplements play a protective role” (Shlisky et al., 2017). Well-controlled longitudinal research on the relationship between particular aspects of the diet and NCD still needs to be done (Coley et al., 2015; Vlachos & Scarmeas, 2019). It is known, however, that people who already have an NCD tend to choose unhealthy foods or forget to eat, hastening their mental deterioration. POLYPHARMACY At home as well as in the hospital, most older adults take numerous drugs — not only prescribed medications but also over-the-counter preparations and herbal remedies — a situation known as polypharmacy. Polypharmacy is increasing. For instance, in 1988, among those over 65, 13 percent took five drugs or more. Twenty years later, in 2018, the rate had more than tripled to 42 percent (National Center for Health Statistics, May 30, 2019). Fortunately, older adults smoke, drink alcohol, and overdose on painkillers less often younger adults. However, when they do, the results are worse. Psychoactive drugs, especially alcohol, cause confusion and hallucinations at much lower doses than in the young. Cognition in Late Adulthood Relatively few adults suffer from major neurocognitive disorders. What about everyone else? Is their thinking the same as it was when they were young? No. It is both better and worse. VIDEO: Brain Development Animation: Late Adulthood shows gray matter loss in the typical aging brain. The Structures of the Brain Brains shrink and slow down over time. By age 80, the average adult brain processes information more slowly than at age 30, or even at age 60. Losses are apparent, not only for speed, but also for memory and logic (Salthouse, 2019). This is evident in almost every test of intellectual ability and almost every cognitive task. For example, when older adults read out loud, they read more slowly, making more mistakes, such as misreading a word (reading “county” when the word is country) or repeating a connecting word (saying “to to” or “in in”) (Gollan & Goldrick, 2019). In general, slower thinking is less proficient. If a person cannot quickly access several ideas at once, that person is less able to think deeply. (See Inside the Brain.) Inside the Brain Thinking Slow Senescence reduces the production of neurotransmitters — including glutamate, acetylcholine, serotonin, and especially dopamine — that allow a nerve impulse to jump quickly across the synaptic gap from one neuron to another. Neural fluid decreases, myelination thins, and cerebral blood circulates more slowly. The result is an overall slowdown, evident in reaction time, movement, speech, and thought. Speed is crucial for many aspects of cognition. In fact, many experts believe that processing speed underlies all intelligence (Schubert et al., 2020; Tourva & Spanoudis, 2020). Deterioration of cognition correlates with slower movement and almost every kind of physical disability. For example, gait speed correlates strongly with many measures of intellect (Cosentino et al., 2020). Walks slow? Talks slow? Oh no — thinks slow! This fear is not baseless. Researchers have studied the connection between walking speed and intellectual sharpness and found that the slower gait predicts cognitive impairment and brain disease (Montero-Odasso et al., 2017). Remember Jeanne Calment, the woman who lived to 122? Caregivers were astonished that she walked much faster after age 100 than most people in their 80s. White-matter lesions in the brain accumulate with age and increase the time it takes for a thought to be processed (Rodrigue & Kennedy, 2011). At the same time, overall white matter of the brain decreases, especially with a lifetime of poor health habits, again slowing down thinking (Wassenaar et al., 2019). Slowed transmission from one neuron to another is not the only problem. With age, transmission of impulses from entire regions of the brain, specifically from parts of the cortex and the cerebellum, is disrupted. Specifics correlate more with cognitive ability than with age. The crucial question is whether speed is essential for cognition. Language connects the two. A smart person is said to be a quick thinker, the opposite of someone who is a slow learner. On the other hand, some sayings and stories question those assumptions. We are told to “look before you leap.” A fable credited to Aesop, a Greek slave who lived 2,600 years ago, concerns a race between a tortoise and a hare. The rabbit lost: Slow and steady won the race. Which is it? LESS ACTIVITY Slow brains may not be bad. Remember that major depression is not caused as much by external events as by neurotransmitters and dendrites that flood, or starve, the brain. Those destructive brain storms happen less often in late adulthood: In 2019, the National Institute of Mental Health reported incidence of major depressive events at various ages: 13 percent for ages 18 to 25; 8 percent for ages 25 to 49; 5 percent for ages 50+. Those data are from the United States, but elders everywhere are less depressed and anxious than younger people (Jorm, 2000; Machado et al., 2019). Likewise, nationally and internationally, impulsive homicide, assault, and suicide are less common after age 60. Older women almost never die by suicide; older men (over age 75) have relatively high rates, but not on impulse (Stone et al., 2021). Suicide among aged men is more often a deliberate reaction to months of loneliness, indignity, and loss of power (Canetto, 2015). Another brain change with age is that older people may use more parts of their brains simultaneously. Both hemispheres of the prefrontal cortex light up on brain scans when older adults solve problems that require only one side of the prefrontal cortex in younger people. Might this be adaptive, and thus not a problem? (See Esteves et al., 2021.) MULTITASKING Multitasking becomes harder with every passing decade because focusing is more difficult when two tasks are done simultaneously. Repeated switches in the brain make multitasking difficult for everyone, but this is particularly true in late adulthood (Lin et al., 2016). Keeping Alert These three men on a park bench in Malta are doing more than engaging in conversation; they are keeping their minds active through socialization and the discussion of current events and politics. This is why statements such as “I can’t do everything at once” and “Don’t rush me” are more often spoken by older adults than by teenagers. Adults compensate for slower thinking by selecting one task at a time. Suppose that a child asks Grandpa a question about dinosaurs while he is reading the newspaper, or asks Grandma which bus to take while she is getting dressed. A wise Grandpa puts down the newspaper and then answers, and Grandma first dresses and then thinks about transportation (avoiding mismatched shoes). When speed is not an issue, and when older people are able to concentrate on a particular task, they may function, intellectually, as well as younger ones. Indeed, single-minded concentration is sometimes beneficial. In one study, older and younger adults (average age 73 and 24) were asked to judge which of two numbers was higher, “as quickly as possible but try to avoid errors.” The older adults were slower but more accurate (Reike & Schwarz, 2019). As a review concludes, changes in brain activation with age can be “adaptive or maladaptive” (Spreng & Turner, 2019, p. 525). Memory The aging brain function that causes most concern is memory. As you read in Chapter 9, stereotype threat causes stress that harms cognition; fear may cause forgetfulness. Baring brain disease, age-based stereotypes interfere with memory more than brain deficiencies do (Lamont et al., 2015). TYPES OF MEMORY Memory is not one thing but many. The single word memory was used before researchers understood the many types of memory — 14 of them according to one source, each with distinct traces in distinct parts of the brain (Slotnick, 2017). In general, explicit memory (such as the ability to recall something verbally without clues) fades faster than implicit memory (the ability to recognize someone or something as familiar, or to perform a habitual action). Both are affected by age (Fraundorf et al., 2019; Ward et al., 2013). The distinction between implicit and explicit memory is evident in what the old-old can and cannot do. Old-old people may still swim, bike, and drive even if they cannot name both U.S. senators from their state. Forgetting names is a common and typical memory loss, called the “tip-of-the-tongue” experience (knowing something but not finding the words). Another common memory deficit with age is source amnesia — forgetting the origin of a fact, idea, or snippet of conversation. Source amnesia is particularly problematic currently, with the internet, many channels of television, and many printed sources bombarding the mind. In practical terms, source amnesia means that elders might believe fake news, a rumor, or a political advertisement because they forget that the information came from a biased source. Elders are less likely than younger adults to analyze, or even notice, who said what and why (Devitt & Schacter, 2016). One memory loss might have serious consequences. That is prospective memory — remembering to do something in the future (take a pill, meet someone for lunch, buy milk). Prospective memory loss becomes dangerous if, for instance, a cook forgets to turn off the stove, or a driver is in the far lane when the exit appears. Associative memory, connecting one idea with another, and episodic memory, remembering details of a past event, are also likely to be less accurate with age, especially with the stress of stereotype threat (Brubaker & Naveh-Benjamin, 2018). BETTER WITH AGE But why focus only on deficiency? Vocabulary is remembered well. Cross-sectional, longitudinal, and cross-sequential studies all show that vocabulary increases over most of adulthood. Even at age 90 it is better, on average, than it was from ages 20 to 40 (Salthouse, 2019). Older people remember words and languages that they learned decades ago. They also continually learn new words and phrases. For example, most elders now know internet, fax, and e-mail, words that did not exist when they were younger. Long-term memory may be surprisingly good. Many older people recount in vivid detail events that occurred decades ago. Some tells stories to fascinated grandchildren about hearing the speeches of Martin Luther King Jr., or participating