Cognitive Decline Related to Substance Use, Aging, and Associated Emotional Challenges

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Cognitive Decline Related to Substance Use, Aging, and Associated Emotional Challenges

Abnormal Psychology · Chapter 20: Cognitive Impairments: Disorders of Thinking and MemorySection 20.4 · lesson 78 of 9718 min · free with a free account

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In this lesson

Treatable contributors, later-life mood, and the people who give care.

  • Describe substance- and medication-related cognitive impairment
  • Distinguish ordinary aging from change that warrants assessment
  • Recognize depression presenting as cognitive impairment
  • Apply the unmet-needs approach, and support carers in their own right

Transcript

Everything said in the video, section by section (2,391 words). Read along, or search it.

Cognitive Impairments: Disorders of Thinking and Memory

Substances, Aging, and Emotional Challenges

This final section of chapter twenty covers cognitive decline related to substance use and aging, and the emotional challenges that come with it. We look at substance- and medication-related impairment, ordinary aging, and cognitive reserve. Then later-life depression, and how it can look like cognitive decline. We cover distressed behavior as communication of unmet needs, and carers as people in their own right, finishing with two composite cases.

Before You Begin

For Carers, Too

This material is educational, and not a basis for diagnosing yourself or anyone else. Some viewers will be carers, or will have personal experience of these conditions. The material on carer strain in particular may be affecting. If any part of it affects you, or if you are concerned about yourself or someone you care for, please speak with a qualified professional.

Substance-Related Neurocognitive Disorders

Impairment That Outlasts Intoxication

The classification recognizes neurocognitive disorders attributable to substance use. The requirement is impairment meeting the criteria for a major or mild neurocognitive disorder, in a person whose substance use could account for it. And the decisive element is that the impairment persists beyond intoxication and acute withdrawal. Impairment present only during those periods is not this condition. Some deficits improve substantially with sustained abstinence, while others persist. Recovery is often considerable over months, especially in executive function, and often incomplete. So cognition assessed during, or shortly after, use says little about a person's eventual functioning. As in chapter eighteen, substances are named by class only, with no quantities, thresholds, or safe levels of any kind.

Alcohol, Other Classes, Medication

Partly Reversible - and Often Overlooked

Alcohol-related impairment characteristically affects executive function and memory, with some domains spared. Two mechanisms contribute. A direct effect, and the nutritional deficiency mechanism from the previous sections, which produces its own amnestic syndrome. Substantial improvement occurs in many people with sustained abstinence and adequate nutrition. So a person assessed soon after stopping may look considerably more impaired than they will be, and concluding a fixed disorder then is a consequential error. For other substance classes, evidence quality varies, and confounding is substantial. Acute effects are better established than persistent ones. Medication matters too. Polypharmacy means many medications taken together, and the risk of cognitive effects rises with the number. Anticholinergic burden is a cumulative effect across several classes, not individually thought of as affecting cognition. Medication review is one of the highest-yield interventions in this population. It is cheap, needs no new resources, and can move someone off a pathway toward a dementia diagnosis. And it is often not done.

Table 20.4.1

Aging Slows Things - It Doesn't Take Them Away

Here is how ordinary aging compares with change that warrants assessment. Processing speed gradually slows, and tasks take longer, while accuracy is kept. Slowing that disrupts tasks the person used to manage warrants assessment. Memory retrieval gets less efficient, like the name that takes a moment, then arrives. Repeating questions within a short time, or information that does not return even with a cue, warrants assessment. Dividing attention gets harder with age. Losing the thread of a single conversation in a quiet room does not. Knowledge and well-practiced skills are preserved, or keep improving. Loss of long-established skills is never an ordinary age change. And read the last row first. Everyday functioning is unchanged by ordinary aging. Any loss of independence in activities the person previously managed warrants assessment. Aging slows things down. It does not take away what a person could do.

Cognitive Reserve

More Pathology Before Symptoms

Cognitive reserve is the proposal that individual differences in how the brain performs tasks, let some people sustain more pathology before symptoms appear. It was proposed to explain why pathology and symptoms correlate imperfectly, with some people showing substantial pathology after death, and no symptoms in life. The evidence is robust. Education, occupational complexity, and social and cognitive engagement are consistently associated with later presentation, for a given level of pathology. But the mechanism and causal status are debated. Do these experiences build protection? Or do they reflect differences in ability that were already there, which also delay detection? Reverse causation is live, since early disease can reduce engagement years before diagnosis. And one implication is often missed. If reserve delays presentation, a person with high reserve who does present may have more advanced pathology than it seems, which can mean faster decline afterward.

Figure 20.4.2

Cognitive Reserve, Schematically

Here is the proposal drawn out. Pathology increases along the bottom, and cognitive function runs up the side. The dashed horizontal line is the threshold at which symptoms appear. The red curve, with lower reserve, falls below that threshold at a lower level of pathology. The green curve, with higher reserve, holds up longer, and crosses the same threshold at a higher level of pathology. The arrow between the two dashed lines is exactly what the proposal claims. Not that the pathology is different, but that the same threshold is reached later. And the causal caution matters as much as the figure. Why some people have more reserve is still an open question.

