impaired judgement and problem solving

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• Mild cognitive impairment (MCI)

Mild cognitive impairment (MCI) is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia. MCI may include problems with memory, language or judgment.

People with MCI may be aware that their memory or mental function has "slipped." Family and close friends also may notice changes. But these changes aren't bad enough to impact daily life or affect usual activities.

MCI may increase the risk of dementia caused by Alzheimer's disease or other brain disorders. But some people with mild cognitive impairment might never get worse. And some eventually get better.

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The brain, like the rest of the body, changes with age. Many people notice they become more forgetful as they age. It may take longer to think of a word or to recall a person's name.

If concerns with mental function go beyond what's expected, the symptoms may be due to mild cognitive impairment (MCI). MCI may be the cause of changes in thinking if:

• You forget things more often.
• You miss appointments or social events.
• You lose your train of thought. Or you can't follow the plot of a book or movie.
• You have trouble following a conversation.
• You find it hard to make decisions, finish a task or follow instructions.
• You start to have trouble finding your way around places you know well.
• You begin to have poor judgment.
• Your family and friends notice any of these changes.

If you have MCI , you also may experience:

• Depression.
• A short temper and aggression.
• A lack of interest.

When to see a doctor

Talk to your health care provider if you or someone close to you notices you're having problems with memory or thinking. This may include trouble recalling recent events or having trouble thinking clearly.

• Changes in brain structure with MCI and Alzheimer's disease

Some changes in brain structure — such as the decrease in size of the brain's memory center (hippocampus) — are typical with aging. However, this reduction in size is greater in those with mild cognitive impairment and even more dramatic in people with Alzheimer's disease.

• Brain shrinkage in MCI and Alzheimer's disease

Dementia causes the brain to lose mass, especially in critical areas. Note the difference in size between a healthy brain (top), a mild cognitive impairment brain (middle) and an Alzheimer's disease brain (bottom).

There's no single cause of mild cognitive impairment (MCI), although MCI may be due to early Alzheimer's disease. There's no single outcome for the disorder. Symptoms of MCI may remain stable for years. Or MCI may progress to Alzheimer's disease dementia or another type of dementia. In some cases, MCI may improve over time.

MCI often involves the same types of brain changes seen in Alzheimer's disease or other forms of dementia. In MCI , those changes occur at a lesser degree. Some of these changes have been seen in autopsy studies of people with MCI .

These changes include:

• Clumps of beta-amyloid protein, called plaques, and tangles of tau proteins that are seen in Alzheimer's disease.
• Microscopic clumps of a protein called Lewy bodies. These clumps are associated with Parkinson's disease, dementia with Lewy bodies and some cases of Alzheimer's disease.
• Small strokes or reduced blood flow through brain blood vessels.

Brain-imaging studies show that the following changes may be associated with MCI :

• Decreased size of the hippocampus, a brain region important for memory.
• Increased size of the brain's fluid-filled spaces, known as ventricles.
• Reduced use of glucose in key brain regions. Glucose is the sugar that's the main source of energy for cells.

Risk factors

The strongest risk factors for MCI are:

• Increasing age.
• Having a form of a gene known as APOE e4 . This gene also is linked to Alzheimer's disease. But having the gene doesn't guarantee that you'll have a decline in thinking and memory.

Other medical conditions and lifestyle factors have been linked to an increased risk of changes in thinking, including:

• High blood pressure.
• High cholesterol.
• Obstructive sleep apnea.
• Lack of physical exercise.
• Low education level.
• Lack of mentally or socially stimulating activities.

Complications

People with MCI have an increased risk — but not a certainty — of developing dementia. Overall, about 1% to 3% of older adults develop dementia every year. Studies suggest that around 10% to 15% of people with MCI go on to develop dementia each year.

Mild cognitive impairment can't be prevented. But research has found some lifestyle factors may lower the risk of getting MCI . Studies show that these steps may help prevent MCI :

• Don't drink large amounts of alcohol.
• Limit exposure to air pollution.
• Reduce your risk of a head injury.
• Don't smoke.
• Manage health conditions such as diabetes, high blood pressure, obesity and depression.
• Practice good sleep hygiene and manage any sleep problems.
• Eat a healthy diet full of nutrients. Include fruits and vegetables and foods low in saturated fats.
• Stay social with friends and family.
• Exercise at a moderate to vigorous intensity most days of the week.
• Wear a hearing aid if you have hearing loss.
• Stimulate your mind with puzzles, games and memory training.

Mild cognitive impairment (MCI) care at Mayo Clinic

• Knopman DS, et al. Alzheimer disease. Nature Reviews. Disease Primers. 2021; doi:10.1038/s41572-021-00269-y.
• Jankovic J, et al., eds. Alzheimer disease and other dementias. In: Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Zhuang L, et al. Cognitive assessment tools for mild cognitive impairment screening. Journal of Neurology. 2021; doi:10.1007/s00415-019-09506-7.
• What is mild cognitive impairment? National Institute on Aging. https://www.nia.nih.gov/health/what-mild-cognitive-impairment. Accessed Sept. 21, 2022.
• Mild cognitive impairment (MCI). Alzheimer's Association. https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/mild-cognitive-impairment. Accessed Sept. 21, 2022.
• Lewis JE, et al. The effects of twenty-one nutrients and phytonutrients on cognitive function: A narrative review. Journal of Clinical and Translational Research. 2021; doi:10.18053/jctres.07.202104.014.
• Kellerman RD, et al. Alzheimer's disease. In: Conn's Current Therapy 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Ferri FF. Mild cognitive impairment. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Petersen RC, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018; doi:10.1212/WNL.0000000000004826.
• Budson AE, et al. Subjective cognitive decline, mild cognitive impairment and dementia. In: Memory Loss, Alzheimer's Disease, and Dementia. 3rd ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Cognitive impairment in older adults: Screening. U.S. Preventive Services Task Force recommendation statement. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening. Accessed Sept. 21, 2022.
• Levenson JL, ed. Dementia. In: The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. 3rd ed. American Psychiatric Association Publishing; 2019. https://psychiatryonline.org. Accessed Sept. 21, 2022.
• Livingston G, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet. 2020; doi:10.1016/S0140-6736(20)30367-6.
• Cummings J, et al. Alzheimer's disease drug development pipeline: 2022. Alzheimer's and Dementia. 2022; doi:10.1002/trc2.12295.
• Memory, forgetfulness and aging: What's normal and what's not? National Institute on Aging. https://www.nia.nih.gov/health/memory-forgetfulness-and-aging-whats-normal-and-whats-not. Accessed Sept. 26, 2022.
• Ami T. Allscripts EPSi. Mayo Clinic. April 21, 2022.
• Alzheimer's disease research centers. National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-disease-research-centers#minnesota. Accessed Sept. 26, 2022.
• About the Alzheimer's Consortium. Arizona Alzheimer's Consortium. https://azalz.org/about/#institutes. Accessed Sept. 26, 2022.
• Shi M, et al. Impact of anti-amyloid-β monoclonal antibodies on the pathology and clinical profile of Alzheimer's disease: A focus on aducanumab and lecanemab. Frontiers in Aging and Neuroscience. 2022; doi:10.3389/fnagi.2022.870517.
• Graff-Radford J (expert opinion). Mayo Clinic. Sept. 30, 2022.
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Special Health Reports

Understanding Mild Cognitive Impairment

This guide from Harvard Medical School explores the subtle differences between various forms of memory problems, breaks down the different types of MCI, and explains brain function and its role in creating and retrieving memories. You will learn the causes and risk factors for MCI, what doctors look for when diagnosing the condition, and medical as well as natural ways to treat or even prevent it.

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The majority of people who find their thinking and learning abilities slowing down as they enter their 60s and 70s are dealing with the predictable effects of aging on the brain. Some people, however, have problems with mental function that are more pronounced than normal age-related forgetfulness. When consistent memory problems disrupt daily living, prompting cause for concern, it may be a sign of Alzheimer’s disease or some other cognitive condition. Early diagnosis helps you better plan your future.

However, if these memory deficits are not severe enough to significantly impede everyday functioning—a hallmark of dementia—the problem can be classified as mild cognitive impairment, or MCI, the gray area that falls between predictable age-related cognitive changes and abnormal mental deficits that stem from disease. MCI is not a disease per se, but rather a collection of symptoms and observations. In addition, MCI is a highly variable condition in which a person may either progress into actual dementia, revert to normal cognitive function, or even remain at a stable level, depending on the individual and the conditions underlying the problem.

This guide from Harvard Medical School explores the subtle differences between various forms of memory problems, break down the different types of MCI, and explains brain function and its role in creating and retrieving memories. You will learn the causes and risk factors for MCI, what doctors look for when diagnosing the condition, and medical as well as natural ways to treat or even prevent it.

Prepared by the editors of Harvard Health Publishing in consultation with Gad A. Marshall, M.D., Associate Professor of Neurology, Harvard Medical School, Director of Clinical Trials, Center for Alzheimer Research & Treatment, Brigham and Women’s Hospital Massachusetts General Hospital. (2024) 27 Pages.  

About guides from Harvard Medical School

Harvard Medical School delivers compact, practical information on important health concerns. These publications are smaller in scope than our Special Health Reports, but they are written in the same clear, easy-to-understand language, and they provide the authoritative health advice you expect from Harvard Health Publishing.

The six cognitive domains

• Memory and learning: registering new information and storing it for future use (acquisition, also known as “encoding,” and consolidation); accessing information from storage when needed (retrieval).
• Social function: interpreting and responding to social signals from other individuals, such as facial expressions and direction of gaze.
• Language: translating sounds into words; generating verbal output; comprehension of written and spoken language.
• Perception and motor skills: recognizing and interpreting sensory stimuli (smell, touch, hearing, etc.); mobilizing your muscles and body; manipulating objects; navigating your environment; perceiving and interpreting visual images and shapes.
• Attention: sustaining concentration on a particular object, action, or thought; managing competing demands in your environment.
• flexibility —the capacity to quickly switch to the appropriate mental mode
• theory of mind —insight into other people’s inner worlds (their plans, likes, and dislikes)
• anticipation —prediction based on pattern recognition
• problem solving —defining a problem in the right way to generate possible solutions and make a reasonable choice
• decision making —the ability to make decisions based on problem solving, incomplete information, and emotions (your own and those of others)
• working memory —the ability to hold information over the short term while perform ing a task
• sequencing —the ability to break down complex actions into manageable units and prioritize them
• cognitive control and response inhibition —the ability to withstand distraction and internal urges.
• Worried about memory failure?
• What is MCI
• The making of a memory
• Risk factors for MCI and dementia
• Evaluating MCI
• Reversible causes of MCI
• Treating MCI
• Protecting against cognitive decline

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Improving Memory: Understanding age-related memory loss

By age 60, more than half of adults have concerns about their memory. However, minor memory lapses that occur with age are not usually signs of a serious problem, such as Alzheimer’s disease, but rather the result of normal changes in the structure and function of the brain. This report,  Improving Memory: Understanding age-related memory loss , describes these normal age-related changes and other more serious causes of memory loss — and how to distinguish between them.

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Impaired Cognition: Frequently Asked Questions

What Is Cognition?

Cognition is another word for thinking and the process that describes how we understand and interact with the world. Cognition also describes how the brain perceives and expresses experiences.

What Is Meant by Impaired Cognition?

When a person is diagnosed with impaired cognition, it means their skills and abilities may have diminished or disappeared as a result of a medical problem. There are special names for some of these impairments; for example, an impairment in language skills that makes it hard for people to speak or understand speech is called aphasia.

How Is Cognition Affected by Brain Injury?

ince a brain injury can occur in any part of the brain, any thinking abilities may be affected. This could include attention, communication, visual perception (the ability to understand what is seen) and memory. Very often, the parts of the brain located toward the front of the skull are most severely damaged. Typical impairments due to injury in this area include:

• Problems with attention, concentration and organization
• Difficulty remembering things that happened since the injury
• Lack of awareness of your behavior or how others see you
• Appearing inconsiderate, selfish, and not caring how others feel or just not being aware of how you make other people feel.

What is “Minimal Consciousness?”

People who are minimally conscious are more awake than someone in a deep coma, but they may actually have little awareness of their surroundings. They may open their eyes and look around the room, but not respond to what they see or hear in the room. Minimally conscious people may benefit by having things to think about; for example, having visitors, talking to them, having the television on, or reading aloud. While none of the following activities has been proven to help recovery, they could be used to assist the individual to get started:

• It may help for the minimally conscious person to start using different senses again, so talking to them or playing music is a reasonable thing to do
• Gentle touching or holding hands
• Having sweet smelling flowers in the room
• Playing recorded messages from family or friends
• Using complex stimuli such as audiobooks or television usually is not helpful.
• When around a minimally conscious patient, avoid speaking as if they are not there and cannot hear you.

How Does Brain Injury Affect Actions and Feelings?

Sometimes brain injuries damage the part of the brain that controls emotional expression. As a result, people may become angry much more easily and their anger may be much more forceful. Often, people with this problem feel embarrassed after an angry outburst because they know their reaction was inappropriate. Other people may laugh or cry at inappropriate times because of the same problem. Doctors describe this lack of control of emotions with a number of terms including “emotional lability” or “affective dysregulation.” People may also act before they think and may do and say things they would never have done or said before. Such behavior is sometimes described as “impulsivity” or “disinhibition.”

How Long Does It Take to Recover From a Brain Injury?

Recovery time depends on the severity of the injury. If someone was unconscious for less than 30 minutes, the recovery usually occurs within three months. If a person was unconscious for more than 24 hours, recovery may take up to a year. Recovery is usually most rapid in the days and weeks immediately after an injury (improvements can often be noticed from one day to another). Then, recovery slows down and improvements may not be noticeable unless compared month to month.

What is the Definition of Recovery?

Rehabilitation helps people to recover but recovery may not mean completely returning to the way things were before the injury. One way to think of recovery is that the person with the injury (impairment) has acknowledged that there is a change, has learned how to do things differently or compensate for problems, and has decided to do as much in life as they can. It means enjoying life as much as possible and feeling good as a person while being aware of one's limitations. It also means feeling valuable to others. It does not mean being exactly the same as before the injury. Recovery is an ongoing process, and after all, everybody changes over time. It has always been very difficult to predict the amount of recovery someone has after brain injury. When a serious injury results in unconsciousness for a long time, there are usually some lasting effects, but it is hard to predict how much they might interfere with normal life. Depending upon how severe the injury, the effects and changes to life can be permanent. In less severe cases, some functions may recover, while others remain weak, such as short–term memory. Either way, recovery can take a long time. At some point, it becomes hard to know if improvement comes from brain recovery or just learning to do things differently.

What Can Help with Recovery from Brain Injury?

Most important is to work at recovery rather than just sit around and wait for improvements to happen.

• Therapies are essential, even after leaving the hospital.
• Keep to a routine and stay active. Think of the brain as a muscle; it will weaken if it is not exercised.
• Look for ways to stimulate thinking. Games, puzzles, reading and performing everyday tasks that offer mental challenge can be useful.
• Focus on doing only one thing at a time.
• Try to strike a balance between doing too little and too much. Go slowly and set realistic goals for the things that you used to do.

Which Activities Could Interfere with Recovery?

These chemicals have direct effects on the brain and can impair judgment and put a person at risk for further injury. Be careful when using them, if at all, and consult with your doctor if you have questions about any particular substance.

• Avoid risky activities like extreme sports that could cause another brain injury.

What about Returning to Work, School, or Driving?

Work (or school) and driving involve very complex behaviors. Some of these activities can be resumed as soon as a person becomes aware of their limitation, has mastered some techniques to make up for weaknesses, and has realistic goals. Limitations due to the injury may, however, present difficulties. Doctors and therapists will have advice on these matters.

Driving can be very dangerous if there are impairments that affect vision, reflexes or problem solving. A special driving evaluation may be necessary.

How Can I Talk to Me Children About Brain Injury?

Children need to know some basic things about brain impairment; for example people with brain injuries may act confused or have trouble remembering or talking about things. Remind your children that a brain impaired person is not ”retarded”, ”stupid” or ”child like” even if other adults use those labels. Find out your child's questions. If you do not have answers, check with a trusted professional to help you find the appropriate response.

How Does a Brain Injury Affect Family?

A brain injury can be scary and confusing, resulting in a number of family reactions. Many of these reactions are understandable, but not helpful. For example:

• Treating the person with brain injury like a child or a baby
• Feeling angry at the person with the impairment because of a sense that they were somehow responsible for what happened
• Disagreeing and arguing about what is best for the individual
• There may be times when some family members are upset and even withdraw from family contact. With patience and time, hopefully they will come to a better understanding of the injury and re–establish contact.

Brain impairments can make family members feel personally vulnerable, frustrated and misunderstood. Like any other serious family problem, it is not always possible to agree about what to do, but it is important to listen to different points of view and treat others with respect and kindness.

What Should I Do If My Family Member with Brain Injury Has Problems with Anger and Becomes Violent?

Sometimes people have difficulty with emotional control after brain injury and this can include having a short temper. Family members need to learn different ways to respond to someone with a brain injury who is easily angered.

• The best way to deal with violence is to learn how to prevent it. Watch for patterns or triggers that set off the person with brain injury; try to avoid responses that only make anger build.
• Remain calm. It is usually not helpful to argue logically when a person with brain injury has become upset.
• Try diversion or redirection in any form. This takes away the irritation and allows the person time to calm down.
• Try to avoid physical restrictions and allow the person (within limits) to freely express themselves physically and verbally.
• If the situation becomes physically violent or threatening, direct appeals for calm can be tried, but may not have the desired effect. In extreme situations, where physical restraint seems necessary, try to have a phone available and numbers to call (such as the doctor or police) for quick, efficient use. Do not try to handle these situations alone.
• If anger control is a chronic problem, ask your doctor about the possibility of medications to help manage the behavior.

Additional Resources

American Stroke Assc., 888-4-STROKE

Brain Injury Assc., 703-236-6000

Gronwall, D, Wrightson, P, and Waddell, P., 1999. Head Injury: The Facts: A guide for families and care-givers. Oxford Press.

National Stroke Assc, 800-STROKES

Osborn, Claudia, 1998. Over My Head: A doctor's own story of head injury from the inside looking out, Andrews McMeel Publishing

Stoler, D and Hill, BA Coping with Mild Traumatic Brain Injury Avery Press, 1998

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Comments (2)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

Anonymous replied on Tue, 04/26/2016 - 7:19pm Permalink

Some of us who have a tbi never recover. Mild medium or severe brain injury doesn't matter . Every brain is different there is no true time line for recovery . There are milestones that are used as gauges.

Anonymous replied on Tue, 08/13/2013 - 9:54am Permalink

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Impaired Judgement

Definition:.

Impaired judgement is a medical condition that results in a person not being able to make good decisions because of an underlying medical problem, environmental factors, diet, or drugs and alcohol .

The Mayo Clinic notes that many people with impaired judgement suffer from mild cognitive impairment, which also causes impairment in memory, language and thinking skills.

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Cognitive impairment

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• Cognitive impairment is not an illness, but it can signal other medical conditions.
• Signs of cognitive impairment can include memory loss, mood swings and behavioural changes.
• There are ways to treat and prevent cognitive impairment and its complications

What is cognitive impairment?

Cognitive impairment is when you have problems remembering things and solving problems. Cognitive impairment is not an illness. It can be caused by many conditions.  

You may struggle with:

• remembering things
• paying attention
• speaking or understanding
• recognising people, places or things
• experiencing new places and situations — you may become overwhelmed

Cognitive impairment can come and go. This is often called delirium . Delirium can be a sign of serious medical problems.

Cognitive impairment can go from mild to severe.

What are the symptoms of cognitive impairment?

If someone you know has cognitive impairment, you may notice:

• they sometimes feel confused , agitated or distressed
• a change in their speech or behaviours
• that they struggle to finish their daily tasks

What causes cognitive impairment?

There are many causes of cognitive impairment. Some causes of short-term or reversible cognitive impairment are:

• head injury
• anxiety or depression
• recreational use of alcohol and/or drugs
• vitamin deficiency
• dehydration
• reactions to medicines

Some causes of cognitive impairment that lasts forever are:

• brain injury
• intellectual disability

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

When should I see my doctor?

If you, or someone you know is showing signs of cognitive impairment, see your doctor. They can help find out the cause, rule out any serious conditions, and help arrange treatment.

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

How is cognitive impairment diagnosed?

To work out if you have cognitive impairment, your doctor might ask questions to test your:

• concentration
• understanding

They may also ask your family or carers questions. This is because they may have noticed changes in your behaviour over time. Doctors may also examine you, and do more tests to try to find the cause.

How is cognitive impairment treated?

Treatment will depend on what is causing your cognitive impairment. Exercise, healthy sleep and relaxation techniques may also help. You may find familiar objects comforting.

Not every older person has cognitive impairment. But cognitive impairment is more common in older people.

What are the complications of cognitive impairment?

People who have delirium and confusion have a higher chance of falls and injuries . It’s important to avoid dangerous activities like driving.

Can cognitive impairment be prevented?

Sometimes, cognitive impairment can be prevented.

A doctor can give advice on preventing cognitive impairment. They can also refer you for more help, such as:

• physiotherapy
• occupational therapy

For people with long-term cognitive impairment, there are ways to prevent delirium, confusion and other complications.

Resources and Support

You can learn more about cognitive impairment on the Caring for Cognitive Impairment website .

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with 24 hours a day, 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: November 2022

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Impaired Thought Processes & Cognitive Impairment Nursing Care Plan and Management

Effective nursing care planning and management is important for patients with impaired thought process or cognitive impairment as they aim to promote safety, optimize functioning, and enhance quality of life for these individuals. Get to know the nursing assessment , nursing diagnosis , and interventions for patients with cognitive impairment or impairment in their thought processes.

Table of Contents

What is cognitive impairment, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1.1. assessing the client’s cognitive abilities, 1.2. determining the etiology of cognitive decline, 2. managing cognitive decline, 3. advocating for the client’s safety, 4. improving client communication, 5. providing interventions to improve nutrition and hydration, recommended resources, references and sources.