in the Summer of Love, or life before cell phones, before television, before sliced bread. That is impressive … if the memories are accurate. That raises the next question, “What is memory for?” IN DAILY LIFE Older adults usually think they remember well enough. Fear of memory loss is more typical at age 60 than at age 80, even though actual loss increases with age. Many older adults are conscientious about setting alarms, writing down appointments, and following routines, so they do not forget something important. Active in the Community One the best ways for older adults to stay mentally active is to be active in their neighborhoods. Registering new voters, as this man is doing, benefits the community while also helping older people to maintain their control processes. When an older person’s implicit and prospective memory function well enough for them to be independent and happy, even at age 100, is that memory enough? Those who study memory in late adulthood write about the prospective memory paradox: that young adults are better at prospective memory in the laboratory, and older adults are better than the young in daily life (Haines et al., 2020). This raises the question of ecological validity. Ecological validity is measuring memory, or cognition, or anything else as it actually occurs, not as it is indicated in well-controlled, scientific, laboratory experiments. This may be important when measuring cognition in older people, because motivation and attitudes are crucial for cognition in later life (Hess et al., 2019). Awareness of the need for ecological validity has helped scientists restructure research on memory, trying to avoid tests that are timed and that use abstractions. Restructured studies find fewer deficits than originally thought. However, any test may misjudge ability. For instance, what is a fair and accurate test of long-term memory? Or is that the wrong question: If an older adult describes life back on the farm to a fascinated grandchild, how important is the accuracy of every detail? New Cognitive Development Remember that the life-span perspective holds that gains as well as losses occur during every period. Are there cognitive gains in late adulthood? Yes, according to many developmentalists. ERIKSON AND MASLOW Both Erik Erikson and Abraham Maslow were particularly interested in older adults, interviewing them to understand their thoughts. Erikson’s final book, Vital Involvement in Old Age (Erikson et al., 1986/1994), written when he was in his 90s, was based on responses from other 90-year-olds who had been studied since they were babies in Berkeley, California. Erikson found that, over their lives, many older people gained interest in the arts, in children, and in human experience as a whole. He observed that elders are “social witnesses,” aware of the interdependence of the generations as well as of all human experience. Erikson’s eighth stage, integrity versus despair, marks the time when life comes together in a “re-synthesis of all the resilience and toughness of the basic strengths already developed” (Erikson et al., 1994, p. 40). Maslow maintained that older adults are more likely than younger people to reach what he originally thought was the highest stage of development, self-actualization. Remember that Maslow rejected an age-based sequence of life, refusing to confine self-actualization to the old. However, Maslow also believed that life experience helps people move forward, so more of the old reach the final stage. The stage of self-actualization is characterized by aesthetic, creative, philosophical, and spiritual understanding (Maslow, 1954/1997). A self-actualized person might have a deeper spirituality than ever; might be especially appreciative of nature; or might see the humor in many aspects of life, laughing often. This seems characteristic of many older people. Studies of centenarians find that they often have a deep spiritual grounding and a surprising sense of humor — surprising, that is, to anyone who thinks that a person with limited sight, poor hearing, and an aching body has nothing to laugh about. Creative Concentration World-famous artists and ordinary people often find that late adulthood allows joyous expression of music, sculpture, and all the arts. That is evident in these two women, one in Jersey City, New Jersey (top), and the other in Grenoble, France (bottom). AESTHETIC SENSE AND CREATIVITY Robert Butler was a geriatrician who popularized the study of aging in the United States. He coined the word ageism and wrote a book titled Why Survive: Being Old in America, first published in 1975. Partly because his grandparents were crucial in his life, Butler understood that elders can contribute to their families and communities. Butler explained that “old age can be a time of emotional sensory awareness and enjoyment” (Butler et al., 1998, p. 65). Older adults learn new skills and take up new activities. For example, some elders begin gardening, bird-watching, sculpting, painting, or making music, each of which requires new learning. Many well-known artists continue to work in late adulthood, sometimes producing their best work. Michelangelo painted the awe-inspiring frescoes in the