Senses and Mood

Correct Senses First - and Take Mood Seriously

Hearing and vision loss contribute to cognitive difficulty in two distinct ways. There is apparent difficulty. A person who cannot hear the question or see the material may perform poorly and seem disoriented, while their cognition is fine. That is a common assessment failure. And there is a real contribution. Sensory impairment is associated with genuine decline over time, perhaps through reduced input, diverted effort, and social isolation. So correct sensory impairment before concluding decline. Make sure the person has, and is wearing, working glasses and hearing aids. Depression in older adults is under-recognized and under-treated, and it is not a normal consequence of aging. Assuming low mood is understandable in an older person facing loss is exactly how it goes untreated. The presentation differs. Somatic complaints like pain, fatigue, or digestive symptoms are often more prominent than sadness. Cognitive complaints are frequent. And anhedonia and withdrawal may be more evident than reported low mood.

Depression Presenting as Cognitive Impairment

2 Findings, Held Together

A depressive episode in an older adult can present with prominent cognitive difficulty, poor concentration, apparent memory failure, and slowed thinking, enough to resemble a neurocognitive disorder. An older name for this is no longer used. It implied the difficulty was not real, which is wrong, since objective impairment is present. Two findings must be held together, and they are not resolved. First, it is treatable. Treating the depression often substantially improves cognition, which is why it must not be recorded as dementia. Second, it can also be an early marker. Follow-up studies find that some people presenting this way, go on to develop a progressive condition at higher rates than expected. Both are supported, and they are not mutually exclusive. There is no reliable way to tell at presentation which group a person is in. But the practical answer does not wait on the debate. Treat the depression, and reassess cognition afterward. That is right in either case.

Table 20.4.4

The 3-Way Differential in Later Life

Here is the three-way differential in an older adult. Depression typically develops over weeks to months, often after a loss. An early neurocognitive disorder begins insidiously, and is hard to date. Delirium develops over hours to days. On assessment, a person with depression often shows low effort, with frequent I don't know answers that improve with encouragement. A person with an emerging neurocognitive condition typically tries hard, and may work to hide their difficulty. In depression, complaint often exceeds the impairment observed. In an early neurocognitive condition, impairment often exceeds complaint, and informants report more. In delirium, insight is impaired and fluctuates. Read the effort and complaint rows together. The person who complains most and tries least is more likely depressed. The person who complains least, while an informant reports more, is more likely to have an emerging condition.

Later-Life Emotion and Neuropsychiatric Features

Beyond the Cognitive Changes

Anxiety conditions are also under-recognized in older adults. Symptoms are put down to physical illness, co-occurring depression draws attention away, and worry about real difficulties is assumed not to be clinical. They are the same conditions, and treatable. Grief, loss, and role change are common in later life. The distinction from depression is one of pattern, not of whether the person has a reason to be distressed. Grief is typically wave-like, with the capacity for pleasure between waves, and a preserved sense of self-worth. And an understandable cause never establishes that a condition is absent. Neurocognitive disorders also involve neuropsychiatric features. Apathy is the most common, and most often mistaken for depression or laziness. Others include depression, anxiety, irritability, disinhibition, and perceptual disturbance. Their importance is disproportionate to the attention they get. They affect carers more than the cognitive changes do, and they are the strongest predictor of a move into residential care.

Table 20.4.3

Distressed Behavior Communicates a Need

Behavior in these conditions is often called challenging. The term is used here only to correct it. Behavior described that way is usually communication of an unmet need, like pain, fear, boredom, or overstimulation, rather than a symptom to be suppressed. That is a claim about mechanism, with a direct consequence. Identifying the trigger is the intervention. Start with physical need. Is the person in pain, constipated, dehydrated, hungry, needing the toilet, too hot or too cold? Pain is the most frequently missed, especially where the person cannot report it. Then the environment. Is it too noisy, too bright, too crowded, or unfamiliar? Then communication. Can the person understand, and be understood? Are glasses and hearing aids present and working? And psychological need. Is the person bored, lonely, or frightened? What did they do and value before? A response that reduces the behavior without addressing what produced it has simply silenced a signal.

Responses

Non-Drug Approaches Come First

Non-drug approaches are first-line. Environmental adaptation reduces demands and stressors. Routine brings predictability, which reduces fear. Meaningful activity, matched to the person's history, has some of the most consistent evidence here. Communication approaches, simpler language, one thing at a time, and enough time, reduce the frustration of not understanding or being understood. And carer training in all of these has good evidence. One pharmacological point is stated plainly. Antipsychotic prescribing in people with dementia carries serious risks, and it is not a first-line response to distressed behavior. It is stated emphatically because this prescribing has historically been common, often used in place of addressing unmet needs. Nothing further is described here, and any decision rests with a prescriber.