Impairment in cognition describes an individual with altered perception and cognition that interferes with daily living. The alteration can result in cognitive and perceptual deficits, including difficulty concentrating, organizing thoughts, and communicating effectively. Disturbances in thought processes can be caused by various conditions, such as mental illness , substance abuse , brain injury , or medication side effects.

Mild cognitive impairment (MCI) exceeds the normal, expected changes related to age. The defining element of MCI, according to Ronald C. Petersen, is a single sphere of slowly progressive cognitive impairment that is not attributable to motor or sensory deficits and to which other areas of involvement may eventually be added before social or occupational impairment supervenes (Mehta & Chawla, 2019).

The focus of nursing management is to reduce impairment in thinking and promote reality orientation. Often, confusion in older adults is erroneously attributed to aging. Confusion in an older adult can be caused by a single factor or multiple factors such as depression , dementia , medication side effects, or metabolic disorders. Depression causes impaired thinking in older adults more frequently than dementia .

Disturbances in thought process can be caused by various factors including psychiatric disorders, neurological conditions, substance abuse , medication side effects, and systemic illnesses affecting the brain. Here are some factors that may cause cognitive impairment:

Physical changes

• Head injuries
• Malnutrition

Biochemical changes

• Medications
• Substance abuse

Psychological conflicts

• Emotional changes
• Mental disorders

Maturational

• Late-life depression

Situational (Personal, Environmental)

• Abuse (physical, sexual, mental)
• Childhood trauma

Nursing Care Plans and Management

Caring for clients with cognitive impairment presents unique challenges that require a comprehensive and individualized approach. Nursing care plans involve a systematic process of assessment , diagnosis, planning , implementation , and evaluation . They are tailored to the specific needs and abilities of each client, recognizing that cognitive impairment varies in its presentation and progress. Management of these clients focuses not only on medical interventions but also on creating a supportive and nurturing environment that fosters a sense of security, engagement, and comfort . 

The following are the nursing priorities for clients with cognitive impairment:

• Client safety. Cognitive impairment can affect balance and coordination , increasing the risk of falls. These clients may also wander and become disoriented, leading to risks to safety.
• Communication. Cognitive impairment can impair communication skills, leading to frustration and isolation .
• Impaired activities of daily living (ADLs). Cognitive impairment often affects the client’s ability to perform ADLs independently.
• Nutrition and hydration. cognitive impairment can lead to forgetfulness or difficulty eating and drinking independently. Prioritizing adequate nutrition and hydration to prevent malnutrition and dehydration is essential.

Common signs and symptoms of cognitive impairment or disturbed thought process may include memory loss, confusion, disorientation , difficulty concentrating, impaired judgment, language difficulties, changes in behavior or personality, and problems with problem-solving and decision-making abilities. The following signs and symptoms characterize cognitive impairment:

• Memory impairment. Significant difficulty in retaining new information or recalling previously learned information.
• Cognitive disorientation. Altered perception of time, place, and person, often resulting in confusion about surroundings and events.
• Impaired attention and concentration. Difficulty focusing, sustaining attention, and staying engaged in activities.
• Executive dysfunction. Challenges in planning, organizing, and executing complex tasks result in difficulties with problem-solving and decision-making .
• Aphasia. Language impairments involve difficulties with speech production, comprehension, or word finding.
• Changes in behavior and personality. Observable alterations in mood, emotions, social interactions, or impulse control.
• Apraxia. Difficulty performing purposeful movements or using objects correctly despite intact motor function.
• Agnosia. Inability to recognize or identify objects, people, or familiar sensory stimuli.
• Disrupted visuospatial abilities. Impairments in perceiving and interpreting spatial relationships, depth perception, or object recognition.
• Psychomotor disturbances. Changes in motor activity, such as agitation, restlessness, or slowed movements.

Nursing diagnosis is a critical step in providing effective care to clients with cognitive disorders. This process involves a systematic assessment and analysis of the client’s condition, which helps the nurse identify the client’s unique nursing care needs. It is essential to maintain open communication with the client and their caregivers to ensure that care plans are client-centered and responsive to changing needs and preferences.

The following are the common goals and expected outcomes:

• The client will maintain reality orientation and communicate clearly with others
• The client will recognize changes in thinking/behavior.
• The client will recognize and clarify possible misinterpretations of the behaviors and verbalization of others.
• The client will identify situations that occur before hallucinations /delusions.
• The client will use coping strategies to deal effectively with hallucinations/delusions.
• The client will participate in unit activities.
• The client will express delusional material less frequently.
• The client will appropriately interact and cooperate with staff and peers in a therapeutic community setting.

Nursing Interventions and Actions

Nursing interventions are crucial in supporting clients with cognitive impairment or disturbed thought processes by ensuring their safety, facilitating effective communication, promoting cognitive functioning, and enhancing their overall well-being and quality of life.

1. Assessing for Cognitive Impairment

Nursing assessment is crucial for clients with cognitive impairment or disturbed thought processes as it helps identify their specific needs, tailor care interventions, and monitor changes in cognitive function, allowing for individualized and effective care.

1. Assess attention span/distractibility and ability to make decisions or problem-solving. This determines the ability of the client to participate in planning/executing care. Attention span can be measured by asking the client to repeat increasingly lengthy strings of information, such as digit sequences, sentences, or spatial locations. A reduced attention span may explain poor performance across a number of domains like language memory due to limited processing.

2. Assist with testing/reviewing results and evaluating mental status according to age and developmental capacity. This is to assess the degree of impairment. The prevalence of mild cognitive impairment increases with age, with a prevalence of 10% in those aged 70 to 79 years and 25% in those aged 80 to 89 years. Clients with mild cognitive impairment may often present with vague and subjective symptoms of declining cognitive performance, which may be difficult to distinguish from the typical performance decline in healthy older adults.

3. Interview significant others (SOs) or caregivers to determine the client’s usual thinking ability, changes in behavior, length of time the problem has existed, and other pertinent information. This is to provide a baseline for comparison. The Alzheimer’s Association released guidelines, including an algorithm, to help clinicians in the primary care setting detect cognitive impairment and determine whether referral or further testing is required, and this includes the use of structured cognitive assessment tools for clients and their significant others or informants.

4. Perform periodic neurological/behavioral assessments, as indicated, and compare with baseline. Early recognition of changes promotes proactive modifications to the plan of care. Few clients have undergone baseline testing before the onset of impairment, therefore the healthcare professional will have to determine whether a particular score represents a significant change from the client’s presumed baseline. Such determinations are not exact, and serial testing eventually will be needed to establish whether the client’s cognitive function is improving, staying stable, or progressing to full-blown clinical dementia .

5. Assess the severity of the level of impairment. Cognitive impairment can be mild, severe, or anything in between. With mild impairment, there are changes in cognitive functions, but the client can still do their everyday activities. Severe levels of impairment, such as dementia, can lead to a point where the client is incapable of living independently because of the inability to plan and carry out regular tasks and apply judgment.

6. Utilize screening tools for the client’s cognitive abilities. There are various screening tools used by clients, families, and healthcare providers to assess the client’s cognitive abilities. Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Dementia Severity Rating Scale (DSRS), AD-8, and General Practitioner Assessment of Cognition (GPCOG) can be used to gather information from caretaker/ family members . The Mini-Mental State Examination (MMSE) is used for the evaluation of clients with Alzheimer disease because of its main focus on testing memory.

1. Identify factors present [acute/chronic brain syndrome (recent stroke , Alzheimer’s disease ), brain injury or increased intracranial pressure, anoxic event, acute infections, malnutrition, sleep or sensory deprivation, chronic mental illness ( schizophrenia )]. Identifying the factors present is important to know the causative/contributing factors. Mood disorders, medical illnesses, and medications may affect cognition in such a way that a client will meet the criteria for mild cognitive impairment. Nonamnestic forms of MCI may be caused by cerebrovascular disease, Lewy body dementia, Parkinson disease, frontotemporal dementias, atypical Alzheimer disease, or no specific underlying pathology.

2. Determine alcohol/other drug use. Drugs can have direct effects on the brain, or have side effects, dose-related effects, and/or cumulative effects that alter thought patterns and sensory perception. Cognitive alterations and deficits that are observed in substance use disorders contribute directly and indirectly to the overall tremendous public health burden that these disorders place on society. The typical cognitive domains contributing to this understanding of addiction are attention, response inhibition, decision-making , and working memory (Ramey & Regier, 2018).

3. Assess dietary intake/ nutritional status . This helps in identifying contributing factors. A high salt diet has been independently linked to an increased risk of cerebrovascular disease and dementia. Therefore, dietary salt, although not currently identified as one of the risk factors targeted for the prevention of dementia, may also contribute to cognitive impairment (Ramey & Regier, 2018). 

4. Review laboratory values for abnormalities such as metabolic alkalosis, hypokalemia , anemia , elevated ammonia levels, and signs of infection . Monitoring laboratory values aids in identifying contributing factors. However, no specific laboratory studies are indicated for cognitive impairment. Most practitioners perform at least a basic workup to rule out treatable conditions that may cause dementia, such as thyroid disease and cobalamin deficiency.

5. Assess for signs of a depressive disorder. Depressive disorders are prevalent in older adults, who frequently exhibit vague somatic symptoms and anxiety and report an inability to concentrate and poor memory. Depression may certainly be accompanied by cognitive dysfunction that abates with successful treatment of the depression.

Research in other populations with chronic conditions suggests that disease management, especially the performance of self-management behaviors like healthy diets and exercise, may be influenced by the way that an individual views the nature and cause of a disease or its symptoms. Healthcare professionals agree that, even as disease-modifying pharmacological treatments become available, lifestyle modifications will be required to stabilize or reverse the course of cognitive impairment (Kim et al., 2022).

1. Assist with treatment for underlying problems, such as anorexia , brain injury/increased intracranial pressure, sleep disorders, and biochemical imbalances. Cognition/thinking often improves with treatment/correction of medical/psychiatric problems. Correcting (to the extent possible) any sensory and motor manifestations compounding the cognitive symptoms is important for minimizing their impact on cognitive impairment.

2. Reorient to time/place/person, as needed. The inability to maintain orientation is a sign of deterioration. Accordingly, a multi-component family reorientation strategy has recently been proposed to achieve better outcomes. Family reorientation messages refer to the use of family members’ voices in orienting clients to reality, providing a familiar, reassuring comfort , and assisting in counteracting inattention , and disorganized thinking in addition to memory and perceptual disturbances (Elcokany & Ahmed, 2019).

3. Have the client write their name periodically; keep this record for comparison and report differences. These are important measures to prevent further deterioration and maximize the level of function. The act of rewriting one’s name engages cognitive functions such as memory, fine motor skills, and concentration. Regular cognitive stimulation can help slow down the progression of cognitive decline and improve overall brain function.

4. Present reality concisely and briefly and do not challenge illogical thinking. Avoid vague or evasive remarks. Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions. Validation therapy is a technique used for older adults who are confused. The focus is on the emotional aspect of the communication. It does not reinforce incorrect perceptions but focuses on validating the client’s feelings (Ernstmeyer & Christman, 2021).

5. Be consistent in setting expectations, enforcing rules, and so forth. Clear, consistent limits provide a secure structure for the client. Predictability is often reassuring for clients with cognitive impairment, as it reduces confusion and anxiety, contributing to a sense of stability. Clear boundaries can prevent confusion and frustration that might lead to agitation or challenging behavior.

6. Reduce provocative stimuli, negative criticism, arguments, and confrontations. This is to avoid triggering fight/flight responses. Negative stimuli or criticism can trigger agitation and challenging behaviors in clients with cognitive impairment. This can include verbal outbursts, physical aggression, or withdrawal . By minimizing provocative stimuli, these reactions can be prevented, creating a calmer and safer environment.

7. Do not flood the client with data regarding his or her past life. Individuals who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. Memories, especially if they involve significant life events or traumatic experiences, can evoke strong emotions. To cope with the flood of information, some clients may withdraw from social interactions, preferring to isolate themselves to avoid emotional turmoil.

8. Identify specific conflicts that remain unresolved, and assist the client in identifying possible solutions. Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary. Conflict can cause stress and anxiety. By resolving conflicts, clients experience emotional relief and a sense of calm, contributing to their overall emotional well-being. Additionally, engaging in conflict resolution exercises the brain’s problem-solving abilities.

9. Recognize and support the client’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated). Recognizing the client’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem . This is especially crucial for clients with cognitive impairments who may face challenges in completing tasks. Recognition of their accomplishments helps them feel valued and competent. Positive feedback also triggers the release of neurotransmitters like dopamine , which can improve the client’s mood and emotional state.

10. Teach the client to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail. Thought-stopping involves using the command “stop!” or loud noise (such as hand clapping) to interrupt unwanted thoughts. This noise or command distracts the individual from the undesirable thinking that often precedes undesirable emotions or behaviors. However, research has found that if the thought is stopped without replacing it with a more positive one, negative thoughts tend to increase. Thought-m is more about noticing these thoughts and then gently redirecting the mind to a more helpful, positive one (Fritscher, 2022).

11. Encourage the client to engage in regular physical activity and exercise. Physical activity and exercise are beneficial for brain health, according to a growing body of evidence. In a prospective study, it was suggested that engaging in moderate exercise of any frequency in midlife or late life was associated with reduced odds of having cognitive impairment. According to one study, aerobic exercise was associated with a slight improvement in cognition.

12. Assist in identifying ongoing treatment needs/rehabilitation programs for the individual. This measure is essential to maintain gains and continue progress if able. Social isolation can be minimized through referral to senior community centers or a day treatment program. Cognitive retraining and rehabilitative strategies offer considerable promise in cognitive impairment and are being explored.

13. Identify problems related to aging that are remediable and assist the client in seeking proper assistance/access to resources. These encourage problem-solving to improve conditions rather than accept the status quo. Many experts suggest that mentally challenging activities, such as crossword puzzles and brain teasers, may be helpful for clients. Such exercises should be kept to a level of difficulty that is reasonable for the client. 

14. Assist the client and SO in developing a plan of care when problems are progressive/long-term. Advanced planning addressing home care, transportation, assistance with care activities, support and respite for caregivers, enhance management of patients in a home setting. Several studies have focused on the importance of including caregivers in interventions, especially those caring for clients with dementia, and since having a cognitive impairment often affects the entire family, it is important to include relatives in the process of interventions (Stigen et al., 2021).

15. Encourage smoking cessation. It was found that young cigarette smokers experienced significant impairment in cognitive function compared to nonsmokers. Cigarette smoking affects cognitive abilities and can trigger demonstrable abnormalities in brain neurocognition (Riaz et al., 2021).

16. Refer to community resources (e.g., daycare programs, support groups, drug/alcohol rehabilitation, and mental health treatment programs). These measures are necessary to promote wellness. Cognitive impairment, such as Alzheimer disease and dementia, can create havoc not only in the client but also in the family, friends, and the community. Therefore, management encompasses the role of the healthcare providers, clients, family and friends, and also policymakers. Healthcare policymakers must explore policy changes and initiatives that will increase support, expand, research, and ultimately improve the quality of life for people with cognitive impairment and their families (Dhakal & Bobrin, 2023).

17. Perform sensory stimulation as recommended. Sensory stimulation is considered one of the therapeutic tools used to prevent cognitive impairments. Its main goal is to provide a similar environment that is close to the real world which cognitively stimulates critically ill clients in a safe and controlled manner. Using auditory stimulation as a non-pharmacological intervention can avoid sensory deprivation that could slow down the client’s recovery. A family member’s voice can grasp the client’s attention without much effort.

18. Refer the client for occupational therapy as appropriate. Occupational therapy can help facilitate the client’s cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Research showed that ten sessions of occupational therapy improved the daily functioning of clients with dementia and diminished the burden of care on their primary caregivers.

Environmental barriers in the home environment can compromise the performance of everyday occupations and modifying the environment is a common compensatory intervention to enhance independent living.

1. Provide safety measures (e.g., side rails , padding, as necessary; close supervision, seizure precautions), as indicated. It is always necessary to consider the safety of the client. The physical home environment is altered based on the needs of the client who lives and performs occupations in the home with an aim to enable occupational performance. However, the occupational therapist also needs to be aware of how many environmental modifications can be done before the environment becomes unfamiliar to the client.

2. Schedule structured activities and rest periods. This provides stimulation while reducing fatigue . Activities that challenge the brain, such as puzzles or memory games, can help maintain cognitive abilities and slow down the progression of cognitive impairment. Some individuals may become overstimulated, therefore, proper rest can provide a break to prevent sensory overload and promote a sense of calm.

3. Maintain a pleasant and quiet environment and approach clients in a slow and calm manner. A client may respond with anxious or aggressive behaviors if startled or overstimulated. A calm and positive environment fosters a sense of security. Clients with cognitive impairment may already feel disoriented or confused; creating a pleasant environment can help establish a stable and secure atmosphere.

4. Refrain from forcing activities and communications. Clients may feel threatened and may withdraw or rebel. Feeling overwhelmed or distressed can lead to agitation or even aggressive behavior. The client might express their frustration physically or verbally, especially if they are unable to communicate their feelings effectively.

5. Encourage the use of assistive devices as recommended. The use of assistive devices is also a means to increase occupational performance. This is described as the ‘traditional way’ of working in community service when providing occupational therapy.

6. Consider the use of assistive technology. Innovative Assistive Technology (IAT) is an important tool for maintaining independence and quality of life for community-living older adults with cognitive impairment. IAT includes sensor-based surveillance and monitoring systems, mobile technology such as wearable fall detectors, and activity bracelets as well as tablets with health information or alarm functions (Thordardottir et al., 2019).

Communication has been defined as a context-dependent construct, which is closely related to well-being and distinct from functional linguistic skills of an individual. The verbal content strongly declines in the course of dementia, whereas non-verbal relationship channels can be preserved for a longer time (Schnabel et al., 2019).

1. Use validated instruments to assess the client’s communication needs. The CODEM instrument, an observational tool to assess Communication Behavior in Dementia, considers both the verbal content and the non-verbal relationship aspect inherent in communication behavior. CODEM allows communication resources and deficits of acutely ill older clients to be detected at different stages of the communication process. This may enable the healthcare team to accommodate their communication behavior in a specific manner leading to more efficient and enriching social interactions.

2. Use touch cautiously, notably if thoughts reveal ideas of persecution. Clients who are suspicious may perceive touch as threatening and may respond with aggression. When appropriate, touch provides comfort for clients. It provides sensory stimulation to avoid sensory deprivation and demonstrates caring and warmth. It is important to assess the client’s reaction to touch before implementing therapeutic gentle touch.

3. Use the techniques of consensual validation and seeking clarification when communication reflects an alteration in thinking. (Examples: “Could you clarify what you mean?” or “I’m not quite following, could you please explain?”) These techniques reveal to the client how others are perceiving him or her, while the responsibility for not understanding is accepted by the nurse. Consensual validation acknowledges the client’s feelings and experiences, validating their emotions. Seeking clarification ensures that both the caregiver and the client have a clear understanding of the communication.

4. Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups. A distrustful client can best deal with one person initially. The gradual introduction of others when the client can tolerate is less threatening. Ideally, the activities should be interactive rather than passive, and they should be administered in a fashion that does not cause excessive frustration. If the activity is not enjoyable or stimulating for the client, it is unlikely to offer much cognitive benefit.

5. Encourage the client to verbalize true feelings. Avoid becoming defensive when angry feelings are directed at him or her. Verbalization of feelings in a non-threatening environment may help the client come to terms with long-unresolved issues. Establishing a therapeutic relationship based on trust by sitting at the level of the client and engaging in eye contact shows an attitude of caring and compassion while maintaining the dignity of the client.

6. Encourage the client to participate in resocialization activities/groups when available. This is to maximize the level of function. A study showed certain activities lower the risk of mild cognitive impairment in cognitively normal clients older than 70 years. These included playing games, reading magazines, being engaged in crafts, computer use, and social activities. Among these, being social and using computers were shown to reduce the risk of MCI the most in clients.

7. Recommend the use of information and communication technologies. According to a study regarding the use of ICTs in the daily life of clients with cognitive impairment, popular devices included telephones or mobile and smartphones, smart TVs, and tablets, as well as desktops and laptops. Clients perceive ICTs as useful because these could improve feelings of belongingness, support interaction with loved ones, and allow the client to be engaged in hobbies, passions, or daily activities. Clients can stay connected to children, siblings, and others with whom they have a close relationship, even without interactive conversation (Blok et al., 2020).

Cognitive decline is particularly feared among people because of the possibility of losing self-sufficiency and the need to depend on others. Therefore, people should be made aware that cognitive impairment can be largely prevented with a long life proper nutrition, and a healthy lifestyle.

1. Provide a nutritionally well-balanced diet, incorporating the client’s preferences as much as possible. Encourage the client to eat. Provide a pleasant environment and allow sufficient time to eat. These enhance intake and general well-being. A study found that the risk of developing MCI is lower in clients who consume a Mediterranean diet, which is high in vegetables and unsaturated fats.

2. Encourage the intake of dietary supplements as prescribed. A randomized study involving older adults diagnosed with cognitive impairment determined that dietary supplementation with an oily emulsion of DHA-phospholipids containing melatonin and tryptophan yielded significant improvements in several measures of cognitive function as compared with supplementation with the placebo.

3. Provide foods rich in folate, vitamin E, and fatty acids. Folate has been studied as a solitary intervention; cognitive improvement in general intelligence, attention span, and visuospatial metrics within six months has been reported in mild cognitive impairment. Two other large studies examined the effect of vitamin E on the progression rate of Alzheimer disease and showed slower functional decline with a focus on the ADL. Omega-3 fatty acids are credited with anti-inflammatory and neuroprotective properties that can cause slower cognitive decline, less agitation, and lower depression scores (Vlachos & Scarmeas, 2019).

4. Recommend the use of olive oil and natural flavorings such as garlic and curcumin. Olive oil is a staple of the Mediterranean diet and is a natural product rich in oleic acid. It has been associated with beneficial effects on human health which is attributable to its composition that gives its antioxidant and anti-inflammatory properties. Garlic also exhibits antioxidant properties that may have protective actions against neurotoxic effects (Dominguez et al., 2021).

