Abstract
It is widely held that cognitive changes occur with aging; yet the impairments and functional correlates remain poorly understood. In the frail elderly patient, where safety is an issue both in basic mobility and in ADLs, cognitive function is often overlooked. Fall prevention does not routinely include cognitive screening, despite the fact that safe mobility depends on cognitive skills to negotiate obstacles and tolerate distractions. This article provides an overview of the effects of aging on cognition and introduces a framework for evaluating and treating cognition. Recommendations for research in this area are provided, as most current interventions are not evidence-based.
WHAT do we really know about cognitive function and how the brain operates to perceive, interact with, and understand our world? What do we know about effective cognitive rehabilitation techniques? The principles of cognitive rehabilitation are not as well defined as those of musculoskeletal or even neuromuscular rehabilitation. For many clinicians, it is tempting to overlook cognition because so much is unknown and inconsistently applied in this field.
While cognitive rehabilitation is not well defined, the link of cognition to functional mobility and activities of daily living (ADL) is undeniable. Attention, memory, awareness, and problem solving are essential to avoid obstacles, adjust forces to meet environmental demands (eg, height of sitting surfaces, friction), and sequence ADLs. Consider the frail elderly patient who has compromised balance and is at risk for falls-a patient in whom cognition is often overlooked. How often is the ability to tolerate distractions or perform with dual-task demands assessed for fall prevention? It is tempting to evaluate strength, range of motion, sensation, and endurance-leaving cognition "neglected." Evaluating and treating cognition can be arduous, and even more difficult to document. This difficulty leads to a central issue: reimbursement! What payer will see cognitive rehabilitation as necessary if therapists do not? To be fair, the concept of cognitive rehabilitation is not foreign to most physical or occupational therapists. Yet, recognizing cognitive impairment and creating a structured, efficacious rehabilitation program is not an easy task.
This article will serve as a bridge over some of the uncertainty in cognitive rehabilitation, with particular emphasis on the frail geriatric patient. The term frail elderly will be used in this article to include those patients with functional limitations and disabilities that prevent them from safely living alone. This may include those with functional limitations due to chronic or late effects of stroke, dementia, Parkinson's disease, or those with undiagnosed pathology leading to their cognitive impairment. Although this article will cover many aspects of cognitive rehabilitation as related to the frail elderly patient, it is not intended to be a comprehensive inclusion of all diagnoses or cognitive rehabilitation approaches. It will address 5 separate goals:
1. Detail the importance of cognitive evaluation and screening as routine in care of the frail elderly
2. Define cognition and cognitive changes as related to aging
3. Establish a framework for evaluating and treating cognitive impairment
4. Provide recommendations for documentation of cognitive rehabilitation
5. Suggest directions for future research