Strategies for Memory Improvement in Older Adults

Jane S. Saczynski, PhD; George W. Rebok, PhD

Disclosures

Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Patient Assessment

Memory Complaints

Memory complaints, from the patient or a close family member or companion, are the most likely way an APN will detect memory impairment. Short office visits are often not sufficient for interactions to detect impairment without a prompt from the patient about "memory worry." Memory worry is not confined to older adults. Middle-aged adults (and even young adults) report considerable worry about their memory performance,[29] but worry in older adults may be a precursor to impairment.

Memory worry is distinct from memory decline. However, memory worry in older adults with normal baseline cognition predicts the occurrence of dementia within less than 5 years.[30] This suggests that memory worry may be indicative of a decline that cognitive tests are unable to detect. Self-reports of memory worry therefore may be an indicator of the need for preventive intervention efforts.

In addition to memory complaints issued by the patient or family member, the APN may detect memory impairment during the office visit. Patients may have a difficult time answering questions pertaining to medications, diet, or family medical history. Although difficulty answering medical questions may be a sign of memory impairment, it may also be related to anxiety about health questions or uncertainty with answers. Because of this, it is important to follow up a memory complaint or a potential cognitive deficit with a standardized memory or cognitive function test.

Assessment Tools

Once a patient describes a concern about memory or the APN notes a cognitive deficit, there are a number of ways to assess the degree of impairment. Brief inventories are designed to assess global cognitive function but are often not sensitive enough to detect minor changes in memory performance. The most widely used assessment tool for global functioning is the Folstein Mini-Mental State Exam (MMSE).[31]

The MMSE is a 30-item measure assessing the domains of orientation, registration, attention and calculation, recall, language, and visual-spatial construction. A score of < 24 on the MMSE is often used as a cut-point for cognitive impairment with individuals having at least 8 years of education.[32] Scores of 18-23 on the MMSE indicate mild to moderate cognitive impairment, while scores below 18 indicate severe cognitive impairment. Educational and age biases have been reported in MMSE scores; thus, results should be interpreted with caution. (For specific age and education norms, see Crum and colleagues.[32])

The Short Portable Memory Status Questionnaire (SPMSQ[33]) is a 10-item cognitive measure that measures short- and long-term memory, orientation, and the ability to conduct serial operations and is scored in terms of the number of errors committed. Scoring on the SPMSQ accounts for race and education, with more errors allowed for African-American individuals and those with less education.[34] In white individuals with 9-12 years of education, subjects who make 3 or more errors are considered impaired. The measure permits 1 more error for less education and 1 less error for more education. At each level, African American subjects are permitted 1 additional error before being considered impaired (eg, for African American individuals with 9 to 12 years of education, subjects who make 4 or more errors would be considered impaired).[33]

While the previous tests measure global cognitive function, there are also tests that focus specifically on memory function. The Memory Impairment Screen (MIS) is a brief, 4-item, delayed free- and cued-recall memory impairment test that has high sensitivity and specificity as a screening test for AD and other dementias.[35] Scores on the MIS range from 0-8, and individuals scoring 4 or less are classified as impaired. This cut-score is based on norms from a sample of community volunteers and may not have the same level of discrimination in specific clinical applications, so it must be used with caution.

The MIS is also intended for clinical evaluation of individuals who are likely to have dementia rather than for detecting individuals with preclinical AD. Despite these limitations, the MIS provides efficient, reliable, and valid screening for AD and other dementias. This information is useful to guide treatment plans. Another memory test, the Memory Monitor , is designed to help clients understand how lifestyle can affect everyday memory abilities. The clinician can use the Memory Monitor to assess a patient's readiness for memory challenges and to evaluate how the patient's memory may be improving as a result of treatment.

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