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Resources to further your research about cognitive impairments:

• Blok, M., van Ingen, E., de Boer, A. H., & Slootman, M. (2020, March). The use of information and communication technologies by older people with cognitive impairments: from barriers to benefits. 104 .
• Butler, R., & Katona, C. (Eds.). (2019). Seminars in Old Age Psychiatry . Cambridge University Press.
• Dhakal, A., & Bobrin, B. D. (2023, February 14). Cognitive Deficits – StatPearls . NCBI.
• Dominguez, L. J., Veronese, N., Vernuccio, L., Catanese, G., Inzerillo, F., Salemi, G., & Barbagallo, M. (2021). Nutrition, Physical Activity, and Other Lifestyle Factors in the Prevention of Cognitive Decline and Dementia . Nutrients , 13 (11).
• Elcokany, N. M., & Ahmed, F. R. (2019). Effect of family reorientation messages on delirium prevention among critically ill patients . Journal of Nursing Education and Practice , 9 (10).
• Fritscher, L. (2022, April 19). 3 Thought Stopping Techniques . Verywell Mind.
• Kim, H., Sereika, S. M., Albert, S. M., Bender, C. M., & Lingler, J. H. (2022). Do Perceptions of Cognitive Changes Matter in Self-Management Behaviors Among Persons With Mild Cognitive Impairment? The Gerontologist , 62 (4).
• Mehta, S., & Chawla, J. (2019, April 22). Mild Cognitive Impairment: Practice Essentials, Overview, Pathophysiology . Medscape Reference.
• Ramey, T., & Regier, P. S. (2018, December). Cognitive impairment in substance use disorders . CNS Spectrums .
• Riaz, T., Murtaza, G., Arif, A., Mahmood, S., Sultana, R., Al-Hussain, F., & Bashir, S. (2021, June 2). Nicotine smoking is associated with impaired cognitive performance in Pakistani young people . NCBI.
• Santisteban, M. M., & Iadecola, C. (2018). Hypertension, dietary salt and cognitive impairment . Journal of Cerebral Flow & Metabolism , 38 (12).
• Schnabel, E.-L., Wahl, H.-W., Penger, S., & Haberstroh, J. (2019). Communication behavior of cognitively impaired older inpatients. Zeitschrift fur Ferontologie und Geriatrie , 52 (4).
• Stigen, L., Bjørk, E., & Lund, A. (2021). Occupational Therapy Interventions for Persons with Cognitive Impairments Living in the Community . Occupational Therapy in Health Care .
• Thordardottir, B., Fänge, A. M., Lethin, C., Gatta, D. R., & Chiatti, C. (2019, March). Acceptance and Use of Innovative Assistive Technologies among People with Cognitive Impairment and Their Caregivers: A Systematic Review . Assistive Technology Innovations in Neurological Conditions , 2019 .
• Vlachos, G. S., & Scarmeas, N. (2019). Dietary interventions in mild cognitive impairment and dementia . Dialogues in Clinical Neuroscience , 21 (1).

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How Anxiety Influences Our Judgment

Anxiety hinders one’s ability to view a situation objectively and rationally..

Posted April 18, 2020 | Reviewed by Abigail Fagan

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Anxiety influences our perceptions, beliefs, reasoning, and ultimately our choices. The experience of anxiety hinders one’s ability to view the situation objectively and rationally.

In some situations, these tendencies may cascade into undesirable outcomes. Furthermore, the repeated practice of worry becomes habitual such that the individual automatically engages in these mental processes. Becoming aware of our thought processes is an important step in overcoming negative biases.

1. The power of emotion . At the basic level, individual decisions are best understood as the interactions between the deliberative system (logical brain) and the emotional system. Cognitive evaluations of risk are sensitive to probabilities and outcomes. In contrast, emotional reactions are sensitive to the vividness of visual imagery and immediacy factors. As a result of these differences, people often experience an inconsistency between the emotional reaction to, and logical evaluations, of a threat. It is easier for emotional information to overwhelm our conscious thought.

2. The “what-if disease. ” Worry is a common characteristic of persistent anxiety. Worry is a form of problem-solving, presumably helping a person plan and prepare for future (potentially) negative events.

However, excessive worrying can take the form of “what if” something terrible happens. And by doing so, the individual sees the worst-case scenario. The worries often focus on issues such as health and illness. Worries can be triggered automatically by several cues, such as listening to news stories. Therefore, catching our distorted thinking is an important strategy for reducing anxiety.

3. The psychological need for control. Uncertainty is the breeding ground of anxiety. People with anxiety have trouble tolerating uncertainty or threats. So they are motivated to reduce uncertainty and eliminate the discomfort. They tend to resort to “ magical thinking ” that they have control over the world, such as runs on toilet paper and paper towels during the current pandemic.

4. Playing it safe. Avoidance is a well-known form of coping with anxiety, such as playing it safe, procrastination , and distraction. Escape and avoidance are the most common unhelpful coping strategies associated with persistent anxiety. Ironically, safety-seeking behavior and avoidance may contribute to the persistence of anxiety.

5. Coping strategies . Anxiety is thought to encourage unhealthy lifestyle behaviors, such as substance abuse and eating disorders. For example, alcohol consumption and binge eating are often seen to cope with anxiety, sadness, and boredom . Indeed, anxiety disorders and impulse control frequently precede drug abuse and represent a specific risk factor for addiction (the need for self- medication ). The escalation of addiction, in turn, worsens anxiety and impulse control disorders .

6. Self-confidence . When we feel anxious, we tend to see ourselves as weak and unable to cope. The greater one’s doubts concerning one’s level of competence, the more one will worry about adverse outcomes taking place.

However, when a confident attitude is adopted, the individual focuses on the positives in a situation, and may even assume a greater sense of personal control. So when someone is anxious about becoming infected with the dreaded virus, it’s best to emphasize their ability to handle the problem rather than reassure them their fear won’t true. Making a specific coping plan so that you are fully prepared to help yourself will calm—rather than accelerate—anxiety.

Shahram Heshmat, Ph.D., is an associate professor emeritus of health economics of addiction at the University of Illinois at Springfield.

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How Poor Judgment Can Be a Sign of Early Dementia

Poor judgment is one of the hallmarks of Alzheimer’s disease . In fact, while a typical symptom of early stages of Alzheimer’s is short-term memory loss , poor judgment can sometimes precede memory loss.

Poor judgment refers to the inability to make appropriate decisions. If your relative has Alzheimer's or another type of dementia, they might be unable to evaluate the different factors that should be considered when making a decision. Looking ahead to the possible outcome of behavior or choice may also be a challenge, as is considering abstract ideas vs. concrete ideas.

Poor judgment in Alzheimer's is not just one questionable decision, but rather a pattern of clearly inappropriate decisions or actions. Here are a few examples of poor judgment in Alzheimer’s disease and other kinds of dementia.

Safety/Danger Recognition

Your loved one recently fell and broke their hip . They had surgery and fortunately came through that well. However, they are not able to accurately assess their safety limits. At times, they clearly seem to have forgotten the restrictions regarding weight bearing. However, even when reminded, they still express an uncharacteristic desire to disregard this important medical advice. They may keep trying to get up and walk. Even the fact that it hurts doesn’t stop them from trying to get up out of the chair.

Another scenario that demonstrates an inability to recognize danger is one in which your loved one wanders away from the house and tries to walk across a very busy street during rush hour. They are not able to assess the traffic to determine that it's too busy to cross the street at this time.

Even though you’ve told your father he can’t give away money anymore, he continues to fall for get-rich-quick scams and phony prize offers. You’ve tried explaining that he needs his money to pay for the groceries and the home health aide who comes to help him shower. You've even put a note in his checkbook reminding him of this. Regardless, he continues to write checks and give away money that he needs, or even money that he doesn't have.

Social Interaction

Perhaps your husband has always been an outgoing, friendly man. Now, however, he doesn't seem to know when to stop.   Yesterday, you took him out to lunch and he was so flirty with the waitress that everyone was uncomfortable. The waitress ended up trading tables with another server because she wasn't sure how to react to him.

Personal Grooming and Hygiene

Your sister, who was diagnosed with Alzheimer's a year ago, doesn't spend any time on her appearance anymore. She always had her hair nicely styled, and now she rarely seems to wash or comb it. When you remind her that it's a special occasion, it doesn't seem to make a difference. You also notice that she could benefit from a bath or shower more frequently.

Even if it’s the middle of a cold, snowy winter day, your wife with Alzheimer’s might try to go outside dressed in shorts and a t-shirt. When you suggest a change of clothes, she appears irritated and continues to try to wander out the door.  

This is an area that can be difficult to address. However, if you’re uncomfortable riding with your loved one as he drives, that’s a pretty clear sign that he shouldn’t be driving anymore. Perhaps he can’t judge the distance from his car to the next one anymore, or he’s not able to discern how fast he should be driving on the expressway.

Driving requires the use of multiple aspects of our brains, and as the symptoms of Alzheimer's progress, these abilities continue to decrease. (If driving is questionable for your loved one, you can request a driving evaluation specialist to assess his safety and ability.)

A Word From ​Verywell

While it can be worrisome and even frustrating to see these signs of poor judgment in your loved one, it may be helpful as you cope to consider that there may be a reason for these behaviors that are beyond their control. An evaluation by a physician can help rule out reversible causes of memory loss , and treatment can begin if it appears that dementia is the cause of these judgment problems.

Capucho PHFV, Brucki SMD. Judgment in mild cognitive impairment and Alzheimer's disease . Dement Neuropsychol . 2011;5(4):297-302. doi:10.1590/S1980-57642011DN05040007

Alzheimer's Association. Home safety .

National Institute on Aging. Managing money problems in Alzheimer's disease .

Daily Caring. 9 Ways to handle Alzheimer's and sexually inappropriate behavior .

National Institute on Aging. Bathing, dressing, and grooming: Alzheimer's caregiving tips .

National Institute on Aging. Driving safety and Alzheimer's disease .

By Esther Heerema, MSW Esther Heerema, MSW, shares practical tips gained from working with hundreds of people whose lives are touched by Alzheimer's disease and other kinds of dementia.

Toward an Understanding of Decision Making in Severe Mental Illness

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How Lack of Sleep Impacts Cognitive Performance and Focus

Staff Writer

Eric Suni has over a decade of experience as a science writer and was previously an information specialist for the National Cancer Institute.

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Dr. Nilong Vyas

Pediatrician

Dr. Vyas is a pediatrician and founder of Sleepless in NOLA. She specializes in helping parents establish healthy sleep habits for children.

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Table of Contents

How Poor Sleep Affects the Brain

How does poor sleep affect creativity and other cognitive processes, are the cognitive impacts of poor sleep the same for everyone, can sleep disorders affect cognition, does too much sleep affect cognition, will improving sleep quality benefit cognition.

Getting enough hours of high-quality sleep fosters attention and concentration, which are prerequisites for most learning. Sleep also supports numerous other aspects of cognition, including memory, problem-solving, creativity, emotional processing, and judgment. Levels of brain activity fluctuate during each stage of sleep — including both rapid eye movement (REM) and non-REM (NREM) sleep — and evidence increasingly suggests that sleep enhances most types of cognitive function.

For people with sleep deprivation, insomnia, sleep apnea, or other conditions that prevent them from getting adequate rest, short-term daytime cognitive impairment is common. Improving sleep quality can boost cognitive performance, promote sharper thinking, and may reduce the likelihood of age-related cognitive decline.

During a typical night of sleep, an individual cycles through the three stages of NREM sleep, followed by a period of REM sleep every 90 to 120 minutes, several times per night. Both the brain and body experience distinct changes during these cycles that correspond to individual stages of sleep . During each part of this process, different chemicals in the brain become activated or deactivated to coordinate rest and recovery.

Poor sleep can take many forms, including short sleep duration or fragmented sleep. Without adequate sleep, the brain struggles to function properly. Because they do not have time to recuperate, neurons in the brain become overworked and less capable of optimal performance in various types of thinking.

The short-term detriments of poor sleep on the brain and cognition can be the result of pulling an occasional all-nighter, while those with chronic sleep problems may see a continuous negative effect on day-to-day tasks. Over the long-term, poor sleep may put someone at a higher risk of cognitive decline and dementia.

What Are the Short-Term Cognitive Impacts of Poor Sleep?

Poor sleep can harm intellectual performance, academic achievement, creative pursuits, and productivity at work. The cognitive impacts of poor sleep can also create safety risks, including drowsy driving . Motor skills, keeping rhythm, and even some types of speech can decline without proper sleep. The potential short-term impacts of poor sleep are wide-ranging:

• Excessive Sleepiness: Drowsiness and fatigue are common daytime effects of a night of poor sleep. In response to excessive fatigue, a person may inadvertently nod off for a few seconds, which is known as a microsleep .
• Poor Attention Span: Poor sleep reduces a person’s attention, as well as their learning and processing. A lack of sleep has also been found to induce effects that are similar to being drunk Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source , which slows down thinking and reaction time . Poor sleep also diminishes placekeeping Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source , which includes the ability to carry out instructions.
• Reduced Adaptability: Some studies have found lack of sleep to hinder cognitive flexibility, reducing the ability to adapt and thrive in uncertain or changing circumstances. A major reason this occurs is rigid thinking and “feedback blunting” Trusted Source Oxford Academic Journals (OUP) OUP publishes the highest quality journals and delivers this research to the widest possible audience. View Source , in which the capacity to learn and improve on-the-fly is diminished.
• Reduced Emotional Capacity: Poor sleep can also alter how emotional information is understood Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source . When learning something new, analyzing a problem, or making a decision, recognizing the emotional context is often important. However, insufficient sleep impedes the ability to properly process the emotional component of information.
• Impaired Judgment: In some cases, this dysregulated emotional response impairs judgment. People who do not get sufficient sleep are more likely to make risky choices Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source and may focus on a potential reward rather than downsides. It can be difficult to learn from these mistakes, since the normal method of processing and consolidating emotional memory is compromised due to lack of sleep.

What Are the Long-Term Cognitive Impacts of Poor Sleep?

Insufficient sleep and sleep fragmentation are frequently associated with cognitive decline and dementia. Furthermore, in people already diagnosed with dementia, poor sleep has been linked to a worse disease prognosis. Some cognitive effects of poor sleep can be felt immediately, but mounting evidence shows that sleep influences your long-term risk of cognition issues:

• Impaired Memory: Both NREM and REM sleep appear to be important for broader memory consolidation Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source , which helps reinforce information in the brain so that it can be recalled when needed. NREM sleep has been linked with declarative memory, which includes things like basic facts or statistics, and REM sleep is believed to boost procedural memory such as remembering a sequence of steps. Poor sleep impairs memory consolidation by disrupting the normal process that draws on both NREM and REM sleep for building and retaining memories. Studies have even found that people who are sleep deprived are at risk of forming false memories Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source .
• Alzheimer’s Disease: Research shows that sleep helps the brain conduct important housekeeping, such as clearing out potentially dangerous beta amyloid proteins. In Alzheimer’s disease, beta amyloid forms in clusters, called plaques, that worsen cognitive function. Studies have found that even one night of sleep deprivation can increase the amount of beta amyloid in the brain Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source . One analysis found a considerably higher risk of Alzheimer’s disease Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source in people with sleep problems, estimating as many as 15% of cases of Alzheimer’s disease were attributable to poor sleep.

Creativity is another aspect of cognition that is hindered by sleeping problems. Connecting loosely associated ideas is a hallmark of creativity, and this ability is strengthened by good sleep. NREM sleep provides an opportunity for information to be restructured and reorganized Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source in the brain, while new ideas and links between thoughts often emerge during REM sleep. These processes enable insight, a core element of innovation and creative problem-solving.

Limited or restless sleep can also indirectly affect cognition. For example, migraine sufferers are more likely to have morning headache attacks Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source when they do not get enough sleep, and lack of sleep can increase the risk of infections Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source like the common cold. Sleep deprivation may worsen symptoms of mental health conditions like anxiety and depression. These and numerous other physical and mental health issues are shaped by sleep quality, and may affect a person’s attention and concentration.

Not everyone is affected by poor sleep in the same way. Studies have found that some individuals may be more susceptible to cognitive impairment from sleep deprivation, and this may be influenced by genetics.

Research has discovered that adults are better at overcoming the effects of sleep deprivation than younger people. Teens are considered to be at a heightened risk for detrimental effects of poor sleep on thinking, decision-making, and academic performance because of the ongoing brain development that occurs during teen years .

Some studies have also found that women are more adept at coping with the effects of sleep deprivation than men, although it is not yet clear if this is related to biological factors, social and cultural influences, or a combination of both.

Sleep disorders, like insomnia, frequently involve insufficient or fragmented sleep, so it comes as little surprise that they can be linked to cognitive impairment.

Obstructive sleep apnea (OSA) is among the most common sleep disorders. It occurs when the airway gets blocked, which then leads to lapses in breathing during sleep and reduced oxygen in the blood. OSA has been associated with daytime sleepiness as well as notable cognitive problems related to attention, thinking, memory, and communication. Studies have also found that people with sleep apnea have a higher risk of developing dementia .

Many studies examining the effects of sleep on thinking have found that an excess of sleep can also be problematic for brain health. In many cases, research has discovered that both too little and too much sleep Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source are associated with cognitive decline.

The explanation for this association remains unclear. It is not known if excess sleep is caused by a coexisting health condition that may also predispose someone to cognitive problems. Overall, these research findings are an important reminder to get the right amount of sleep each night.

For people with sleeping problems, improving sleep quality offers a practical way to enhance cognitive performance. Getting the recommended amount of uninterrupted sleep can help the brain recuperate and avoid many of the negative consequences of poor sleep on diverse aspects of thinking.

Researchers and public health experts increasingly view good sleep as a potential form of prevention against dementia and Alzheimer’s disease Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source . Although more studies are needed to conclusively determine sleep’s role in preventing cognitive decline, early research suggests that taking steps to improve sleep may reduce the longer-term likelihood of developing Alzheimer’s disease.

Tips To Improve Sleep and Cognitive Performance

Anyone who feels that they are experiencing cognitive impairment or excessive daytime sleepiness should first speak with their doctor. A physician can help identify or rule out any other conditions, including sleep disorders, that may be causing these symptoms. They can also discuss strategies to get better sleep.

Many approaches to improving sleep start with healthy sleep hygiene . By optimizing your bedroom environment and everyday habits and routines, you can eliminate many common barriers to sleep. Setting a regular bedtime and sleep schedule, avoiding alcohol and caffeine in the evening, and minimizing electronics in the bedroom are a few examples of sleep hygiene tips that can make it easier to rest well each night.

About Our Editorial Team

Eric Suni, Staff Writer

Medically Reviewed by

Dr. Nilong Vyas, Pediatrician MD

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Judgment in older adults: Development and psychometric evaluation of the Test of Practical Judgment (TOP-J)

1 Dartmouth Medical School, Lebanon, NH, USA

2 Brooklyn College/City University of New York, NY, USA

M.J. Borgos

A.j. saykin, h.a. wishart.

3 University of Washington School of Medicine, Seattle, WA, USA

K.E. Nutter-Upham

L.a. flashman.

This article reports on the development and validation of a novel, objective test of judgment for use with older adults. The Test of Practical Judgment (TOP-J) is an open-ended measure that evaluates judgment related to safety, medical, social/ethical, and financial issues. Psychometric features were examined in a sample of 134 euthymic individuals with mild Alzheimer’s disease (AD), amnestic mild cognitive impairment (MCI), or cognitive complaints but intact neuropsychological performance (CC), and demographically-matched healthy controls (HC). Measures of reliability were adequate to high, and TOP-J scores correlated with select measures of executive functioning, language, and memory. AD participants obtained impaired TOP-J scores relative to HCs, while MCI and CC participants showed an intermediate level of performance. Confirmatory factor analyses were consistent with a unidimensional structure. Results encourage further development of the TOP-J as an indicator of practical judgment skills in clinical and research settings. Longitudinal assessments are being performed to examine predictive validity of the TOP-J for cognitive progression in our clinical groups.

Judgment can be defined as the capacity to assess situations and draw sound conclusions after careful consideration of the relevant circumstances. From a neuropsychological perspective, judgment falls under the domain of executive functioning ( Woods, Patterson, & Whitehouse, 2000 ) and includes both a cognitive appraisal process (i.e., determining what to do in a situation) and the behavioral follow-through (i.e., engaging in the adaptive/safe behavior). Numerous processes are involved in the execution of good judgment including generating appropriate strategies to approach a problem, identifying suitable goals, shifting from one idea to another, evaluating the potential consequences of different courses of action, inhibiting inappropriate responses, initiating and carrying out purposeful behavior, and monitoring the progress and effectiveness of a chosen solution. In the absence of practiced routines for solving problems in unstructured situations, individuals with compromised executive functioning may exercise poor judgment for a variety or reasons. For example, they may make impulsive decisions based on inadequate exploration of pertinent issues, fixate on a single solution due to compromised mental flexibility, or fail to consider the long-term consequences of their solutions ( Channon, 2004 ; Thornton & Dumke, 2005 ; Woods et al., 2000 ).

In addition to executive functioning, judgment relies upon other cognitive processes including aspects of memory and language. For example, when making difficult decisions it is often useful to call to mind relevant past experiences and practical knowledge. Additionally, successful problem solving and good judgment rely upon the ability to comprehend complex aspects of verbal and non-verbal language and effectively communicate one’s decision to others involved ( Allaire & Marsiske, 1999 ; Marson & Harrell, 1999 ). Social and emotional skills also play a role in judgment, including perspective taking, empathizing, understanding the ramifications of a situation for others, appreciating the subtleties of the social context in which events are occurring, balancing competing social priorities and obligations, and responding appropriately to environmental or social feedback ( Blanchard-Fields, Stein, & Watson, 2004 ; Channon, 2004 ).