Sistine Chapel at age 75; Verdi composed the opera Falstaff when he was 80; Frank Lloyd Wright completed the design of the Guggenheim Museum when he was 91. In a study of extraordinarily creative people, very few felt that their ability, their goals, or the quality of their work had been much impaired by age. The leader of that study observed, “in their seventies, eighties, and nineties, they may lack the fiery ambition of earlier years, but they are just as focused, efficient, and committed as before … perhaps more so” (Csikszentmihalyi, 2013, p. 207). Music and singing are often used to reduce anxiety in those who suffer from neurocognitive impairment, because the ability to appreciate music is preserved in the brain when other functions fail. The evidence is clear: Music, the visual arts, and creative work of all kinds help the mind, the mood, and overall well-being (Charise & Eginton, 2018). THE LIFE REVIEW One particular method to deepen older adults’ cognition is the life review, in which elders provide an account of their personal lifelong journey by writing or telling their story. They want others to know their history, not only their personal experiences but also those of their family, cohort, or ethnic group. According to Robert Butler: We have been taught that this nostalgia represents living in the past and a preoccupation with self and that it is generally boring, meaningless, and time-consuming. Yet as a natural healing process it represents one of the underlying human capacities on which all psychotherapy depends. The life review should be recognized as a necessary and healthy process in daily life as well as a useful tool in the mental health care of older people. Hundreds of developmentalists, following Butler’s lead, have guided older people in self-review. Sometimes elders write down their thoughts, and sometimes they simply tell their story, responding to questions from the listener. The result is almost always positive, especially for the person who tells the story. The life review is a potent antidote to depression (Lan et al., 2019). For instance, half of a group of 202 older people in a study in the Netherlands were randomly assigned to a life-review process. For them, depression and anxiety were markedly reduced compared to the control group (Korte et al., 2012). A study of elders in the United States also found that telling their story helped them see a purpose in life — just what Erikson would hope (Robinson & Murphy-Nugen, 2018). Wisdom It is possible that “older adults … understand who they are in a newly emerging stage of life, and discovering the wisdom that they have to offer” (Bateson, 2011, p. 9). A massive international survey of 26 nations from every corner of the world found that most people agree that wisdom is a characteristic of elders (Löckenhoff et al., 2009). Wisdom builds over time. People who are open to new experiences in early adulthood, who cope well with stress in middle age, and who strive for self-actualization in late adulthood, are more likely to be wise. As one study concludes, “a balance between personality adjustment and growth, aided by social support and competence during the formative years, might be required to promote wisdom development throughout life” (Ardelt et al., 2018, p. 1514). Long Past Warring Many of the oldest men in Mali, like this imam, are revered. Unfortunately, Mali has experienced violent civil wars and two national coups in recent years, perhaps because 75 percent of the male population are under age 30 and less than 2 percent are over age 70. In 2019, the British newspaper The Guardian described Mali as the most dangerous nation in the world. An underlying quandary is that a universal definition of wisdom is elusive: Each culture and each cohort have their own concepts, with fools sometimes seeming wise (as happens in Shakespearean drama) and those who should be wise sometimes acting foolishly (provide your own examples). Older and younger adults differ in how they make decisions; one interpretation of these differences is that the older adults are wiser, but not every younger adult would agree. Several factors just mentioned, including self-reflective honesty (as in integrity), perspective on past living (the life review), and the ability to put aside one’s personal needs (as in self-actualization), are considered part of wisdom. If this is true, elders may have an advantage in developing wisdom, particularly if they have (1) dedicated their lives to the “understanding of life,” (2) learned from their experiences, and (3) become more mature and integrated. That may be why popes and U.S. Supreme Court justices are usually quite old. As two psychologists explain: Wisdom is one domain in which some older individuals excel.… [They have] a combination of psychosocial characteristics and life history factors, including openness to experience, generativity, cognitive style, contact with excellent mentors, and some exposure to structured and critical life experiences. [Baltes & Smith, 2008, p. 60] A review of personality development during adulthood found that some people became wiser but not everyone does (Reitz & Staudinger, 2017). Why not? The next chapter has some answers.