Carers

Clients in Their Own Right

Most care for people with cognitive conditions is provided unpaid, by family members. The literature uses the word burden for the strain involved. It should never be used of a person. Someone is not a burden, and a relative who hears themselves described that way carries it. Carers show higher rates of psychological difficulty, worse physical health, disrupted sleep, social isolation, and financial consequences where work is reduced or given up. Anticipatory grief deserves naming. It is grieving for a person who is still present, as aspects of the person one knew become less accessible. It is genuine grief, without the recognition that follows a death, and naming it helps. Carer wellbeing predicts the person's outcomes, including when a move into residential care happens. But the ethical position stands on its own. Carers are clients in their own right. So ask the carer how they are, separately and directly. Ask about their own health, since many postpone their own care. And support them because they need it, not only so they can keep caring.

Table 20.4.5 and Beyond

Support, Safeguarding, and Systems

Several carer interventions have evidence. Education about the condition changes how carers interpret what they see, like apathy as a feature, not giving up. Skills training reduces both distressed behavior and carer distress. Respite is highly valued, though its evidence on outcomes is more mixed. And psychological and peer support help, with multi-component approaches outperforming any single element. A leaflet alone is not a complete response. Elder abuse and neglect are a safeguarding concern requiring professional response and reporting. People with cognitive impairment are at elevated risk, and knowing your local reporting duties is part of competent practice. Transitions between care settings are high-risk periods, for delirium, medication error, distress, and lost information. And poverty and inequality shape who gets diagnosed, how early, and what support follows. Advance planning, while the person can still express preferences, lets their wishes govern end-of-life care.

Case Vignette 1 (Composite)

Alan: 2 Treatable Causes

Now two composite cases, constructed for instruction. Alan is seventy-seven. He attends with his daughter, reporting eight months of memory difficulty, which he describes as going the way his mother went. He was widowed fourteen months ago, has several long-term conditions, and takes a number of medications. He has stopped going to a club he belonged to for years, and sleeps poorly, though he manages his household and personal care. The reversible contributors were worked through properly. A formal medication review found a substantial anticholinergic burden, across several medications not individually thought of as affecting cognition. His mood was assessed in its own right, not explained away by bereavement. He met criteria for a depressive episode, with prominent somatic and cognitive complaint, and relatively little reported sadness. The pattern favored depression. His complaint exceeded the observed impairment, his effort was low, and the onset followed an identifiable loss. His depression was treated, and his medication burden reduced with his prescriber. Months later, his cognition had improved substantially. No neurocognitive diagnosis was recorded. He stays under review, because this can also be an early marker.

Case Vignette 2 (Composite)

Vera: Distress Traced to an Unmet Need

Vera is eighty-four. She lives in a residential setting, and has a major neurocognitive disorder. Staff asked for advice about episodes of distress most days. No behavior is described here. The reasoning is what matters. The request was for medication. Nothing else had been tried systematically, and the episodes had been recorded as a feature of her condition. Staff recorded when and where episodes happened, who was present, and what came just before. Over two weeks, a pattern emerged. The episodes came at a consistent time, linked to one particular care task. Working the categories revealed a lot. Vera has long-standing arthritis, cannot report pain reliably, and had never had a pain assessment adapted for people who cannot self-report. The task involves moving the affected joints. The setting was also busier and noisier at that time. Her hearing aid was not working. And she had little occupation during the day. Her pain was assessed and treated with her prescriber. The task was moved to a quieter time and adapted, her hearing aid was repaired, and meaningful activity was introduced. The episodes reduced substantially, and no antipsychotic was prescribed. A request for medication is usually a request for the distress to stop, not a clinical judgment that medication is indicated.

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About Cognitive Decline Related to Substance Use, Aging, and Associated Emotional Challenges

What is cognitive reserve?
Cognitive reserve is the proposal that individual differences in how the brain performs tasks let some people sustain more brain pathology before symptoms appear. Education, occupational complexity, and social and cognitive engagement are consistently associated with later onset of symptoms for a given level of pathology. Whether these experiences build protection or reflect pre-existing ability is still debated, and high reserve can mean more advanced disease by the time symptoms show.
Can depression look like dementia in older adults?
Yes, depression in older adults can cause poor concentration, apparent memory failure, and slowed thinking that resemble a neurocognitive disorder. Clues pointing to depression include onset after a loss, low effort with frequent I don't know answers, and complaints that exceed observed impairment. Treating the depression often improves cognition substantially, though some people later develop a progressive condition, so clinicians treat the depression and then reassess cognition.
Why do people with dementia become agitated or distressed?
Distressed behavior in dementia is usually communication of an unmet need rather than a symptom to suppress. Common triggers include pain, which is often missed, constipation, hunger, noise, unfamiliar surroundings, broken hearing aids, boredom, loneliness, and fear. Identifying the trigger is the intervention. Non-drug approaches come first, and antipsychotic medication carries serious risks in people with dementia, so it is not a first-line response.
Can cognitive problems caused by alcohol improve?
Yes, many people show substantial cognitive improvement over months of sustained abstinence and adequate nutrition, especially in executive function, though recovery is often incomplete. Alcohol-related impairment mainly affects executive function and memory, through direct effects and through thiamine deficiency. Because someone assessed soon after stopping may look far more impaired than they will later be, diagnosing a fixed disorder too early is a consequential error.

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