Loss of judgment ability is a common consequence and diagnostic feature of dementia, as executive cognitive functions that permit complex, goal-directed use of existing knowledge progressively fail ( Duke & Kaszniak, 2000 ; Karlawish, Casarett, James, Xie, & Kim, 2005 ; Knopman et al., 2001 ; LaFleche & Albert, 1995 ; Marson & Harrell, 1999 ). Neuropsychologists often assess judgment when conducting evaluations of older adults with suspected dementia ( Borgos, Rabin, Pixley, & Saykin, 2006b ), and this knowledge can inform decisions about diagnosis, functional and cognitive competence, and treatment ( Bertrand & Willis, 1999 ; Karlawish et al., 2005 ; Kim, Karlawish, & Caine, 2002 ; Willis et al., 1998 ). For example, dementia patients who are unaware of their judgment deficits may persist in behaviors that are no longer safe, such as using the stove, driving, or managing finances or prescription medications without assistance. Patients and their family members can be educated about the nature and consequences of impaired judgment skills and the relationship of observed symptoms to the disease process. With this information, caregivers may be better prepared to assume new responsibilities within the family system or provide the necessary structure and supervision to reduce the likelihood of dangerous incidents ( Duke & Kaszniak, 2000 ).

Despite the need for instruments to assess judgment abilities in the growing number of elders with cognitive decline, there appears to be a lack of clinically useful, ecologically relevant, and psychometrically sound tools for this purpose. A comprehensive search of the literature revealed only two standardized neuropsychological tests of judgment: (a) the Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Exam (NCSE JQ; Northern California Neurobehavioral Group, Inc., 1988 ) and (b) the Judgment/Daily Living subtest of the Neuropsychological Assessment Battery (NAB JDG; Stern & White, 2003 ). These instruments have several limitations, particularly when utilized with older adults. For example, Woods et al. (2000) evaluated the utility of the NCSE JQ and found significant content and statistical problems, including the insensitivity of this measure to impaired judgment in Alzheimer’s disease (AD) patients. Drane and Osato (1997) also found that scores on the NCSE JQ failed to discriminate dementia patients from healthy older adults. The 10-item NAB JDG ( Stern & White, 2003 ) appears to possess better psychometric properties (see Results section); however, the test items deal predominantly with basic safety and hygiene issues rather than everyday, high-level judgment dilemmas. Further, answers typically require a statement about why something is dangerous rather than how one would personally resolve a situation requiring real-world judgment or decision-making skills.

In a recent survey of neuropsychologists, approximately 90% of respondents indicated the need for additional/improved standardized tests of judgment ( Borgos et al., 2006b ). Survey results also indicated that the most commonly used tests to assess judgment were the Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, & Curtiss, 1993 ) and the Wechsler Adult Intelligence Scale–Third Edition (WAIS-III) Comprehension subtest ( Wechsler, 1997 ), which received mention by 37% and 31% of the 285 respondents, respectively. Cited less frequently were the NCSE JQ and NAB JDG, which received mention by 14% and 6% of survey respondents, respectively. While providing useful information about aspects of executive functioning, the WCST and WAIS-III Comprehension were not designed to assess judgment skills and may fail to capture cognitive processes and content areas associated specifically with judgment. WAIS-III Comprehension, for example, requires individuals to draw upon general knowledge about social rules and conventions and to abstract the meaning of proverbs rather than generate solutions to complex, real-world problems about medical or financial matters.

Cognitive constructs that overlap with judgment include everyday problem solving, everyday decision making, social problem solving, and practical intelligence ( Marsiske & Margrett, 2006 ; Thornton & Dumke, 2005 ; Willis, 1996 ), and objective measures of these constructs include the following: Predicaments Task ( Channon & Crawford, 1999 ), Reflective Judgment Dilemma s ( Kajanne, 2003 ), Practical Problems Test ( Denney & Pearce, 1989 ); Everyday Cognition Battery ( Allaire & Marsiske, 1999 ); Everyday Problems Test ( Willis & Marsiske, 1993 ), Everyday Problem Solving Inventory ( Cornelius & Caspi, 1987 ), Everyday Problems Test for Cognitively Challenged Elderly (EPCCE; Willis, 1993 ; Willis et al., 1998 ), and the Direct Assessment of Functional Status ( Lowenstein et al., 1989 ). Instruments also have been developed to assess competence to consent to medical treatment and/or research (see Fitten, Lusky, & Hamann, 1990 ; Grisso, Appelbaum, & Hill-Fotouhi, 1997 ; Marson, Hawkins, McInturff, & Harrell, 1997 ; Marson, Schmitt, Ingram, & Harrell, 1994 ; Vellinga, Smit, van Leeuwen, van Tilburg, & Jonker, 2004 ). Taken together, these measures provide useful information about factors contributing to successful and unsuccessful everyday problem solving and decision making about one’s medical care. These tests, however, were developed primarily for research purposes and are not routinely utilized by neuropsychologists. Many lack detailed information about their psychometric properties (including norms, cutoff scores, and measures of reliability and validity) and clinical utility when included as part of a clinical assessment battery. In addition, some instruments (e.g., EPCCE) were designed for elderly individuals known to have deficits in cognitive functioning and therefore might not be appropriate for use in preclinical stages of dementia.

We developed the Test of Practical Judgment (TOP-J) in response to the need for a brief, clinically relevant measure of everyday judgment in older adults. This paper describes the development and validation process of the TOP-J including item selection, scale development, and preliminary psychometric properties (i.e., reliability, validity, and dimensionality). Another goal was to investigate the TOP-J’s ability to detect differences in groups of older adults in various stages of cognitive decline. Participants included nondepressed older adults diagnosed with probable mild AD or amnestic mild cognitive impairment (MCI) and demographically matched healthy controls (HC). MCI is conceptualized as a transition state between normal cognitive aging and the earliest clinical features of dementia ( Petersen, 2004 ; Winblad et al., 2004 ). Though impaired executive functioning is a prominent feature of dementia, research has yet to determine at which point during the disease course judgment skills first become affected. We also included a fourth group of healthy, nondepressed older adults who present with significant cognitive complaints (CC) but who perform normally on neuropsychological testing. Recent research suggests that CCs show structural brain changes intermediate between those seen in MCI and those seen in healthy older adults without such complaints ( Saykin et al., 2006 ). Thus, inclusion of participants with MCI and CCs permitted preliminary investigation of the relative preservation or impairment of judgment ability in preclinical stages of neurodegenerative disease.

METHOD AND PROCEDURE

Participants.

The Dartmouth Memory and Aging Study is a longitudinal investigation of memory and other cognitive processes in older adults in the preclinical and early stages of dementia. Comprehensive assessment included neuropsychological evaluation, structural and functional neuroimaging, and genotyping. Participants were recruited from flyers, public lectures, newspaper advertisements, and referrals from medical center clinics. They provided written informed consent according to procedures approved by the institutional Committee for the Protection of Human Subjects. Comprehensive screening included a standardized phone interview and memory screen ( Rabin et al., 2004 ), in-person interview, and medical chart review. Participants were at least 60 years of age, right-handed, and fluent in English, and they had a minimum of 12 years of formal education. Each participant had a knowledgeable collateral informant (i.e., an individual who knew the participant well and could answer questions about his or her cognition and general health). Exclusion criteria included any significant or uncontrolled medical, psychiatric, or neurological condition (other than AD or MCI) that could affect brain structure or cognition, history of head trauma with loss of consciousness lasting more than five minutes, and current or past history of substance dependence.

Participants underwent detailed neuropsychological evaluation, including measures of memory, attention, executive function, language, spatial ability, general intellectual functioning, and psychomotor speed, as well as standard dementia screens and self- and informant-report measures. All tests were administered by postdoctoral fellows or highly trained technicians. Level of cognitive complaint was determined from responses on multiple self- and informant-report measures, and a Cognitive Complaint Index (CCI) was calculated as the percentage of all items endorsed by the participant and/or the informant ( Saykin et al., 2006 ). Appendix A provides a list of instruments administered during the assessment process. A Board-certified geropsychiatrist conducted a semi-structured interview to rule out depression or other psychiatric disorders. Blood samples were obtained to determine apolipoprotein E (apoE) genotype. Participants underwent structural brain magnetic resonance imaging scans (MRIs), which were reviewed by a Board-certified neuroradiologist to rule out incidental pathology.

A panel of neuropsychologists and a geropsychiatrist reviewed the evaluation results at a weekly consensus conference to determine group classification. ApoE status, functional neuroimaging findings, and TOP-J performance were not considered during the diagnostic process. Table 1 presents a summary of classification criteria. The AD group met criteria for a diagnosis of probable mild AD, as defined by the NINCDS-ADRDA 1 criteria ( McKhann et al., 1984 ). The MCI group met criteria developed by Petersen et al. (2001a , 2001b ) for amnestic MCI. Participants were classified as CC based on the following criteria: (a) significant memory complaints, (b) normal activities of daily living, (c) normal cognitive functioning, and (d) no dementia, depression, or other psychiatric disorder that would account for or contribute to the cognitive complaints. Participants were classified as HC if they showed: (a) no significant cognitive complaints, (b) normal activities of daily living, (c) normal cognitive functioning, and (d) no dementia, depression or other psychiatric disorder.

Criteria used to classify study participants

Note. HC: healthy control; CC: cognitive complaints; MCI: mild cognitive impairment; AD: Alzheimer’s disease.

Study participants were consecutively enrolled or longitudinally followed in the Dartmouth Memory and Aging Study and included 14 patients with probable mild AD, 34 patients with amnestic MCI, 35 older adults with significant cognitive complaints despite normal cognition (CC), and 39 demographically matched older adults with no cognitive complaints or deficits (HC). An additional 12 patients with probable AD were recruited from our clinical service to complete the TOP-J, NCSE JQ, and phone interview despite not being eligible or willing to participate in the full study. Reasons for their ineligibility included current use of psychoactive medications (e.g., antidepressant, cholinesterase inhibitor), unwillingness or inability to undergo MRI, or comorbid conditions such as cardiovascular disease. These individuals did not differ from the other AD patients with regard to TOP-J total score, t (24)=0.27, ns , age, t (24)=−0.99, ns , gender, χ 2 (1, n =26)=1.5, ns , or level of education, t (24)=−1.3, ns . We therefore combined all AD participants into a single group ( n =26) for subsequent analyses and discussion.

Select demographic and neuropsychological variables are presented in Table 2 . There were no significant group differences in gender, education, or apoE ε 4 allele status. AD participants were slightly older than members of the HC group. As expected, based on the study classification criteria, performance on the Dementia Rating Scale–2 ( Jurica, Leitten, & Mattis, 2001 ) and Mini-Mental State Examination ( Folstein, Folstein, & McHugh, 1975 ) was lower in MCI and AD than that in the other groups, though MCI participants scored above the respective cutoff scores for dementia. Similarly, MCI and AD participants showed significant deficits on tests of memory—for example, California Verbal Learning Test, Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 2000 ) and Wechsler Memory Scale, Third Edition (WMS-III; Psychological Corporation, 1997 )—relative to HCs and CCs. The Cognitive Complaint Index was elevated in the AD, MCI, and CC groups relative to HCs ( p < .001). Post hoc comparisons using Bonferroni correction indicated that the CC, MCI, and AD groups did not differ from each other, and participants from these groups endorsed more than three times as many complaints as the control group. Though no participant was clinically depressed or scored in the depressed range on the Geriatric Depression Scale (GDS), CC and AD participants tended to endorse several more items than did HCs (see Table 2 ). The sample was predominantly Caucasian, with one Asian and one Hispanic participant, consistent with the demographic composition of the surrounding region.

Descriptive information for participant groups

Note. Data are mean ( SD ) except where indicated. HC: healthy control; CC: cognitive complaints; MCI: mild cognitive impairment; AD: Alzheimer’s disease.

Development of measure

Our overall goal was to develop a clinically useful and psychometrically sound measure of judgment in older adults that would be easy to administer, score, and interpret. Item development commenced with a review of the psychological and neuropsychological literature related to the clinical assessment of judgment. We next reviewed research on problem solving, medical decision making, and related executive processes in older adults. Colleagues in neuropsychology were asked about their use of the term “practical judgment” and what domains this term might encompass. In addition, Dartmouth Memory and Aging Study participants and their informants occasionally mentioned experiencing difficulties with aspects of judgment, and these comments were compiled. This comprehensive data-gathering process yielded four content domains: (a) safety, (b) medical, (c) social/ethical, and (d) financial matters. Given the goal of developing a brief instrument, other potential categories identified in the literature (e.g., consumerism, home management, family conflict resolution) were not a primary focus.

After establishing the content domains, we created a group of scenarios thought to be ecologically representative of the kinds of judgment problems regularly faced by older adults. Several goals guided our item development process. Items should be straightforward and easily understood, yet complex enough to require active problem solving and consideration of options and potential consequences of various courses of action. To maximize face and content validity, most items were based on actual situations reported by older adults in our study. We anticipated that respondents would draw upon crystallized information and social/personal knowledge about the world when answering the questions posed to them. Therefore, we strove to create scenarios for which the generation of successful solutions would also require higher order executive cognitive abilities. A related goal was to develop items appropriate for both high- and low-functioning examinees to avoid ceiling and floor effects. We sought to minimize the amount of structure imposed on participants and therefore chose an open-ended response format in which participants would listen to brief scenarios and report aloud their proposed solutions. During administration, use of prompts to guide participants was minimized, though examiners were instructed to query ambiguous, incomplete, or multiple responses. In such cases, the examiner would say: “Tell me more about that” or “Explain what you mean.”

The authors reviewed the initial pool of 20 items and identified those that were redundant or potentially confusing; 17 items were retained. Preliminary scoring criteria were developed based on theoretical and practical considerations. Specific score values were assigned to each unique response and groups of responses with the same salient elements. Scores per response ranged from 0 to 2 (0=poor, 1= adequate, 2=good). To score items, the examiner matched the examinee’s response against sample responses listed with each item; though not an exhaustive list, sample responses encompassed a broad range of possible replies. Unusual responses were judged according to their degree of similarity with sample responses in terms of specific content or general meaning. Because we were trying to measure judgment rather than idea fluency, only one response per test item was scored. In cases where examinees spontaneously gave multiple responses to an item, and it was not clear which was the intended response, examiners were instructed to query (i.e., “You stated x, y, and z—which is your final response?”).

The initial test version was administered over the telephone to 45 participants. After these pilot data were collected, we re-evaluated all test items and scoring criteria. Two questions were dropped due to problems with aspects of their administration, scoring, or level of comprehension by participants. An additional 6 items were deleted based on preliminary factor analytic findings of low negative loadings on the unitary general TOP-J factor (see below). The final version contained 9 items, which were ordered randomly on the test protocol. Scoring criteria were revised based on actual participant responses and feedback from neuropsychology colleagues until we attained a final set that could be used reliably. Individual responses were now scored on a 4-point scale (0, 1, 2, or 3 points) to reflect a greater range and variety of possible responses, with a higher number indicating better judgment. Total score was derived by summing the 9 items (range 0–27). The content of the test items were as follows (items presented are numbered according to their placement on the 9-item TOP-J protocol. Appendix B provides two sample items, along with complete scoring criteria.

• Runs out of medication while vacationing.
• Caller asks for financial/personal information.
• While vacationing realizes stove possibly left on.
• Reads about important changes in social security benefits.
• Learns of cancer risk associated with a current medication.
• Starts having trouble with driving.
• Finds wallet with money.
• Finds small dog with a collar.
• Financial advisor suggests changing investment portfolio.

As noted above, we administered the initial TOP-J version to 45 randomly selected study participants. These protocols were later rescored when the new criteria were implemented. TOP-J scores from the initial 45 protocols did not differ from those from the remainder of the sample, t (132) = 0.20, ns. The final test version was then added to our assessment battery and administered to all new and returning participants. The number of participants who received the TOP-J according to their year in the study was variable due to attrition and ongoing changes in our recruitment strategies, but was equivalent across participant groups: Year 1, 41; Year 2, 28; Year 3, 26; Year 4, 19; Year 5, 6; Year 6, 2; χ 2 (15, n =122)=23.8, ns . Scoring of the first 65 protocols was accomplished by a single rater; these protocols were rescored by a second rater for interrater reliability analyses. A subsample of participants ( n =50) received a second TOP-J administration for the purpose of establishing test–retest reliability.

To help establish content validity, we measured consensus regarding the assignment of each item to its corresponding subdomain. The test protocol was distributed to a group of 16 neuropsychologists and neuropsychology trainees who were asked to indicate the judgment domain(s) best represented by each item. Because the domains were not independent or mutually exclusive, raters ranked each item’s primary and secondary membership (if more than one content domain applied). This process served to refine and determine the feasibility of item-scale membership. Table 3 shows that the independent, expert raters agreed strongly (90% or more) with the intended scale for seven of the nine TOP-J items. For the 2 items with 69% agreement, expert raters agreed with the intended scale for their second choice. In developing the TOP-J, the authors recognized that the content of 4 items fell into more than one category. Given the relatively small number of total items and the overlap of content domains for almost half the test items, the recommended practice is to sum all TOP-J items into a single overall score.

Expert ratings for TOP-J items

Note. Items presented above are numbered according to their placement on the 9-item TOP-J version.

Statistical analyses were performed using SPSS Version 12.0.1 for Windows (SPSS Inc., Chicago, IL), Mplus 3.11 ( Muthén and Muthén, 2004 ), and MedCalc ( http://www.medcalc.be/ ). All reported analyses are for the 9-item TOP-J version, except where otherwise noted.

Reliability

Internal consistency, or item homogeneity, was examined using an alpha coefficient ( Cronbach, 1951 ). With this method, scale consistency is determined by the interrelationships between items, accounting for the total number of items that the scale comprises. Simply put, alpha estimates the proportion of variance that is systematic or consistent in a set of test scores, and widely accepted cutoff scores in the social sciences range from approximately .60 to .80 ( Nunnally & Bernstein, 1994 ; Santos, 1999 ). The alpha coefficient for the 134 TOP-J protocols was .63 ( p < .001). One might expect a moderate alpha coefficient for a test such as the TOP-J, which is thought to involve several aspects of practical judgment skills through a set of items with diverse content. Additionally, .63 compares favorably with the overall average alpha of .45 reported for older adults on the NAB JDG ( White & Stern, 2003 ) and with alpha values of .04 and .46 reported for AD patients and healthy older adults, respectively, on the NCSE JQ ( Woods et al., 2000 ; see Table 4 ). In our sample, the alpha coefficient for the 115 NCSE JQ protocols was .07 ( p > .05). Finally, item-to-total correlations and interitem correlations were calculated to ensure adequate associations between individual items and TOP-J total score and to rule out redundancy in test items. The average correlation of each item with the TOP-J total score was .51 ( SD =.09), with no items correlating less than .36. The average interitem correlation was .17 ( SD =.09), and no items correlated higher than r > .36, suggesting that the items tap reasonably independent content.

Comparison of reliability estimates for judgment tests

Note. TOP-J=Test of Practical Judgment; NCSE JQ=Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Exam; NAB JDG=Judgment/Daily Living subtest of the Neu-ropsychological Assessment Battery. Reliability coefficients for the NAB JDG and NCSE JQ were taken from the secondary sources provided in the table. All reliability coefficients were based on samples of older adults with the exception of NAB JDG interrater reliability, which was based on a mixed sample of adults and older adults.

The first 65 protocols were scored by a single rater and then rescored by a second rater, both of whom were blind to participant group. Interrater reliability was assessed using the intraclass correlation coefficient ( Shrout & Fleiss, 1979 ). As shown in Table 4 , interrater reliability for the TOP-J total score was .95 ( p < .001) with a mean difference of 1.56 ( SD =1.53). The test–retest sample included 50 participants who received a second TOP-J administration approximately 4 months after the first ( M =15.94 weeks, SD =8.68). Diagnostic composition was 30% HC, 26% CC, 24% MCI, and 20% AD. Test–retest reliability was .78 ( p < .001), and Time 1 scores ( M =21.49, SD =4.24) did not differ significantly from Time 2 scores ( M =21.41, SD =4.15). The average change in TOP-J total score (calculated by subtracting Time 1 from Time 2 score) was −0.08 ( SD =2.9), with 21 participants showing mild improvement, 20 showing mild decline, and 9 showing no change. Additionally, the 21 participants who manifested improved scores were evenly distributed across diagnostic groups: 6 HCs, 6 CCs, 5 MCIs, and 3 ADs; χ 2 (3, n =50)=0.64, ns . Thus, results did not reveal practice effects over a 4-month time interval.

Internal consistency using confirmatory factor analysis

All factor analysis models were run using Mplus, employing the weighted least squares with mean and variance (WLSMV) estimator applied to the polychoric correlation matrix, as appropriate for the ordered categorical nature of these items. Criteria for goodness of fit included comparative fit index (CFI) >.95 and Tucker–Lewis Index (TLI) >.95. For the root mean square error of approximation (RMSEA), values <.08 indicated adequate fit, and <.05 indicated good fit ( Hu & Bentler, 1998 ). We initially fit the data to a single-factor model including all 15 items. The single-factor model fit the data surprisingly well, with χ 2 (41)=48.59, p =.19; CFI was .961; TLI was .963; and RMSEA was .037. Standardized loadings of each of the items on the general factor are shown in Table 5 . Item 5 (social/ethical) had a negative loading on the common factor, while 5 other items had relatively low loadings, including Items 9 (safety), 10 (social/ethical), 11 (safety), 13 (medical), and 14 (social/ethical). We thus excluded those 6 items and ran the single-factor model with the remaining 9 items. This model also fit the data well, with χ 2 (19)=27.885, p =.09; CFI was .956; TLI was .956; and RMSEA was .060. Standardized loadings of each of the items on the general factor are shown in Table 5 . Notably, we present standardized loadings (not correlation coefficients); therefore, as the standard deviation of an item changes by 1 unit level, the level of the general factor correspondingly changes by more than 1 standard deviation unit. Removing items with low values had a negligible impact on the loadings of the 9 remaining items. All subsequent study analyses were conducted using the 9-item TOP-J version.

