Cognitive Changes in Aging Clients

Definitions

• Cognitive changes are changes in a person’s thinking and memory.
• Dementia is a severe, chronic mental condition involving changes in a person’s memory, personality, reasoning, and ability to care for themselves.

Although aging is a normal part of life, elders may experience some specific challenges that you will need to be aware of in order to work effectively with them. For example, they may be experiencing:

• Adjustment to chronic medical conditions.
• Changes in their ability to care for themselves.
• Grief and loss.
• Memory loss or dementia.
• Depression and anxiety.

BHA/Ps working with elders and their families will need to be aware of how to recognize, evaluate, and assist with these problems. BHA/Ps will also need to know when it is necessary to work with an elder’s medical provider to give the best possible care. For more information, see: Caring for Elders.

Elders are often experiencing changes in their roles within their families and communities. These changes can be both positive and stressful. Even as they remain a source of wisdom and guidance for families and communities, elders may also increasingly have to rely on others to get their day-to-day needs met. Remember the following guiding principles:

• It is important to strengthen and encourage elders’ roles as teachers and leaders in the community.
• Elders should be involved in decisions about their own care as much as possible.
• Elders’ families and caregivers will often need to be involved in their care.
• Elders may be vulnerable because of physical illness or cognitive changes, so you need to pay special attention to their safety and security.

Referral information, including reports from medical providers, family members, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history, including major illnesses or medical conditions they have experienced that may account for some changes in their physical or mental functioning over time.

Treatment Plan

Before you work with elderly people, obtain answers to the following:

• Who are their primary caregivers?
• Do they have a guardian, power of attorney, or other legal decision-maker?
• What medical conditions do they experience?
• What physical or mobility limitations do they have? For example, if an elder is in a wheelchair, can he still sit comfortably in your office?
• What hearing or vision problems do they experience?
• What languages do they speak comfortably? If an elder’s primary language is different from yours, do you need an interpreter?
  • Consult with your supervisor about local interpreters or interpretation services you can access to support your clients.

Elders may have difficulty adjusting to changes in their physical health, ability to care for themselves, and roles within their families. They may also experience side effects to their medication, that they need to adjust to.It may be difficult for them to discuss these changes and the feelings they cause. Signs of adjustment problems in elders might include:

• Feeling worried or sad about a new medical diagnosis.
• Difficulty following medical recommendations related to a medical problem.
• Limiting activities or social interaction because of physical health concerns.
• Feeling unhappy with current family and/or social relationships.
• Family stress related to the elder’s increased need for care.
• Family conflict about decisions related to the elder’s care.

Elders may also be at an increased risk of experiencing grief and loss. Their friends, spouses, or other similar-aged peers may have passed away. Elders dealing with losses may display the following signs of grief and loss:

• Tearfulness.
• Loneliness.
• Feelings of emptiness.
• A lack of interest in social connection or other activities.
• Sleep problems.
• Lack of appetite.
• Spiritual concerns.
• Wanting to talk or reminisce about loved ones who have passed away.

Sometimes, elders can develop depression and/or anxiety. These problems may be overlooked by medical or mental health providers because they may be seen as “normal” grieving or stress related to aging. However, you should carefully assess for these problems in elders you work with:

• Signs of grief that do not change or improve as time goes on.
• Feelings of low self-worth, e.g., “I feel like I can’t do anything, and I’m no good to anyone anymore.”
• Thoughts of death or suicide, e.g., “My family will be better off when I’m dead.”
• Excessive worry.
• Excessive fearfulness.
• Changes in sleep or appetite.
• Social withdrawal.
• Irritability.
• Frequently seeking medical care for no clear medical reason.
• Family members expressing concern about the elder “not acting like herself.”

Finally, elders might be experiencing cognitive changes that raise concerns for them or their families. Again, you may need to gather this information from family or caregivers. Thoroughly document the presence, duration, and frequency of signs of cognitive changes, including:

• Forgetting the names of family or friends.
• Forgetting other information they used to know well (like birthdates or the location of a friend’s home).
• Episodes of confusion, sometimes accompanied by wandering.
• Agitation or intense fear for reasons that are difficult for family or caregivers to understand.
• Becoming socially or verbally withdrawn.
• No longer caring for themselves as they used to.
• Changes in their personality or “not acting like themselves” according to the people around them.

Elders may experience sudden changes in the way they think or act. When this happens, they could be experiencing an underlying medical problem that needs to be treated right away. If you are unsure, consult with your supervisor and consider referring your client for a medical evaluation.

Current activities at home and in the community:

• Do you leave your house by yourself? If not, who takes you out?
• Do you still fish, gather berries, etc.?
• Do you still prepare food?
• Do you visit your friends and family? Do they come visit you?
• Do you attend community events or meetings?

Health and access to medical care:

• How do you feel in your body?
• What medical problems do you have?
• Do you have pain?
• Do you take medicines? Do you take them yourself, or does someone help you take them?
• Do you go see the doctor or health aide? When was the last time you saw them? When is the next time you will see them?

Mood and worries:

• How have you been feeling lately?
• Do you feel sad or down?
• What kinds of things do you worry about?
• Do you ever feel like your thoughts are making you sad, scared, or uncomfortable?
• Have you lost people close to you?

Thinking and memory:

• As we get older, we all become more forgetful. Is this happening to you?
• Do you ever feel confused or mixed up?
• Does someone have to help you remember important things (like your medicines or appointments)?

Comfort and safety at home:

• Do you like where you are living?
• Who takes care of you?
• Do you feel safe at home?
• Do you have enough to eat?
• Is your house warm enough?
• Does anyone mistreat you?

An elder who is experiencing cognitive changes may not be able to answer all of these questions completely by himself.

You may need to ask the elder’s caregiver some of these questions to get a complete picture of the elder’s current condition. The caregiver may be willing or able to share concerns that the elder is not aware of or not willing to talk about.

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specific goals and objectives when working with aging clients include maintaining their quality of life, maximing their functioning in daily activities, maintaining or increasing approriate physical activity, and promoting regular social engagement (e.g., attending elders' lunch regularly). It is also important to provide support to the aging client's primary caregivers. People who are the primary caregivers for individuals experiencing dementia can be put under significant stress, and many experience depression. Providing social support to the caregiver can indirectly increase the wellbeing of the aging client.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.