TOP-J loadings on a general factor defined by individual TOP-J items

Note. Items presented above are numbered according to their placement on the original 15-item TOP-J protocol. Items numbered 6, 7, 8, 12, and 15 were subsequently reordered as 5, 6, 7, 8, and 9 on the final 9-item version. Values represent standardized loadings, not correlation coefficients.

Evidence for convergent and discriminant validity

We examined associations between the TOP-J and presumably related and unrelated measures. It is worth noting that this process posed a challenge given that, as a presumed measure of executive functioning, the TOP-J was likely to show varying degrees of relation with most other cognitive domains. Comparison of the TOP-J and an existing judgment test, the NCSE JQ, indicated a weak but statistically signification correlation ( r =.22, p < .05). We also examined associations with specific neuropsychological tests with which the TOP-J theoretically should correlate strongly (e.g., executive functioning, language) or less strongly (e.g., visuoconstruction, emotional functioning). Table 6 presents results of these correlational analyses; sample sizes vary because a subset of AD participants did not complete all measures. In the entire sample, there were moderate correlations between performance on the TOP-J and scores on select measures of executive functioning, expressive language, verbal memory, and general fund of information, range r =.39 to r =.52. No significant correlations emerged between the TOP-J and select tests of simple auditory and visual attention, visual scanning, visuoconstruction, and depressive symptoms, range r =.09 to .15. We also compared the convergent and discriminant correlation coefficients (presented in Table 6 ) to determine whether they were reliably different from each other ( Hinkle, Wiersma, & Jurs, 1988 ; http://www.medcalc.be/ ). The resulting z -statistics ranged from 2.52 to 3.76, and all corresponding p values were less than .05. Collectively, these analyses provide preliminary evidence of convergent and discriminant validity for the TOP-J.

Correlations between TOP-J and selected neuropsychological measures

Note. Total raw scores were utilized for all correlational analyses. NCSE JQ=Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Exam. WCST=Wisconsin Card Sorting Test. DRS=Dementia Rating Scale. DKEFS=Delis–Kaplan Executive Function System. CVLT-II=California Verbal Learning Test, Second Edition. WAIS-III=Wechsler Adult Intelligence Scale, Third Edition. GDS=Geriatric Depression Scale.

Evidence for criterion-related validity

Group differences and distribution characteristics.

Degrees of asymmetry and peakedness in the distribution were evaluated by calculating skew and kurtosis statistics, applying cutoff values recommended by Tabachnick and Fidell (1996) . TOP-J scores were normally distributed for the CC, MCI, and AD groups (skewness=0.05, −0.38, −0.57; kurtosis=−0.59, −0.18, −0.64). Statistically significant negative skew was observed in the HC group, however, indicating a slight ceiling effect in cognitively intact older adults (skewness=−0.81; kurtosis=0.40). Analysis of variance (ANOVA) was used to evaluate group differences in TOP-J total scores (see Table 7 and Figure 1 ). Results were statistically significant, F (3, 130)=20.64, p < .001, revealing the overall effect of diagnostic group membership. Due to the nonnormal distribution of TOP-J scores in the HCs, group differences also were evaluated using the nonparametric Kruskal–Wallace H Test, with no change in findings. Post hoc comparisons using Bonferroni correction indicated that HCs obtained higher scores than CC, MCI, and AD participants, while ADs obtained lower scores than HC, CC, and MCI participants (approximately 2 SD s below the mean of HCs). CC and MCI participants showed an intermediate level of performance (approximately 1 SD below the mean score of HCs).

TOP-J and NCSE JQ scores by participant group.

TOP-J and NCSE JQ performance by group

Note. Data are mean ( SD ); TOP-J (n/27), NCSE JQ (n/6). TOP-J=Test of Practical Judgment. NCSE JQ=Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Exam. HC=healthy control. CC=cognitive complaints. MCI=mild cognitive impairment. AD=Alzheimer’s disease.

One-way analysis of covariance (ANCOVA) also was used to evaluate mean differences across groups. Age, gender, and education did not account for a significant amount of the variance between groups ( p > .05). Further correlational analyses revealed that TOP-J performance was not significantly correlated with age, r (131)=−.15, ns , gender, r (131)=.01, ns , or depressive symptoms endorsed on the GDS, r (130)=−.11, ns. However, TOP-J score showed a statistically significant association with level of education, r (130)=.28, p =.001. ANOVA also was used to evaluate mean group differences in NCSE JQ score. Participants were administered the last 3 NCSE JQ items, and each item was scored on a scale of 0 to 2 (creating a total score that ranged from 0 to 6). The groups did not differ significantly on the NCSE JQ. Due to the nonnormal distribution of NCSE JQ scores (skewness=−1.5; kurtosis=2.0), group differences also were evaluated using the nonparametric Kruskal–Wallace H Test, with no change in findings.

Relation to informant report of functioning

In order to explore the relation between TOP-J performance and everyday functioning, we examined associations between TOP-J score and informant responses on a Neurobehavioral Function/Activities of Daily Living Scale (NBF/ADL, Saykin, 1992 ) in the patient groups. MCI and AD participants with available data ( n =50) were combined for this analysis. Informants rated current level of ability on a 7-point scale ranging from above average (score=1) to severe disability (score=7). Total score on the NBF/ADL measure was derived by summing responses to the 7 items most closely related to TOP-J content including: decision making, reasoning through complicated problems, awareness of danger, judgment in potentially dangerous situations, managing money (e.g., paying bills, balancing checkbook), making purchases, and managing medications. Results revealed a statistically significant, moderate association between informant NBF/ADL and TOP-J total scores, r (50)=−.43, p =.002.

We report on the development and initial validation of a brief, objective measure of everyday judgment suitable for use with older adults. Our approach relied primarily on a rational-empirical method, in which practical and theoretical considerations served as the basis for test development, and empirical methods served as the basis for evaluation of item and scale qualities. Item development involved review of the literature related to clinical assessment of judgment and related executive processes (e.g., everyday decision making, social problem solving), survey of neuropsychology colleagues regarding what constitutes lapses in judgment, and examination of relevant participant and informant data from our Memory and Aging Study. We strove to develop stimuli that were representative of the types of judgment problem regularly faced by older adults. Another goal was to create scenarios that were easily understood, yet complex enough to require active problem solving and higher order cognitive abilities. The TOP-J employs an open-ended format in which participants listen to brief scenarios of everyday problems and report aloud their proposed solutions, which are recorded verbatim; unclear or ambiguous responses are queried in a neutral manner.

The initial TOP-J protocol contained 15 items, and it was possible to fit a single-factor model to all items. Unfortunately, the loading for 1 item was close to zero, and 4 other items had relatively modest loadings. Further analyses indicated that a single-factor model with 9 items fitted the data well, and loadings for all of the items were greater than .30, a guideline McDonald (1999) endorses for salience in this context. The final TOP-J contained 9 items, all of which relate to important safety, medical, social/ethical, and financial concerns. 2 A survey of practicing neuropsychologists confirmed that formal assessment of everyday judgment ability should incorporate issues related to the identified content domains ( Borgos et al., 2006b ). Given the limited number of questions and overlap of content domains for many of the test items, it was not possible to identify a four-domain measure using factor analytical techniques. Therefore, the recommended practice is to sum all TOP-J items into a single overall composite score rather than dividing the test into subscales. Individual responses earn 0, 1, 2, or 3 points (maximum score=27), with higher scores indicating better judgment. Detailed examiner instructions are included on the protocol, and the test takes approximately 10 minutes to administer and score.

The TOP-J demonstrated strong interrater agreement ( r =.95) and temporal stability over a 4-month interval ( r =.78). Internal consistency was adequate ( r =.63) in a sample of 134 elderly individuals with varying degrees of cognitive decline. These reliability and internal consistency properties exceed those of existing judgment tests (i.e., NCSE JQ and NAB JDG). As the construct of executive functioning is thought to direct all cognitive activity and behavior to some degree ( Gioia, Isquith, & Guy, 2001 ), few cognitive instruments would be expected to have little or no association with the TOP-J. Nonetheless, evidence for convergent validity was demonstrated by moderate correlations with theoretically related constructs (e.g., tests of executive functioning, language, and memory), whereas discriminant validity was demonstrated by low correlations with measures involving minimal executive demands (e.g., rote attention, visuoconstruction, and emotional functioning).

Another study goal was to investigate the TOP-J’s ability to detect group differences in older adults with varying degrees of decline. As noted by Marsiske and Margrett (2006) , the ability to use everyday problem-solving measures to identify subtle preclinical neurodegenerative change is an important issue requiring further study. Results indicated that the mild AD patients scored approximately 2 standard deviations below the mean of HCs on the TOP-J (clinically impaired range). A related goal was to determine whether judgment is compromised in preclinical disease stages. Although episodic memory impairment is the hallmark feature of MCI, research has revealed mild declines in executive functioning as well ( Crowell et al., 2002 ; Davie et al., 2004 ; Rabin et al., 2006 ; Ready, Ott, Grace, & Cahn-Weiner, 2003 ). The MCI group showed an intermediate level of performance relative to the HC and AD groups. While significantly lower than the HCs, however, MCI patients generally scored within normal limits clinically (i.e., approximately 1 SD below the HC mean, low average range). The CC group showed the same pattern of findings, also scoring approximately 1 standard deviation below the mean of HCs. Cognitive complaints in otherwise healthy older adults are common but their clinical significance is controversial, with some research suggesting that such complaints may be a harbinger of dementia. Overall, our findings indicated a relative weakness in judgment ability in both MCI and CC and suggest the need for further investigation of the temporal course of declining judgment skills from probable preclinical to clinical stages of dementia. This research may have important implications for early detection and remediation.

Study limitations and directions for future research

While the TOP-J may be sensitive to the influence of nonneurologic demographic factors such as education and cultural background, we were unable to explore such factors systematically in the current study given the relatively homogenous ethnic and educational composition of our participants. Future research will sample from a broader demographic range with the goals of replicating the current findings and establishing improved TOP-J norms and cutoff scores. We also will investigate whether some of the TOP-J items have differential item function related to education or intelligence ( Camilli & Shepard, 1994 ; Holland & Wainer, 1993 ). We employed strict criteria for entry into our Memory and Aging Study such as the exclusion of individuals with significant medical, psychiatric, or neurological conditions other than AD or amnestic MCI. In future research, we plan to assess additional MCI subtypes (e.g., multiple domain, single nonmemory domain), as these individuals often present with complaints of executive dysfunction. A related goal is to use the TOP-J with other clinical groups with presumed compromised judgment including frontal-subcortical dementias, stroke, and traumatic brain injury. We recently utilized the TOP-J in a sample of adults with mixed neuropsychiatric conditions ( Borgos et al., 2006a ), and preliminary results indicated that patients exhibited difficulty with practical judgment relative to controls. Additionally, the TOP-J was well tolerated and understood by this group of participants who presented with lower levels of education and estimated baseline intellect than did our older adult cohort. It is worth noting that in the current study our initial 45 participants were administered the TOP-J by telephone. These participants reported no difficulty hearing or understanding test questions and performed at a level equivalent to the larger sample. In future research, however, we will use a single mode of administration to maximize consistency in assessment methods.

The judgment scenarios developed for this instrument were based on hypothetical situations, and while many participants spontaneously mentioned having experienced similar problems, it is uncertain how they would actually behave in the real world. It would be desirable but extremely difficult to probe the actual execution of judgment responses outside formal assessment settings. Future research, however, will attempt to correlate TOP-J performance with real-world outcomes such as high-level activities of daily living. The associations already observed between the TOP-J and items from an informant ADL scale represent a starting point for this effort, and we are working to develop an informant rating scale specifically focused on judgment ability. We also plan to incorporate other commonly used tests that are related to the construct of judgment into our existing battery (e.g., WAIS-III Comprehension) and to examine relations between those instruments and the TOP-J. Another potential direction for research involves altering the administration procedures to allow for multiple responses for each question posed. This would enable investigation of solution fluency in addition to solution efficacy and might yield valuable information about participants’ cognitive processes during active problem solving ( Marsiske & Margrett, 2006 ).

As with any assessment tool, it is essential to consider TOP-J results in the context of other information about judgment such as collateral reports or examiner observations. Clinicians and researchers should not place too much interpretive significance on individual items, due to the lower reliability of such items relative to the entire scale. Careful review of individual items in the context of the assessment tool as a whole, however, may uncover specific circumstances or cognitive processes that contribute to poor judgment. For example, some patients may show an impaired ability to organize information while others may have trouble generating solutions, initiating a response, or filtering out irrelevant data to arrive at a satisfactory solution. Finally, it is important to note that the TOP-J is not meant to serve as a global severity marker for the dementing process. While very poor scores certainly suggest impaired judgment, some individuals with AD will score within the expected range of functioning, especially early in the disease process.

Judgment in everyday situations is an important aspect of cognition that warrants formal assessment during neuropsychological evaluations of older adults. Knowledge gained from this process can be used for diagnostic purposes and to address issues related to functional competence and required level of present and future care. Despite the significance of this cognitive domain, few objective tests of judgment have been developed, and those currently in use are limited with regard to psychometric properties, content validity, and/or clinical utility. This study reported on the development of a psychometrically sound and clinically useful measure of judgment that is easy to administer, score, and interpret. The TOP-J shows promise for reliable assessment of judgment that can be included in comprehensive neuropsychological evaluations. Future research utilizing the TOP-J has the potential to enhance general clinical knowledge and practice approaches to the assessment of judgment in older adults in varying stages of cognitive impairment. Longitudinal assessments are being performed to examine predictive validity of the TOP-J for cognitive progression in AD, MCI, and other clinical groups. Additional goals include the collection of more demographically-diverse normative data, development of an alternative test form, and determination of cutoff scores for our clinical groups. We also plan to examine relations with neuroimaging data to investigate the neural basis for impaired judgment.

Acknowledgments

The authors would like to thank Drs. Howard Cleavinger, Robert Santulli, Gwen Sprehn, Robert Roth, Peter Isquith, Nadia Pare, and Brenna McDonald, as well as Harris Rabin, Heather Pixley, Paul Wang, John West, and Mark Root for their contributions with various aspects of this project. This research was supported by funding from the National Institute of Aging (R01 AG19771, K08 022232), Alzheimer’s Association, National Science Foundation, and Ira DeCamp Foundation.

Assessment battery

Neuropsychological assessment.

• Action Fluency Task ( Piatt, Fields, Paolo, & Troster, 1999 )
• American National Adult Reading Test (ANART; Grober, Sliwinski, Schwartz, & Saffran, 1989 )
• Barona algorithm ( Barona, Reynolds, & Chastain, 1984 )
• Boston Naming Test (BNT; Goodglass, Reynolds, & Chastain, 2001 )
• Behavior Rating Inventory of Executive Functions–Adult Version (BRIEF-A; Roth, Isquith, & Gioia, 2005 )
• California Verbal Learning Test, Second Edition (CVLT-II; Delis et al., 2000 )
• Delis–Kaplan Executive Function System (DKEFS, Verbal Fluency, Trail Making Test; Delis & Kaplan, 2001 )
• Mattis Dementia Rating Scale, Second Edition (DRS-2; Jurica et al., 2001 )
• Mini-Mental State Examination (MMSE; Folstein et al., 1975 )
• Neuropsychiatric Inventory (NPI; Cummings et al., 1994 )
• Wechsler Adult Intelligence Scale, Third Edition (WAIS-III, Information, Block Design, Digit Span, Digit Symbol, Vocabulary; Wechsler, 1997 )
• Wechsler Memory Scale, Third Edition (WMS-III, LMI & LMII; VRI & VRII; Psychological Corporation, 1997 )
• Wisconsin Card Sorting Test (WCST, short form; Heaton et al., 1993 )

Cognitive complaint index

• Neurobehavioral Function and Activities of Daily Living Scale (self- and informant versions; Saykin, 1992 )
• Geriatric Depression Scale, four cognitive items (GDS; Yesavage et al., 1982 )
• Informant Questionnaire on Cognitive Decline in the Elderly (self- and informant versions; Jorm, Scott, & Jacomb, 1989 )
• Memory Assessment Questionnaire ( Santulli et al., 2005 )
• Memory Self-Rating Questionnaire ( Squire, Wetzel, & Slater, 1979 )
• Memory and Aging Telephone Screen, 10 cognitive items ( Rabin et al., 2004 )

Sample TOP-J items and scoring criteria

Administration notes.

( Q ) indicates that examiner should query the examinee with the statement “Tell me more about that” or “Explain what you mean.” Additional information (* in italics ) can be provided if the participant directly requests this information or gives a response that contradicts this information. More extensive scoring criteria are provided on the actual TOP-J protocol.

Sample Item 1

You are vacationing far from home and realize you don’t have enough blood pressure pills for the entire trip. What would you do?

• 3 contact physician (or insurance company) and have prescrip called/faxed into local pharmacy/ call home, have pills Fedexed/call local pharmacy or doctor (Q) – (and have them call in prescrip)/call local WALMART/CVS, etc. since they have your prescrip records on computer
• 2 visit local doctor/ER/hospital at vacation site and ask for prescription or describe problem/ take pills to local pharmacy, see if they can help/(*you don’t have prescription with you)/ have doc or pharmacy send free samples or prescription/get pharmacy to give you enough pills to make it
• 1 take smaller doses to make it last longer/ration them/vague response even after query (e.g., “go to pharmacy & get some,” “call home & ask for help,” “have pharmacist mail them” “get some”)
• 0 wait to see if you need them, no reason to worry in advance/nothing, wait until you get home/wait until something bad happens/don’t know, go without/avoid strenuous activity

Sample Item 2

You read a report that the government will reduce monthly social security payments from $1,000 to $500 for a certain percentage of recipients. What would you do?

• 3 find out how likely it is your benefits will be reduced/call to gather more info in attempt to determine if it affects you/call SS office to find out more (Q) – if you are affected
• 2 vague attempt at getting more info without directly trying to determine if you are affected or assumption that you are affected (e.g., “look into it because it’s not right” “determine validity of info” “call & see what I can do (Q) ”)/call Senator to get info (Q)/ research issue or “find out why” (without determining if benefits will change)/research how much reduction will be
• 1 reduce monthly spending/get bills paid so you can budget $ more closely/go to work/borrow cash/adjust finances
• 0 do nothing/wait to see what happens/this doesn’t affect me/you can’t fight gov (Q)/tell gov it’s a bad idea/complain or call local papers/don’t believe it/just live on my resources/write my senator/congressman and complain/be mad

1 NINCDS-ADRDA refers to the National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association.

2 While factor analytic findings supported the 9-item TOP-J, clinicians and researchers may opt to use the original 15-item version, which also showed good psychometric properties, and which may provide additional information about patients’ judgment ability. The 9- and 15-item TOP-J protocols are both available upon request from the corresponding author.

Portions of this research project were presented at the 33 rd annual International Neuropsychological Society conference in February 2005.

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Cognitive Problems after Traumatic Brain Injury

What is Cognition?

Cognition is the act of knowing or thinking. Some thinking abilities that can be affected by TBI include:

• Attention and concentration
• Processing and understanding information
• Planning, organizing, and assembling
• Reasoning, problem-solving, decision-making, and judgment
• Monitoring and watching behavior to ensure that it is socially acceptable
• Communicating thoughts or ideas in ways that others can understand

Cognition after TBI

This factsheet discusses common difficulties with cognition (or thinking) that some individuals have after a TBI and presents some tips that may help reduce these challenges.

People who have experienced TBI might have trouble paying attention or staying focused. The ability to pay attention is an important thinking skill. Trouble paying attention can often lead to other problems and challenges, such as:

• Getting distracted more easily
• Having trouble finishing things
• Difficulty switching attention from one task to another
• Learning and remembering new information
• Difficulty holding long conversations or focusing on one conversation when many people are talking

What can be done to improve attention?

• Decrease distractions. Distractions can come from the environment or from within oneself, such as headaches or worries. Find the right place and the right time for activities that require more attention (e.g., reading). For example, work in a quiet room.
• Focus on one task at a time.
• Break large or complex tasks into smaller tasks.
• Practice attention skills on simple but practical activities (such as reading a paragraph or adding numbers) in a quiet room. Gradually make tasks harder. For example, read a short story, balance a checkbook, or work in a slightly noisier environment.
• Take breaks when doing tasks that require a lot of mental energy. Return to the task when you’re more refreshed.
• Talk with a doctor if you think your mood (e.g., sadness or worrying) is making it harder to concentrate.
• Get plenty of rest. Talk to your doctor about any problems you have sleeping.

Processing and Understanding Information

After a TBI, a person’s ability to process and understand information often slows down and can become more challenging. This can result in some of the following problems:

• Having trouble understanding what others are saying or needing more time to understand what others are saying.
• Taking more time to understand and follow directions.
• Having trouble following storylines in television shows and movies.
• Taking longer to read and understand written information, including books, newspapers, or magazines.
• Reacting slowly to changes or warning signs in the surroundings. Slow reactions make certain activities, such as driving, unsafe. For example, not reacting quickly enough to stop signs, traffic lights, and other warning signs.
• Taking longer to carry out physical tasks, including routine activities, such as getting dressed or cooking.

What can be done to improve the ability to process and understand information?

• Decrease distractions. For example, turn the television off and silence your phone so that you can focus fully on what you’re trying to understand.
• Allow more time to think about the information before moving on.
• Re-read information as needed. Try using a highlighter to identify the most important parts of what you are reading.
• Take notes and summarize information in your own words.
• If needed, ask people to repeat themselves, to say something in a different way, or to speak slowly. Repeat what you just heard to make sure you understood it.

Cognitive Communication

Thinking difficulties can make it harder to express your thoughts and understand what others are trying to say. Examples of cognitive communication problems include:

• Difficulty thinking of the right word
• Trouble starting or following conversations or understanding what others say
• Rambling or getting off topic easily
• Difficulty expressing thoughts in an organized manner
• Trouble expressing your thoughts and feelings through facial expressions, tone of voice, and body language (nonverbal communication)
• Having problems reading others’ nonverbal communication and social cues that indicate others’ feelings, thoughts, expectations, or intentions
• Misunderstanding jokes or sarcasm
• Aphasia is a disorder that can affect your speech or your ability to understand language properly. A speech therapist can test you for aphasia. Some of the suggestions below may be helpful to individuals with aphasia. However, speech therapy with a trained therapist who can teach strategies specific to aphasia may be needed.

Related Factsheets

What can people with tbi do to improve communication.

• Practice communicating one on one or in small groups and in environments with few distractions.
• If someone is speaking too fast, ask them to speak slowly so you can better understand them.
• If people are trying to tell you too much at once, ask them to tell you one thing at a time or ask one question at a time.
• If people ask too many questions at once, ask for one question at a time.
• If you didn’t understand something someone said to you, ask him or her to repeat it or say it in a different way.
• To make sure you understand what someone says, offer to summarize what you heard.
• Before you start a conversation, think about the main point that you want to communicate. Plan what you need to say and consider what, if any, background information the person may need to better understand your message.
• When you write emails and post to social media, make sure to proofread, and read the text aloud before sending or posting it.

How can others help with communication?

People with TBI may not be able to interpret or understand words, messages, thoughts, and feelings that are part of a conversation. In such instances, others can help people with TBI by:

• Using kind words and a gentle tone of voice.
• Limiting conversations to one person at a time.
• Clearly communicate to your loved one what you are thinking or feeling or want.
• Helping them practice communication tips outlined above. Practice should be one on one or small group settings in environments with few distractions.
• Helping to redirect the conversation if the person gets off topic, by saying, “We were talking about...”
• If you are working with a speech therapist, it can be helpful to have a loved one join those sessions. Including family members in sessions can help you to carry over new skills to everyday life.

Learning and Remembering New Information

People with TBI may have trouble learning and remembering new information and events. People with TBI may also have problems remembering entire events or conversations. When this happens, the mind will sometimes try to fill in the gaps of missing information with things that did not really happen. These false memories are not lies. False memories are the brain’s attempt to use the best information it has to make up for what is missing.

What can be done to improve memory problems?

• Structure your day with routine daily tasks and activities.
• Be organized: always put commonly used items back in the same place.
• memory notebooks to keep track of important information.
• calendar reminders on smartphones, tablets, and computers to remember appointments and scheduled activities.
• Minimize distractions when learning new information and tasks (e.g. sit in a quiet area).
• Devote time and attention to reviewing and practicing new information you want to memorize.
• Link the information you want to remember with an image. Rehearse this connection either out loud or writing it down.
• Try to connect new information with something you already know. Building on existing knowledge can improve memory.
• Write down step-by-step instructions that you can reference when learning something new, such as directions to a new location, a new recipe, or learning a new computer task.
• Get plenty of rest. This will improve your focus during learning and result in better memory.
• Use relaxation techniques, such as deep breaths or meditation. This could help you focus better and reduce memory problems associated with stress and anxiety.
• Pay attention to possible side-effects of your medications, which may affect your thinking. If you notice changes in memory and are taking prescription medications, speak with your doctor about how your prescription medications may affect your memory.

Planning and Organization

People with TBI may have trouble planning the steps needed to accomplish a goal or organizing their ideas or belongings in a systematic way. Examples include:

• Difficulty planning their day and scheduling appointments
• Trouble organizing and keeping track of things like important papers, mail, and other items
• Trouble with tasks that require multiple steps to be completed in a particular order, such as laundry or cooking

What can be done to improve planning and organization?

• Use a calendar to schedule appointments and tasks. Look out for scheduling conflicts.
• List goals or things that need to be done and when. List them in order of what should be done first.
• Many mobile phones have apps with calendars and checklists that can be helpful.
• Break down activities into smaller steps.
• When figuring out what steps you need to do first to complete an activity, think of the end goal and work backwards.
• Organize items based on similarity and use. For example, store all medical bills in one place and separate them by the type of medical service.
• Look for free smartphone apps designed to plan, organize, and remind you of appointments and events. Some apps may allow you to set alarms for reminders throughout the day.

Judgment, Reasoning, Problem-Solving, and Self-Awareness

Judgment, reasoning, problem-solving and self-monitoring are complex cognitive skills that are often affected after a TBI. Problems in these areas also impact decision-making and behaviors. People with TBI who have difficulty in these areas may have the following problems:

• Analyzing information or changing the way they think (being flexible)
• Deciding the best solution to a problem
• Getting stuck on one solution and not considering other options
• Acting quickly without thinking about the possible consequences
• Knowing what information is needed and how to evaluate the information needed to make decisions
• Judging what is safe versus unsafe behavior
• Being unaware of cognitive problems, even if the problems are clear to others
• Lacking awareness of social boundaries and others’ feelings, such as being too personal with people they don’t know well or not realizing what they have done or said to make someone feel uncomfortable

What can people with TBI do to improve judgment, reasoning, problem-solving, and awareness?

• Engage a trusted family member or friend when solving problems; they don’t need to be solved alone.
• Goal: Define the problem and the ultimate goal.
• Plan: Brainstorm possible solutions, list the pros and cons of each solution, and pick a solution.
• Do: Try the solution.
• Check: Evaluate the success of the solution, and try another solution if the first one doesn’t work.
• Before acting on a decision, wait a few hours or sleep on it overnight. Seek advice about your decision from a trusted friend or family member before acting on it.
• Work with friends and family to come up with cues to alert you to stop and monitor what you are doing.
• Think about your actions ahead of time and consider how they might appear to others and the consequences that your actions may have on yourself and others. Practice this with a family member or friend and make it a habit to do on your own.

How can family members help?

• Attend therapy sessions with your loved one in order to know what they are working on and help reinforce skills which are being taught.
• Give the person extra time to think things through and arrive at a solution.
• Offer to work with your loved one to problem-solve together, instead of solving problems for them.
• Give realistic, supportive feedback referring to a situation that happened and the unwanted consequence. Work together to come up with a different approach.
• Help your loved one to generate different options and alternative solutions to problems.

Cognitive Evaluation, Recovery, and Rehabilitation

• A neuropsychologist usually evaluates changes in thinking abilities after TBI. The results of this testing can be used to design a treatment plan.
• Many factors affect how someone’s cognition will improve over time, which makes it very difficult to predict how much someone’s cognition will recover.
• In many cases, cognition can improve with cognitive rehabilitation. Cognitive rehabilitation is a therapy known to help improve many of the cognitive skills described above.
• Some cognitive therapy approaches focus on improving skills that have been lost or impaired. Other approaches help the person to learn different ways to achieve a goal.
• Individuals with changes in thinking skills after TBI should consider getting help from a therapist who specializes in cognitive rehabilitation.
• Clinicians—such as occupational therapists, speech therapists, and neuropsychologists—often deliver cognitive therapy. A clinical psychologist or psychotherapist may not directly deal with cognitive difficulties but can be helpful in cases where depression, anxiety, or frustration are interfering with clear thinking.

Discuss Your Concerns With Your Physician or Treatment Provider

You should discuss any questions or concerns you have with a physiatrist (rehabilitation specialist) or the rehabilitation team. Do not ignore new problems. Mention new problems as they develop to your health care team. New problems could be the result of medication or require further evaluation. Bring a journal to your doctor appointments. Because you have a limited amount of time with the doctor, it is helpful to have a list of things you want to discuss prepared ahead of time so that you do not miss the opportunity to discuss important issues or ask questions. A journal can also be used during your appointment to take notes with regard to what the doctor tells you so that you can remember it later.

Recommended Reading

• Memory and Traumatic Brain Injury , https://msktc.org/tbi/factsheets/memory-and-traumatic-brain-injury
• Emotional Problems after Traumatic Brain Iinjury , https://msktc.org/tbi/factsheets/emotional-problems-after-traumatic-brain-injury
• Emotional Changes after Traumatic Brain Injury , https://msktc.org/tbi/infocomics/emotional-changes-after-tbi-infocomic
• Fatigue and Traumatic Brain Injury , https://msktc.org/tbi/factsheets/fatigue-and-traumatic-brain-injury
• Sleep and Traumatic Brain Injury , https://msktc.org/tbi/factsheets/sleep-and-traumatic-brain-injury
• Traumatic Brain Injury and Sleep , https://msktc.org/tbi/infocomics/tbi-and-sleep-infocomic
• Social Skills after Traumatic Brain Injury , https://msktc.org/tbi/factsheets/social-skills-after-traumatic-brain-injury

Cognitive Problems after TBI was developed by Dawn Neumann, PhD and Anthony Lequerica, PhD, in collaboration with the Model Systems Knowledge Translation Center.

Factsheet Update

Cognitive Problems after TBI was reviewed and updated by Dawn Neumann, PhD, and Anthony Lequerica, PhD, in collaboration with American Institutes for Research Model Systems Knowledge Translation Center.

Source: The content is based on research and/or professional consensus. This content has been reviewed and approved by experts from the Traumatic Brain Injury Model Systems (TBIMS), funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, as well as experts from the Polytrauma Rehabilitation Centers (PRC), funded by the U.S. Department of Veterans Affairs.

Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider regarding specific medical concerns or treatment. This publication was produced by the TBI Model Systems in collaboration with the University of Washington Model Systems Knowledge Translation Center with funding from the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education, grant no. H133A060070. It was updated under the American Institutes for Research Model Systems Knowledge Translation Center, with funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0082). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this factsheet do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.

Copyright © 2020 Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.

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How Does ADHD Affect Decision Making? Plus 8 Tips That Can Help

ADHD can affect your daily activities and ability to perform tasks, such as making decisions.

Attention deficit hyperactivity disorder (ADHD) is a mental health condition that often begins during childhood but can continue into adulthood.

According to the National Institute of Mental Health, about 4.4% of adults in the United States receive a diagnosis of ADHD.

ADHD is a neurodevelopmental disorder that interferes with your relationships and ability to function. It’s characterized by a pattern of:

• challenges with attention
• hyperactivity
• impulsivity

For adults with ADHD, many of the symptoms can affect your decision making process. For example, you may sometimes procrastinate when trying to make a decision or be more likely to make a split decision at the last minute.

What are ADHD symptoms in adults?

ADHD symptoms can vary depending on what type of ADHD you have.

Some people with ADHD have problems paying attention. Others are more likely to have symptoms of hyperactivity or impulsivity. Some people have a combination of both types of symptoms.

Common ADHD symptoms in adults include:

• being easily distracted
• difficulty paying attention
• disorganization
• excessive talking
• forgetfulness
• impulsive behavior
• inability to sit still for a long time
• issues with task switching
• problems with working memory (short-term memory needed to complete tasks and solve problems)
• restlessness
• higher risk-taking behavior

Is indecisiveness a symptom of ADHD?

A 2021 study shows that adults with ADHD can have a range of problems related to decision making, including indecisiveness. Several factors can contribute to indecisiveness, including:

• inattention
• memory problems
• distractibility

How can ADHD affect the decision making process?

ADHD can affect your decision making in several ways. One of the common symptoms of ADHD is impaired working memory. This means that some adults with ADHD have difficulty holding several thoughts and ideas in their memory long enough to make a decision.

Making decisions often also requires you to evaluate options. Adults with ADHD may have difficulty sifting through too many choices. They may spend so much time analyzing that they can’t come to a decision. Some people with ADHD call this “analysis paralysis.”

Outcomes from earlier decisions may lead to negative feelings or insecurity about making good decisions. This can hinder you from making other decisions.

Strategies and tips for decision making with ADHD

Decision making poses challenges for adults with ADHD, but you can take steps to make the process easier and feel more comfortable with it.

1. Define the problem

The first step is to define the problem. What challenges are you facing? What outcome do you need?

Defining the problem first will allow your thoughts to have a guide and a filter, helping you to focus on the challenge at hand.

2. Write down your thoughts

One way to improve your working memory is to write down all the details and facts you need to decide. Writing your thoughts down eliminates the need to remember things. Seeing the facts in writing helps organize your thoughts and makes the process easier.

3. Make a list

Another way to organize your thoughts is to make a list.

You can make a list of the pros and cons of each choice available. If you’re overwhelmed with the number of tasks you need to do, you can also list them.

For example, you can group tasks by how much time it’d take to complete them. This can help you decide which task to work on first based on how much time you have available.

4. Find a quiet space

People with ADHD can experience hypersensitivity to their environment. Visual clutter, noise, and busy environments can be distractions when you’re trying to make a decision. Finding a quiet room or space to think can help you focus.

You can learn more here about tips on how to focus with ADHD.

5. Create a deadline

People with ADHD can sometimes get caught up in analyzing. So, coming to a concrete decision can be challenging. Giving yourself a deadline to decide on something can help you avoid procrastination .

6. Limit your choices

Having too many choices can be overwhelming. To simplify your decision making, consider narrowing down your options.

For example, if you’re trying to decide where to go on vacation, you can narrow your choices by affordability. Then you can further narrow those choices by location climate. From those options, you can choose based on how easy it is to get to your destination.

7. Ask for help

It’s OK to ask for help. Asking someone you trust to help you sort your ideas and get their feedback can ease the decision making process. You can even delegate some decisions to someone you trust.

8. Celebrate your good decisions

It can be hard to feel confident about your decision making if you’ve had negative experiences with the process.

But celebrating all the good decisions you make each day, no matter how small, can help boost your self-confidence. It can also build positive reinforcement for making good decisions in the future.

ADHD is different for everyone, and decision making can be challenging for some. But having the right tools is key in developing strategies to make the process easier and smoother.

A trusted family member or friend, your therapist, and support groups are resources you can turn to for help.

For more help and support, explore:

• ADHD Resources: Support Groups, Books, Apps, and More
• Support Groups for Adults with ADHD
• CHADD for Adults
• What to Know About ADHD in Adults
• ADHD Coaches Organization

Looking for a therapist but not sure where to start? Psych Central’s How to Find Mental Health Support resource can help.

6 sources collapsed

• Attention-deficit/hyperactivity disorder (ADHD). (n.d.). https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd
• Attention-deficit/hyperactivity disorder in adults: What you need to know. (2021). https://www.nimh.nih.gov/health/publications/adhd-what-you-need-to-know#part_6210
• Cowan N. (2013). Working memory underpins cognitive development, learning, and education. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207727/
• Dekkers TJ, et al. (2018). Decision-making deficits in ADHD are not related to risk seeking but to suboptimal decision-making: Meta-analytical and novel experimental evidence. https://journals.sagepub.com/doi/10.1177/1087054718815572
• Schulze M., et al. (2021). Disentangling ADHD’s presentation-related decision-making — A meta-analytic approach on predominant presentations. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.519840/full
• Targum SD, et al. (2014). Our current understanding of adult ADHD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301030/

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The  National Institute on Aging , a component of the National Institutes of Health ( NIH ), is a leading federal funder of research on  dementia . 

Introduction

A diagnosis of dementia can be frightening for those affected by the syndrome, their family members, and caretakers. Learning more about this medical condition can help. This page provides an overview of various types of dementia, describes how the disorders are diagnosed and treated, and offers highlights of research supported by the National Institute of Neurological Disorders and Stroke ( NINDS ) and the National Institute on Aging ( NIA ), both part of the National Institutes of Health ( NIH ).

Alzheimer's disease and related dementias have a high impact on public health and are a priority for NIH-supported research. A glossary of terms is found at the bottom of the page.

The basics of dementia and cognitive impairment

Dementia is the loss of cognitive functioning—the ability to think, remember, or reason—to such an extent that it interferes with a person's daily life and activities. These functions include memory, language skills, visual perception, problem solving, self-management, and the ability to focus and pay attention. Some people with dementia cannot control their emotions, and their personalities may change. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person's functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living (ADLs).

Age is the primary risk factor for developing dementia. For that reason, the number of people living with dementia could double in the next 40 years as the number of Americans age 65 and older increases to more than 88 million in 2050. Regardless of the form of dementia, the personal, economic, and societal demands can be devastating.

Dementia is not the same as age-related cognitive decline—when certain areas of thinking, memory, and information processing slow with age, but intelligence remains unchanged. Unlike dementia, age-related memory loss isn't disabling. Occasional lapses of forgetfulness are normal in elderly adults. While dementia is more common with advanced age (as many as half of all people age 85 or older may have some form of dementia), it is not an inevitable part of aging. Many people live into their 90s and beyond without any signs of dementia.

Dementia is also not the same as delirium, which is usually a short-term complication of a medical condition and most often can be treated successfully. Signs and symptoms of dementia result when once-healthy neurons (nerve cells) in the brain stop working, lose connections with other brain cells, and die. While everyone loses some neurons as they age, people with dementia experience far greater loss.

Mild cognitive impairment (MCI) is a stage between normal cognitive changes that may occur with age and more serious symptoms that indicate dementia. Symptoms of MCI can include problems with thinking, judgment, memory, and language, but the loss doesn't significantly interfere with the ability to handle everyday activities. Symptoms of MCI include mild memory loss; difficulty with planning or organization; trouble finding words; frequently losing or misplacing things; and forgetting names, conversations, and events. Someone with MCI may be at greater risk of eventually developing Alzheimer's or another type of dementia, particularly if the degree of memory impairment is significant, but MCI does not always progress to dementia. Symptoms may remain stable for several years, and even improve over time in some people.

It is common to have more than one cause of dementia. Many people with dementia have both Alzheimer's disease and one or more closely related disorders that share brain scanning or clinical features (and sometimes both) with Alzheimer's disease. When a person is affected by more than one dementia disorder, the dementia can be referred to as a mixed dementia.

Autopsy studies of the brains of people who had dementia suggest that a majority of those age 80 and older probably had mixed dementia caused by Alzheimer's-related neurodegenerative processes, vascular disease-related processes, or another neurodegenerative condition. In fact, some studies indicate that mixed vascular-degenerative dementia is the most common cause of dementia in the elderly.

Researchers are still trying to understand the underlying disease processes involved in dementia. Scientists have some theories about mechanisms that may lead to different forms of dementia, but more research is needed to better understand if and how these mechanisms are involved.

Dementias associated with aging and neurodegeneration

Various disorders and factors contribute to dementia, resulting in a progressive and irreversible loss of neurons and brain functions. Currently, there are no cures for these neurodegenerative disorders.

Some specific causes of dementia disorders are explained below.

Alzheimer's disease (AD) is the most common cause of dementia in older adults. As many as five million Americans age 65 and older may have the disease. In most neurodegenerative diseases, certain proteins abnormally clump together and are thought to damage healthy neurons, causing them to stop functioning and die. In Alzheimer's disease, fragments of a protein called amyloid form abnormal clusters called plaques between brain cells, and a protein called tau forms tangles inside nerve cells.

It seems likely that damage to the brain starts a decade or more before memory and other cognitive problems appear. The damage often initially appears in the hippocampus, which is the part of the brain essential in forming memories. Ultimately, the plaques and tangles spread throughout the brain, and brain tissue significantly shrinks.

As Alzheimer's disease progresses, people experience greater memory loss and other cognitive difficulties. Problems can include wandering and getting lost, trouble handling money and paying bills, repeating questions, taking longer to complete daily tasks, and personality and behavior changes.

People are often diagnosed in this stage. Memory loss and confusion worsen, and people begin to have problems recognizing family and friends. They may be unable to learn new things, carry out multi-step tasks such as getting dressed, or cope with new situations. In addition, people at this stage may have hallucinations, delusions, and paranoia and may behave impulsively.

People with severe Alzheimer's disease cannot communicate and are completely dependent on others for their care. The person may be in bed most or all of the time as body functions shut down. Certain drugs can temporarily slow some symptoms of Alzheimer's from getting worse, but currently there are no treatments that stop the progression of the disease. 

Researchers have not found a single gene solely responsible for Alzheimer's disease; rather, multiple genes are likely involved. One genetic risk factor—having one form of the apolipoprotein E (APOE) gene on chromosome 19—does increase a person's risk for developing AD. People who inherit one copy of this APOE ε4 allele have an increased chance of developing the disease; those who inherit two copies of the allele are at even greater risk. (An allele is a variant form of a pair of genes that are located on a particular chromosome and control the same trait.) The APOE ε4 allele may also be associated with an earlier onset of memory loss and other symptoms. Researchers have found that this allele is associated with an increased number of amyloid plaques in the brain tissue of affected people.

Frontotemporal disorders are forms of dementia caused by a family of neurodegenerative brain diseases collectively called frontotemporal lobar degeneration. They primarily affect the frontal and temporal lobes of the brain, rather than the widespread shrinking and wasting away (atrophy) of brain tissue seen in Alzheimer's disease.

In these disorders, changes to nerve cells in the brain's frontal lobes affect the ability to reason and make decisions, prioritize and multitask, act appropriately, and control movement. Changes to the temporal lobes affect memory and how people understand words, recognize objects, and recognize and respond to emotions. Some people decline rapidly over two to three years, while others show only minimal changes for many years. People can live with frontotemporal disorders for two to 10 years, sometimes longer, but it is difficult to predict the. The signs and symptoms may vary greatly among individuals as different parts of the brain are affected. No treatment for curing or reversing frontotemporal disorders is currently available.

Clinically, FTD is classified into two main types of syndromes:

• Behavioral variant frontotemporal dementia (bvFTD) involves changes in behavior, judgment, and personality. People with this disorder may have problems with cognition, but their memory may stay relatively intact. They may do impulsive things that are out of character or may engage in repetitive, unusual behaviors. People with bvFTD may say or do inappropriate things or become uncaring. Over time, language and/or movement problems may occur.  
• Primary progressive aphasia (PPA) involves changes in the ability to speak, understand, and express thoughts and/or words, and to write and read. Many people with PPA, though not all, develop symptoms of dementia. Problems with memory, reasoning, and judgment are not apparent at first but can develop and progress over time. Sometimes a person with PPA cannot recognize the faces of familiar people and common objects (semantic PPA). Other individuals have increasing trouble producing speech and may eventually be unable to speak at all (agrammatic PPA). PPA is a language disorder that is not the same as the problems with speech and ability to read and write (aphasia) that can result from a stroke.

Other types of frontotemporal disorders include:

• Corticobasal degeneration (CBD) involves progressive nerve-cell loss and atrophy of specific areas of the brain, which can affect memory, behavior, thinking, language, and movement. The disease is named after parts of the brain that are affected—the cerebral cortex (the outer part of the brain) and the basal ganglia (structures deep in the brain involved with movement). Not everyone who has CBD has problems with memory, cognition, language, or behavior. The disease tends to progress gradually, with early symptoms beginning around age 60. Some of the movement symptoms of CBD are similar to those seen in Parkinson's disease.
• Frontotemporal dementia with motor neuron disease (FTD/MND; also known as FTD-ALS) is a combination of behavioral variant frontotemporal dementia and the progressive neuromuscular weakness typically seen in amyotrophic lateral sclerosis (ALS). ALS is a neurodegenerative disease that attacks nerve cells responsible for controlling voluntary muscles (muscle action that can be controlled, such as in the arms, legs, and face). Symptoms of either disease may appear first, with other symptoms developing over time.
• Pick's disease is characterized by Pick bodies—masses comprised of the tau protein that accumulate inside nerve cells, causing them to appear enlarged or balloon-like. It is usually seen with bvFTD but sometimes with PPA. Some symptoms are similar to those of Alzheimer's disease, including loss of speech, changes in behavior, and trouble with thinking. However, while inappropriate behavior characterizes the early stages of Pick's disease, memory loss is often the first symptom of AD. Antidepressants and antipsychotics can control some of the behavioral symptoms of Pick's disease, but no treatment is available to stop the disease from progressing.
• Progressive supranuclear palsy (PSP) is a brain disease that can cause problems with thinking, memory, behavior, problem solving, and judgment. It also affects the control of eye movements, mood, speech, swallowing, vision, concentration, and language. Because certain parts of the brain that control movement are damaged, this disease shares some of the problems with movement seen in people with corticobasal degeneration and Parkinson's disease.

Lewy body dementia (LBD) is one of the most common causes of dementia after Alzheimer's disease and vascular disease. It typically begins after age 50, but can occur earlier. It involves abnormal protein deposits called Lewy bodies, which are balloon-like structures that form inside nerve cells. The abnormal buildup of the protein alpha-synuclein and other proteins causes neurons to work less effectively and die. Initial symptoms may vary, but over time, people with these disorders develop similar cognitive, behavioral, physical, and sleep-related symptoms.

Lewy body dementia includes two related conditions—dementia with Lewy bodies and Parkinson's disease dementia. In dementia with Lewy bodies, the cognitive symptoms are seen within a year of movement symptoms called parkinsonism (including tremor, difficulty with walking and posture, and rigid muscles). In Parkinson's disease dementia, the cognitive symptoms develop more than a year after movement problems begin.

• Dementia with Lewy bodies (DLB) is one of the more common forms of progressive dementia. Neurons in the outer layer of the brain (cortex) and in the substantia nigra (a region involved with the production of dopamine) degenerate. Many neurons that remain contain Lewy bodies. Symptoms such as difficulty sleeping, loss of smell, and visual hallucinations often precede movement and other problems by as many as 10 years. Later in the course of DLB, some signs and symptoms are similar to Alzheimer's disease and may include memory loss, poor judgment, and confusion. Other signs and symptoms of DLB are similar to those of Parkinson's disease, including difficulty with movement and posture, a shuffling walk, and changes in alertness and attention. There is no cure for DLB, but there are drugs that control some symptoms.
• Parkinson's disease dementia (PDD) can occur in people with Parkinson's disease, but not all people with Parkinson's disease will develop dementia. PDD may affect memory, social judgment, language, or reasoning. Autopsy studies show that people with PDD often have Lewy bodies in the cortex and other brain areas, and many have amyloid plaques and tau tangles like those found in people with Alzheimer's disease, though the causes of these similarities are not clear. The time from the onset of movement symptoms to the onset of dementia symptoms varies greatly from person to person. Risk factors for developing PDD include the onset of Parkinson's-related movement symptoms followed by mild cognitive impairment and REM sleep behavior disorder, which involves having frequent nightmares and hallucinations.

Vascular contributions to cognitive impairment and dementia (VCID) cause significant changes to memory, thinking, and behavior. Cognition and brain function can be significantly affected by the size, location, and number of brain injuries. Vascular dementia and vascular cognitive impairment arise as a result of risk factors that similarly increase the risk for cerebrovascular disease (stroke), including atrial fibrillation, hypertension, diabetes, and high cholesterol. Symptoms of VCID can begin suddenly and progress or subside during one's lifetime. VCID can occur along with Alzheimer's disease. People with VCID almost always have abnormalities in the brain on magnetic resonance imaging (MRI) scans. These include evidence of prior strokes, often small and asymptomatic, as well as scattered changes in the brain's “white matter," or the connecting “wires” of the brain that are critical for relaying messages between brain regions. Microscopic brain examination shows thickening of blood vessel walls called arteriosclerosis and thinning or loss of components of the white matter.

Forms of VCID include:

• Vascular dementia refers to progressive loss of memory and other cognitive functions caused by vascular injury or disease within the brain. Symptoms of vascular dementia may sometimes be difficult to distinguish from Alzheimer's disease. Problems with organization, attention, slowed thinking, and problem solving are all more prominent in VCID, while memory loss is more prominent in Alzheimer's.
• Vascular cognitive impairment involves changes with language, attention, and the ability to think, reason, and remember that are noticeable but are not significant enough to greatly impact daily life. These changes, caused by vascular injury or disease within the brain, progress slowly over time.
• Post-stroke dementia can develop months after a major stroke. Not everyone who has had a major stroke will develop vascular dementia, but the risk for dementia is significantly higher in someone who has had a stroke.
• Multi-infarct dementia is the result of many small strokes (infarcts) and mini-strokes. Language or other functions may be impaired, depending on the region of the brain that is affected. The risk for dementia is significantly higher in someone who has had a stroke. Dementia is more likely when strokes affect both sides of the brain. Even strokes that don't show any noticeable symptoms can increase the risk of dementia.
• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an extremely rare, inherited disorder caused by a thickening of the walls of small- and medium-sized blood vessels, which reduces the flow of blood to the brain. CADASIL is associated with multi-infarct dementia, stroke, and other disorders. The first symptoms can appear in people between ages 20 and 40. CADASIL may have symptoms that can be confused with multiple sclerosis. Many people with CADASIL are undiagnosed.
• Subcortical vascular dementia (previously known as Binswanger's disease) involves extensive microscopic damage to the small blood vessels and nerve fibers that make up white matter. Some consider it an aggressive form of multi-infarct dementia. Cognitive changes include problems with short-term memory, organization, attention, decision making, and behavior. Symptoms tend to begin after age 60, and they progress in a stepwise manner. People with subcortical vascular disease often have high blood pressure, a history of stroke, or evidence of disease of the large blood vessels in the neck or heart valves.
• Cerebral amyloid angiopathy is a buildup of amyloid plaques in the walls of blood vessels in the brain. It is generally diagnosed when multiple tiny bleeds in the brain are discovered using MRI.

Neuropathology of neurodegenerative disorders

The different forms of age-related dementia, as well as many age-related neurodegenerative diseases, are thought to be caused by changes in various proteins. These diseases are called proteinopathies because they involve the abnormal buildup of specific proteins in the brain. Mutations in genes that provide instructions for making these proteins have been found to cause dementia in families. However, in the vast majority of affected individuals, dementia is not inherited, and the cause is unknown. Alzheimer's disease, frontotemporal disorders, and Lewy body dementia are proteinopathies.

In some dementias, changes in the tau protein cause it to form clumps inside nerve cells in the brain, which is believed to make the cells stop functioning properly and die. Disorders that are associated with the abnormal buildup of tau are called tauopathies.

In Alzheimer's disease, the tau protein aggregates (accumulates into abnormal clumps) and becomes twisted and tangled, forming fibers—neurofibrillary or tau tangles—inside neurons. Abnormal clumps (plaques) of the beta-amyloid protein are prominent in spaces between brain cells. Both plaques and tangles are thought to contribute to reduced function and nerve-cell death in AD and are the hallmarks of the disease.

Beta-amyloid plaques are also seen in some forms of LBD, cerebral amyloid angiopathy, and Parkinson's disease dementia. They are also common in elderly individuals who do not have dementia.

Some, but not all, forms of frontotemporal disorders are tauopathies. Other forms of these disorders are associated with the buildup of the protein TDP-43. A mutation in a gene called progranulin, and another in a gene called C9orf72, can cause frontotemporal disorders with accumulation of TDP-43 in nerve cells.

In other dementias and some brain disorders, the protein synuclein becomes misshapen and forms harmful clumps inside neurons in different brain regions. Disorders in which synuclein builds up inside neurons are called synucleinopathies. Changes in synuclein and/or its function are the basis of LBD and other disorders such as multiple system atrophy. Multiple system atrophy is a progressive neurodegenerative disorder characterized by a combination of symptoms that affect both the autonomic nervous system (the part of the nervous system that controls involuntary action such as blood pressure or digestion) and movement. These changes cause parkinsonism, a condition resembling Parkinson's disease.

Reversible dementia-like disorders and conditions

Many conditions that cause dementia-like symptoms can be halted or even reversed with the appropriate treatment.

• Normal pressure hydrocephalus is a buildup of cerebrospinal fluid in the brain. Elderly individuals with the condition usually have trouble walking and with bladder control before the onset of dementia. Normal pressure hydrocephalus can be treated or even reversed by implanting a shunt system to divert fluid from the brain.
• Nutritional deficiencies of vitamin B 1 (thiamine), caused by chronic alcoholism, and of vitamin B 12 can be reversed with treatment. People who have abused substances such as alcohol and recreational drugs sometimes display signs of dementia even after the substance abuse has stopped.
• Side effects of medications or drug combinations may cause cognitive impairment that looks like a degenerative or vascular dementia but which could reverse upon stopping these medications. 
• Vasculitis , an inflammation of brain blood vessels, can cause dementia after multiple strokes and may be treated with immunosuppressive medications.
• Subdural hematoma , or bleeding between the brain's surface and its outer covering (the dura), is common after a fall. Subdural hematomas can cause dementia-like symptoms and changes in mental function. With treatment, some symptoms can be reversed.
• Some non-malignant brain tumors can cause symptoms resembling dementia and recovery occurs following their removal by neurosurgery.
• Some chronic infections around the brain, so-called chronic meningitis, can cause dementia and may be treatable by drugs that kill the infectious agent.

Other neurodegenerative diseases and conditions that include dementia or dementia-like symptoms

Doctors have identified many other conditions that can cause dementia or dementia-like symptoms. The diseases have different symptoms that involve body and brain functions, and affect mental health and cognition.

• Argyrophilic grain disease is a common, late-onset degenerative disease that affects brain regions involved in memory and emotion. It causes cognitive decline and changes in memory and behavior, with difficulty finding words. The disease's signs and symptoms are indistinguishable from late-onset AD. Confirmation of the diagnosis can be made only at autopsy. 
• Creutzfeldt-Jakob disease (CJD)  is a rare brain disorder that is characterized by rapidly progressing dementia. Scientists have found that infectious proteins called prions become misshapen and tend to clump together, which causes brain damage. Initial symptoms include impaired memory, judgment, and thinking, along with loss of muscle coordination and impaired vision. Some symptoms of CJD can be similar to symptoms of other progressive neurological disorders, such as Alzheimer's disease.
• Chronic traumatic encephalopathy (CTE) is caused by repeated traumatic brain injury (TBI) in some people with multiple concussions. People with CTE may develop dementia, poor coordination, slurred speech, and other symptoms similar to those seen in Parkinson's disease 20 years or more after the injury. Late-stage CTE is also characterized by brain atrophy and widespread deposits of tau in nerve cells. In some people, even just 5 to 10 years beyond the traumatic brain injury, behavioral and mood changes may occur. Dementia may not yet be present and the brain may not have started to shrink, but small deposits of tau are seen in specific brain regions at autopsy.
• Huntington's disease is an inherited, progressive brain disease that affects a person's judgment, memory, ability to plan and organize, along with other cognitive functions. Symptoms typically begin around age 30 to 40 years and include abnormal and uncontrollable movements (chorea) as well as problems with walking and lack of coordination. Cognitive problems worsen as the disease progresses, and problems controlling movement lead to complete loss of ability for self-care.
• HIV-associated dementia (HAD) can occur in people with human immunodeficiency virus, the virus that causes AIDS. HAD damages the brain's white matter and leads to a type of dementia associated with memory problems, social withdrawal, and trouble concentrating. People with HAD may develop movement problems as well. The incidence of HAD has dropped dramatically with the availability of effective antiviral therapies for managing the underlying HIV infections.
• Secondary dementias occur in people with disorders that damage brain tissue. Such disorders may include multiple sclerosis, meningitis, and encephalitis, as well as Wilson's disease (in which excessive amounts of copper cause brain damage). People with malignant brain tumors may develop dementia or dementia-like symptoms because of damage to their brain circuits or a buildup of pressure inside the skull.

Risk factors for dementia and vascular cognitive impairment

The following risk factors may increase a person's chance of developing one or more kinds of dementia. Some of these factors can be modified, while others cannot.

• Age —Advancing age is the best known risk factor for developing dementia.
• Hypertension —High blood pressure has been linked to cognitive decline, stroke, and types of dementia that damage the white matter regions of the brain. High blood pressure causes “wear-and-tear” to brain blood vessel walls called arteriosclerosis.
• Stroke —A single major stroke or a series of smaller strokes increases a person's risk of developing vascular dementia. A person who has had a stroke is at an increased risk of having additional strokes, which further increases the risk of developing dementia.
• Alcohol —Most studies suggest that regularly drinking large amounts of alcohol increases the risk of dementia. Specific dementias are associated with alcohol abuse, such as Wernicke-Korsakoff syndrome.
• Atherosclerosis —The accumulation of fats and cholesterol in the lining of arteries, coupled with an inflammatory process that leads to a thickening of the vessel walls (atherosclerosis), can lead to stroke, which raises the risk for vascular dementia.
• Diabetes —People with diabetes appear to have a higher risk for dementia. Poorly controlled diabetes is a risk factor for stroke and cardiovascular disease, which in turn increases the risk for vascular dementia.
• Down syndrome —Many people with Down syndrome develop symptoms of Alzheimer's disease by the time they reach middle age.
• Genetics —The chance of developing a genetically linked form of dementia increases when more than one family member has the disorder. In many dementias, there can be a family history of a similar disease. In some cases, such as with the FTDs, having just one parent who carries a mutation increases the risk of inheriting the condition. A very small proportion of dementia is inherited.   
• Head injury —An impact to the head can cause a traumatic brain injury (TBI). Certain types of TBI, or repeated TBIs, can cause dementia and other severe cognitive problems.
• Parkinson's disease —The degeneration and death of nerve cells in the brain in people with Parkinson's disease can cause dementia and significant memory loss.
• Smoking —Smoking increases the risk of developing cardiovascular diseases that slow or stop blood from getting to the brain.

The National Academies of Sciences, Engineering, and Medicine published a report of the evidence on preventing dementia .

To diagnose dementia, doctors will first assess whether an individual has an underlying treatable condition such as abnormal thyroid function, vitamin deficiency, or normal pressure hydrocephalus that may relate to cognitive difficulties. Early detection of symptoms is important, as some causes can be treated. In many cases, the specific type of dementia may not be confirmed until after the person has died and the brain is examined.

An assessment may include:

• Medical history and physical exam—Assessing a person's medical and family history, current symptoms and medication, and vital signs can help the doctor detect conditions that might cause or occur with dementia. Some conditions may be treatable.
• Neurological evaluations—Examining balance, sensory response, reflexes, and other functions can help doctors identify signs of conditions that may affect the diagnosis or are treatable with drugs. Doctors also might use an electroencephalogram (EEG), a test that records patterns of electrical activity in the brain, to check for abnormal electrical brain activity.
• Brain scans—Computed tomography (CT) and magnetic resonance imaging (MRI) can detect structural abnormalities and rule out other causes of dementia. Positron-emission tomography (PET) can look for patterns of altered brain activity that are common in dementia. Advances in PET can detect amyloid plaques and tau tangles in AD.
• Cognitive and neuropsychological tests—These tests are used to assess memory, language skills, math skills, problem-solving, and other abilities related to mental functioning.
• Laboratory tests—Testing a person's blood and other fluids, as well as checking levels of various chemicals, hormones, and vitamin levels, can identify or rule out conditions that may contribute to dementia.
• Presymptomatic tests—Genetic testing can help some people who have a strong family history of dementia identify their own risks.
• Psychiatric evaluation—This evaluation can help determine if depression or another mental health condition is causing or contributing to a person's symptoms.

Guidelines prepared by the National Institute on Aging ( NIA ) and the Alzheimer's Association focus on three stages of Alzheimer's disease:

• Dementia due to AD
• Mild cognitive impairment (MCI) due to AD
• Preclinical (presymptomatic) AD—presymptomatic identification is exclusively used as a research diagnosis at this point and has no relevance to routine clinical practice.

The guidelines also include biomarker tests used in studies to measure biological changes in the brain associated with Alzheimer's disease and criteria for documenting and reporting Alzheimer's-related changes observed during an autopsy.

Treatment and management

There are currently no treatments to stop or slow dementia in neurodegenerative diseases. Some diseases that occur at the same time as dementia, such as diabetes and depression, can be treated. Other symptoms that may occur in dementia-like conditions can also be treated, although some symptoms may only respond to treatment for a period of time. A team of specialists—doctors, nurses, and speech, physical, and other therapists—familiar with these disorders can help guide patient care.

Therapists can help with maintaining physical movement, address speech and swallowing issues, and help people learn new ways to handle loss of skills with everyday tasks such as feeding oneself. It is important to educate family, friends, and caregivers about a loved one's medical issues. Also, in-person and online support groups available through many disease awareness and caregiver advocacy organizations can give families and other caregivers additional resources, as well as opportunities to share experiences and express concerns.

Medications are available to treat certain behavioral symptoms, as well as delusions, depression, muscle stiffness, and risk factors for vascular cognitive impairment such as high blood pressure. Always consult with a doctor, as some medications may make symptoms worse.

Most drugs for dementia are used to treat symptoms in AD. One class of drugs, cholinesterase inhibitors, can temporarily improve or stabilize memory and thinking skills in some people by increasing the activity of the cholinergic brain network—a subsystem in the brain that is highly involved with memory and learning. These drugs include donepezil, rivastigmine, and galantamine.

The drug memantine is in another class of medications called NMDA receptor antagonists, which prevent declines in learning and memory. Memantine may be combined with a cholinesterase inhibitor for added benefits. The U.S. Food and Drug Administration (FDA) approved the drug aducanumab (Aduhelm™) to reduce the building up harmful amyloid beta plaques.

There are no medications approved to treat or prevent frontotemporal disorders   and most other types of progressive dementia. Sedatives, antidepressants, and other drugs used to treat Parkinson's and Alzheimer's symptoms may help manage certain symptoms and behavioral problems associated with the disorders.

Medicines available for managing Lewy body dementia are aimed at relieving symptoms such as gait and balance disturbances, stiffness, hallucinations, and delusions. Studies suggest that the cholinesterase inhibitor drugs for Alzheimer's disease may offer some benefit.

Some studies suggest that the cholinesterase inhibitors used to treat people with AD might improve cognitive, behavioral, and psychotic symptoms in people with Parkinson's disease dementia. Many of the medications used to treat the motor symptoms of PD worsen the cognitive problems. The FDA has approved rivastigmine (an Alzheimer's drug) to treat cognitive symptoms in PDD.

Vascular dementia is often managed with drugs that prevent strokes or reduce the risk of additional brain damage. Some studies suggest that drugs that improve memory in AD might benefit people with early vascular dementia. Treating the modifiable risk factors can help prevent additional stroke.

The National Institute of Neurological Disorders and Stroke ( NINDS ) is a leading federal funder of research on nervous system disorders, including dementia. Another NIH Institute, the National Institute on Aging ( NIA ), is a leading federal funder of research on Alzheimer's disease and Alzheimer's disease-related dementias. Although scientists have some understanding of the dementias and the mechanisms involved, ongoing research may lead to new ways to understand the cause(s) of the disease, diagnose, treat, or perhaps prevent or block disease development.

Research partnerships on dementia involving NINDS and  NIA include:

• The National Alzheimer's Project Act (NAPA) is a coordinated national plan to address Alzheimer's disease and improve care and services. The project calls for increased collaboration between scientists, the federal government, and public organizations while improving patient care. NAPA's  National Plan to Address Alzheimer's Disease is designed to expand research in Alzheimer's disease and related dementias prevention and treatment, and to move the most promising drugs from discovery into clinical trials. The plan also calls for increased federal funding for AD research, as well as support for those affected by AD and their families, increased public awareness about AD, and improved data collection and analysis. These goals also apply to dementia with Lewy bodies as well as frontotemporal, mixed, and vascular dementias. The plan's overarching research goal is to “prevent or effectively treat Alzheimer's disease by 2025.”
• The Accelerating Medicines Partnership® Program for Alzheimer's Disease (AMP ® AD)  is a multi-sector partnership among the NIH, 10 biopharmaceutical companies, and several nonprofit organizations to develop new clinically relevant therapeutics and biomarkers to confirm existing therapies. The goal is to speed up the process of bringing new medicines to people with AD or who are at risk for developing AD.
• M2OVE—AD: Molecular Mechanisms of the Vascular Etiology of Alzheimer's Disease  is a program that allows scientists from diverse fields to work collaboratively to understand the complex molecular mechanisms by which vascular risk factors influence AD. The work also identifies new targets for treatment and prevention. It builds on the open-science approach and the big data infrastructure established by the AMP ® AD mentioned above.
• The Tau Center Without Walls program is designed to increase collaboration and sharing of data and resources among researchers to better understand the protein tau and its involvement in such disorders as frontotemporal degeneration (FTD). These efforts may lead to advances in prevention, diagnosis, or treatment of tau toxicity associated with FTD, and contribute to tool development that can be applied in FTD clinical trials and other tau-related disorders.
• The Dementia with Lewy Body Biomarkers Consortium is designed to expand the collection of clinical data and biological specimens in NINDS ' Parkinson's Disease Biomarkers Program to include data from people with Lewy body dementias. Standardized research and data collection and reporting systems will make it easier for researchers to share and confirm their research.
• Researchers in The Small Vessel Vascular Contributions to Cognitive Impairment and Dementia (VCID) Biomarkers Program hope to develop biomarkers of key vascular processes related to VCID in Alzheimer's disease. Identifying biomarkers may improve the efficiency and outcome of trials designed to test drug effectiveness and safety in humans, and speed the development of therapies for the dementias.

Additional NINDS and NIA research on age-related and other dementias includes:

• For information about participating in clinical studies, visit NIH Clinical Research Trials and You .
• For a list of AD and related dementias clinical trials and studies, visit Alzheimers.gov .
• For a comprehensive list of all clinical trials, visit Clinicaltrials.gov and type in the name of the dementia (e.g., “Lewy Body dementia” or “vascular dementia”).
• Several research projects hope to identify biomarkers (measurable biological signs that may indicate disease risk and progression or confirm diagnosis) for the dementias. Such biomarkers could be detected through imaging or even blood tests. Research projects include the study of possible biomarkers to predict cognitive decline in people with Parkinson's disease, the Alzheimer's Biomarkers Consortium in Down Syndrome (many people with Down syndrome have Alzheimer's-related brain changes in their 30s that can lead to dementia in their 50s and 60s), and genetic and biomarker studies that may lead to promising treatments for FTD. The Alzheimer's Disease Neuroimaging Initiative (ADNI) is a longitudinal study to validate the use of biomarkers for Alzheimer's disease clinical trials and diagnosis.
• A number of drugs and compounds that might slow the progression of AD and other dementias are in various stages of testing. A NINDS study found that tau antisense oligonucleotides—compounds that are genetically engineered to block a cell's assembly line production of the toxic form of the tau protein—could prevent and reverse some of the brain injury in animal models of the disease. NIH-supported prevention trials are testing drugs that target amyloid proteins that form plaques in the brain. Other NIH studies include the use of drugs being developed to treat autism spectrum disorders to see if they can improve cognitive functions in people with age-related cognitive decline.
• Physical activity can benefit mental well-being and improve daily functioning and quality of life in people with dementia. Researchers are assessing the combined approach of aerobic and cognitive exercise to see if it can delay or slow the progression of Alzheimer's disease in at-risk older adults. Other research is assessing the benefit of exercise to delay mild cognitive impairment in older individuals, and to improve brain function in older adults who may be at risk for developing AD.
• NIH scientists continue to look for new genes that may be responsible for the development of AD and other forms of dementia. One approach is using genome-wide association studies which can rapidly scan the complete sets of DNA, or genomes, of many people to find genetic variations associated with a particular disease. Identifying new genetic associations for neurodegenerative diseases may lead to better strategies to detect, treat, and prevent the dementias.
• Clinical imaging may help researchers better understand changes in the brains of people with dementia, as well as help diagnose these disorders. For example, researchers hope to enhance brain imaging techniques to make it possible to detect, and therefore try to stop, the earliest changes in the protective blood-brain barrier that may contribute to vascular contributions to cognitive impairment and dementia. 
• The International Alzheimer's Disease Research Portfolio (IADRP) helps individuals learn about both AD research related dementias at public and private organizations around the world. It also helps organizations leverage resources to avoid duplication of efforts. The Common Alzheimer's Disease Research Ontology—a classification system that allows organizations to integrate and compare research portfolios—was developed by the NIA, NIH, and Alzheimer's Association.
• Studying groups of people over time may lead to ways to identify those at risk of developing dementia or cognitive impairment. Three NIH-funded research teams are conducting longitudinal studies of individuals in which frontotemporal disorders run in families and appear on their own (sporadic) to understand the progression of FTD both before and after symptom onset; identify genes; discover biomarkers for diagnosis, progression, and prognosis; and establish a clinical research consortium to support FTD therapy development.
• A number of proteins—including tau, alpha-synuclein, TDP-43, and amyloid-beta—are involved with various cellular processes. When there is a change in the genes that direct the production or rate of clearance (degradation) of these proteins, the proteins can build in abnormal amounts and form abnormal clumps that damage nerve cells in the brain, causing dementia and other symptoms such as motor function disorders. NIH-funded research projects are aimed at better understanding the toxic effects of protein buildup and how it is related to the development of dementia. A number of studies are targeting the buildup of amyloid, which forms plaques that are characteristic in Alzheimer's disease. Other research hopes to better understand how proteins become harmful in frontotemporal disorders and Lewy body dementia.
• Stem cells are unique in that they have the potential to develop into many different cell types in the body, including brain cells. Scientists are exploring them to discover nerve cell mechanisms that lead to the onset and progression of AD and other forms of dementia. For example, scientists converted human skin cells into a model of human neurons. Such neurons, when created from individuals with familial forms of AD, show biochemical changes that represent the disease. Researchers are investigating the mechanism by which human AD neurons develop cellular and molecular defects in protein production and degradation. 

More information about research supported by NINDS , the  NIA , and other NIH Institutes and Centers can be found using NIH RePORTER , a searchable database of current and past research projects supported by NIH and other Federal agencies. RePORTER also includes links to publications and resources from these projects.

Currently, there are no cures for the common dementias caused by progressive neurodegeneration, including AD, frontotemporal disorders, and Lewy body dementia. There is some evidence suggesting that controlling vascular risk factors such as high blood pressure may reduce the risk of developing dementia decades later. Some symptoms of dementia and conditions that cause dementia or have dementia-like symptoms are treatable. A better understanding of dementia disorders, as well as their diagnosis and treatment, will make it possible for affected individuals and their caretakers to live their lives more fully and meet daily challenges. NIH , primarily through research activities funded by NINDS and  NIA , continues to improve diagnostics, design therapeutic approaches to dementias, and create tools and resources to help speed the development of treatments that can be used in practice. These discoveries may eventually lead to ways to slow disease progression or even cure and prevent the dementias.

Where can I find more information about the dementias?

Information may be available from the following organizations and resources:

Alzheimer's Association Phone: 312-335-8700 or 800-272-3900

Alzheimer's Drug Discovery Foundation Phone: 212-901-8000

Alzheimer's Foundation of America Phone: 866-232-8484

Alzheimer's and Related Dementias Education and Referral (ADEAR) Center Phone: 800-438-4380

Association for Frontotemporal Degeneration (AFTD) Phone: 267-514-7221 or 866-507-7222

BrightFocus Foundation Phone: 800-437-2423

John Douglas French Alzheimer's Foundation Phone: 310-445-4650

Lewy Body Dementia Association Phone: 404-935-6444 or 800-539-9767

National Institute of Mental Health (NIMH) Phone: 301-443-4513 or 866-415-8051

National Organization for Rare Disorders (NORD) Phone: 203-744-0100 or 800-999-6673

The National Task Group on Intellectual Disabilities and Dementia Practices (NTG)

The Bluefield Project to Cure Frontotemporal Dementia

Alpha-synuclein —The major protein present in abnormal clumps called Lewy bodies which are seen in the brains of people with Parkinson's disease and some dementias. Disorders in which alpha-synuclein accumulates inside nerve cells are called synucleinopathies.

Alzheimer's disease (AD) —The most common cause of dementia. Nearly all brain functions, including memory, movement, language, judgment, and behavior, are eventually affected. Alzheimer's disease is defined by observing high levels of amyloid-containing plaques and tau protein-containing neurofibrillary tangles in the brain.

Amyloid —A protein with beta-pleated sheets that aggregate to form the characteristic clumps (plaques) that appear in the brains of people with AD. Other proteins that form aggregates are tau proteins also seen in AD, and alpha-synuclein present in dementia with Lewy bodies and in Parkinson's Disease.

Biomarkers —Measurable biological signs in the living body that may indicate risk or progression of a disease and improve diagnosis.

Corticobasal degeneration —A progressive disorder characterized by abnormal buildup of the tau protein, nerve cell loss, and atrophy in multiple areas of the brain.

Dementia —A term for a condition that significantly interferes with daily life because of impaired thinking and memory.

Dementia with Lewy bodies —A type of Lewy body dementia that is a form of progressive dementia.

Frontotemporal disorders (FTD) —A group of dementias characterized by degeneration of nerve cells, especially those in the frontal and temporal lobes of the brain.

Lewy body dementia —A progressive dementia characterized by the presence of abnormal structures called Lewy bodies in the brain.

mild cognitive impairment —a stage between normal cognitive changes that may occur with age and the more serious symptoms that indicate dementia

Mixed dementia —Dementia in which one form of dementia and another condition or dementia cause damage to the brain; for example, Alzheimer's disease and small vessel disease or vascular dementia.

Multi-infarct dementia —A type of vascular cognitive impairment and dementia caused by numerous small strokes in the brain.

Neurodegeneration —The progressive loss of nerve cell structure or function.

Neurofibrillary tangles —Bundles of twisted filaments largely made up of tau protein and found in nerve cells in the brains of people with AD and other types of dementia such as FTD.

Parkinson's disease dementia —A secondary dementia that can occur in people with advanced Parkinson's disease. Many people with Parkinson's have the amyloid plaques and neurofibrillary tangles found in Alzheimer's disease, but it is not clear if the diseases are linked.

Plaques —Abnormal clumps of amyloid protein that are found in large numbers in the brains of persons with Alzheimer's disease.

Tau —A protein that helps the functioning of microtubules, which are part of the cell's structural support that help deliver substances throughout the cell. In several dementia disorders, tau will twist into filaments that become tangles. Disorders associated with an accumulation of tau, such as frontotemporal dementia, are called tauopathies.

Vascular dementia —A type of dementia caused by brain damage from cerebrovascular or cardiovascular problems, usually strokes.

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No. 95; September 2017

Many parents do not understand why their teenagers occasionally behave in an impulsive, irrational, or dangerous way. At times, it seems like teens don't think things through or fully consider the consequences of their actions. Adolescents differ from adults in the way they behave, solve problems, and make decisions. There is a biological explanation for this difference. Studies have shown that brains continue to mature and develop throughout childhood and adolescence and well into early adulthood.

Scientists have identified a specific region of the brain called the amygdala that is responsible for immediate reactions including fear and aggressive behavior. This region develops early. However, the frontal cortex , the area of the brain that controls reasoning and helps us think before we act, develops later. This part of the brain is still changing and maturing well into adulthood.

Other changes in the brain during adolescence include a rapid increase in the connections between the brain cells and making the brain pathways more effective. Nerve cells develop myelin, an insulating layer that helps cells communicate. All these changes are essential for the development of coordinated thought, action, and behavior.

Changing Brains Mean that Adolescents Act Differently From Adults

Pictures of the brain in action show that adolescents' brains work differently than adults when they make decisions or solve problems. Their actions are guided more by the emotional and reactive amygdala and less by the thoughtful, logical frontal cortex. Research has also shown that exposure to drugs and alcohol during the teen years can change or delay these developments.

Based on the stage of their brain development, adolescents are more likely to:

• act on impulse
• misread or misinterpret social cues and emotions
• get into accidents of all kinds
• get involved in fights
• engage in dangerous or risky behavior

Adolescents are less likely to:

• think before they act
• pause to consider the consequences of their actions
• change their dangerous or inappropriate behaviors

These brain differences don't mean that young people can't make good decisions or tell the difference between right and wrong. It also doesn't mean that they shouldn't be held responsible for their actions. However, an awareness of these differences can help parents, teachers, advocates, and policy makers understand, anticipate, and manage the behavior of adolescents.

Coping with an Alzheimer’s or Dementia Diagnosis

Age-related memory loss, alzheimer’s disease: signs, symptoms, and causes.

• Stages of Alzheimer’s Disease: What to Expect as it Progresses

Excerpt: Floating in the Deep End by Patti Davis

Early-onset alzheimer’s disease, living with alzheimer’s or dementia, creutzfeldt-jakob disease (cjd).

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What is dementia?

Signs and symptoms of dementia, normal memory changes vs. dementia symptoms, dementia causes, dementia risk factors, types of dementia, diagnosing dementia, preventing dementia or slowing its progression, dementia symptoms, types, and causes.

Suspecting you or a loved one have dementia can be extremely distressing. But the more you understand about the condition, the more you can do to improve the outcome.

Dementia is an umbrella term for disorders resulting from disease or trauma to the brain that lead to memory loss, personality change, and impaired intellectual functions. These changes are not part of normal aging and are severe enough to impact daily living, independence, and relationships. According to figures from Alzheimer’s Disease International, about 50 million people around the world are currently living with dementia and a new case is diagnosed every 3.2 seconds. While Alzheimer’s disease is the most common type of dementia, there are also many other forms, including vascular and mixed dementia.

With any type of dementia, there will likely be noticeable decline in communication, learning, remembering, and problem solving. These changes may occur quickly or very slowly over time. The progression and outcome vary, but are largely determined by the type of dementia and which area of the brain is affected.

Facing up to the possibility of dementia inevitably shifts your perceptions, relationships, and priorities. But experiencing symptoms doesn’t have to mean the end of your normal life. Certain types of dementia can be slowed and some causes even reversed if caught in time. The first step is to understand what distinguishes normal memory loss from dementia symptoms, and how to identify the different types of dementia. Whatever your diagnosis, though, there can be plenty of things you can do to help manage symptoms and continue to enjoy a full and rewarding life for as long as possible.

As we age, many of us experience lapses in memory. It can be worrying and confusing to realize that something you once took for granted isn’t working as well as it used to. But not all memory changes indicate dementia—and dementia impacts more than just memory. Symptoms can also affect visual and spatial skills, executive functioning, language, and mood or personality. To meet the diagnostic criteria for dementia, you’d need to experience difficulties in at least one of those areas in addition to memory loss.

Common signs and symptoms include:

• Memory loss. Changes in short-term memory, forgetting dates, events, needing more memory aids, repeatedly asking the same questions.
• Impaired judgement. Fall victim to scams , give away money, struggle to care for a pet.
• Difficulties with abstract thinking. Trouble thinking about ideas, solving puzzles, being creative, completing daily tasks.
• Faulty reasoning. Trouble problem solving, working with numbers, balancing check book, or following directions or recipes.
• Inappropriate behavior. Loss of inhibitions, improper sexual comments or actions.
• Loss of communication skills. Difficulty finding words, following conversations or storylines.
• Disorientation and confusion. Become lost in familiar places, confusion about dates or seasons. Not recognizing or being confused about familiar people.
• Gait, motor, and balance problems. Loss of coordination, increasing falls or accidents.
• Neglect of personal care and safety. Self-neglect , decline in personal hygiene, wearing inappropriate clothing for the weather, neglecting nutrition.
• Personality changes. Withdraw from social activities, apathy or listlessness, sleep problems, depression, hallucinations, paranoia, or agitation.

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It’s something we all have to face but the inevitable changes of aging can still be both humbling and surprising. But while experiencing wrinkling skin, fading hair color, and mild, short-term memory loss is common as we age, severe and rapid memory loss is definitely NOT a part of normal aging. In fact, many people are able to preserve their brainpower as they get older by staying mentally and physically active and making other healthy lifestyle choices.

Differentiating the signs of dementia from normal aging can help to either set your mind at rest or encourage you to begin taking steps to slow the progression of symptoms. In broad terms, normal memory changes associated with aging don’t significantly interfere with your ability to function in your daily life. These may include:

Slower thinking and problem solving – The speed of learning slows down; short-term memory takes longer to function; reaction time increases.

Decreased attention and concentration – More distractedness. All of the interruptions make learning more difficult.

Slower recall – A greater need for hints to jog the memory.

[Read: Age-Related Memory Loss]

Distinguishing between normal memory loss and dementia symptoms is not an exact science but there are some clues to look for:

Are your memory changes typical aging or symptoms of dementia?

In a healthy brain, mass and speed may decline in adulthood, but this miraculous organ continues to form vital connections throughout life. However, when connections are lost through inflammation, disease, or injury, neurons eventually die and dementia can develop . While the prospect of literally losing one’s self can be extremely traumatic, early intervention can dramatically alter the outcome.

In recent years, scientists have greatly demystified the origins of dementia, although there is still much that remains unclear. Genetics may increase your risks, but it’s likely a combination of hereditary, environmental, and lifestyle factors are also at work.

Dementia can be caused by:

Medical conditions that progressively attack brain cells and connections, most commonly seen in Alzheimer’s disease, Parkinson’s disease , or Huntington’s disease .

Vascular conditions such as strokes that disrupt oxygen flow and rob the brain of vital nutrients. Additional strokes may be prevented by reducing high blood pressure , treating heart disease, and quitting smoking .

Poor nutrition, dehydration, and certain substances, including drugs and alcohol. Treating conditions such as insulin resistance, metabolic disorders, and vitamin deficiencies may reduce or eliminate symptoms of dementia.

Single trauma or repeated injuries to the brain. Depending on the location of the brain injury, cognitive skills and memory may be impaired.

Infection or illness that affects the central nervous system, including Creutzfeldt-Jakob disease and HIV. Some conditions are treatable, including liver or kidney disease, depression-induced pseudo dementia, and operable brain tumors.

Some risk factors for dementia are outside your control. Advancing age, a family history of dementia, head injury, or Down syndrome, for example, may increase your risk of developing dementia. However, you may have more influence over other lifestyle factors, such as your diet and activity levels.

Factors that put you at a higher risk of dementia include:

Poor heart health. Heart and brain health are strongly linked. Hypertension , high cholesterol, atherosclerosis (narrowing of the arteries), heart disease, and stroke can all increase your risk for dementia.

Diabetes. Poorly managed diabetes can lead to stroke and heart disease, increasing your risk for dementia, especially vascular, Alzheimer’s, or mixed dementia.

Smoking. Smoking increases your risk of cardiovascular disease, which in turn heightens your risk of mental decline and dementia.

Alcohol abuse. Heavy or binge drinking can increase your risk of developing Alzheimer’s disease and other forms of dementia, including Korsakoff syndrome, a type of dementia commonly caused by alcohol abuse.

Neglected mental health. Untreated depression , loneliness, social isolation, and a lack of mental stimulation can all contribute to an increase in the likelihood of developing dementia.

[Read: Building Better Mental Health]

Sleep apnea. Untreated sleep apnea can disrupt your sleep and lead to daytime sleepiness, impaired brain function, and an increased risk of developing dementia later in life.

Poor diet. Eating a diet high in processed food, unhealthy fats, sugar, and refined carbs can take a toll on your heart and brain health and increase your risk of diabetes, vascular disease, and Parkinson’s , all red flags for dementia.

Lack of exercise. Leading a sedentary lifestyle can impact your resilience, disrupt your sleep, increase your risk of heart disease, and accelerate cognitive decline and the onset of dementia symptoms.

Hearing loss. Hearing impairment may cause a faster rate of atrophy in the brain and cognitive decline. It can also make it harder to socialize with friends, another risk factor for dementia.

All dementias involve cognitive decline that can impact daily living. However, it’s important to pinpoint the specific type of dementia in order to optimize treatment. More than 50 conditions involve dementia, including:

Alzheimer’s disease

This is the most common form of dementia, which according to the Alzheimer’s Association accounts for 60 to 80 percent of all diagnosed cases. The following 10 warning signs may indicate that your dementia symptoms are the result of Alzheimer’s disease :

1. Your memory loss is sufficient to disrupt your daily life. You forget things you’ve recently learned, forget important dates or events, repeatedly ask for the same information, or rely more and more on memory aides or family members.

2. You’re having difficulties with problem-solving. You’re not able to follow plans, work with numbers, follow recipes, or keep track of bills.

3. Having trouble completing daily tasks such as driving to a familiar place, remembering rules to a game, or completing assignments at work.

4. Experiencing confusion over time or place. You lose track of dates, forget where you are or how you got there.

5. Misplacing things. Putting things in strange places, being unable to retrace your steps, perhaps even accusing others of stealing.

6. Developing problems with spoken or written words. You have difficulties following a conversation, often repeat yourself, struggle to find the right word, or call things by the right name.

7. Having difficulty understanding visual images. Trouble reading, judging distances, colors, or contrast, or recognizing your own reflection.

8. Displaying poor judgement. There’s a decline in your decision making, you’re giving away large sums of money, paying less attention to personal grooming.

9. Withdrawing from work or social activities. You have trouble remembering how to complete a work project or favorite hobby, difficulty following sports, withdraw from social events.

10. Exhibiting changes in mood. Becoming confused, depressed, suspicious, fearful, or anxious.

[Read: Alzheimer’s Disease: Signs, Symptoms, Causes, and Stages]

Early diagnosis of Alzheimer’s can help to prolong independence and is the first step towards treatment, management, and continuing to enjoy a full life.

Vascular dementia

Vascular dementia results from a series of small strokes or changes in the brain’s blood supply. A sudden onset of symptoms can indicate vascular dementia, and while it severely impacts memory and cognitive functioning, there are ways to reduce its severity.

Mixed dementia

This is a condition in which Alzheimer’s disease and vascular dementia occur simultaneously. The combination of the two types of dementia most commonly occurs in advanced senior years, often indicated by cardiovascular disease and dementia symptoms that get worse slowly over time.

Less common forms of dementia

Pick’s Disease affects personality, orientation and behavior. Pick’s disease may be more common in women and occurs at an early age.

Creutzfeldt-Jakob Disease (CJD) is often associated with exposure to beef that is contaminated with bovine spongiform encephalopathy (BSE), the scientific term for mad cow disease. Creutzfeldt-Jakob disease progresses rapidly along with mental deterioration and involuntary movements.

Huntington’s Disease is an inherited, degenerative disease. Huntington’s causes involuntary movement and usually begins during mid-life.

Parkinson’s Disease Dementia can develop in the later stages of Parkinson’s disease , a progressive disorder of the central nervous system.

Lewy Body Dementia causes symptoms similar to Alzheimer’s disease. People with Lewy Body dementia experience hallucinations and can become fearful.

Mild cognitive impairment (MCI)

Mild cognitive impairment (MCI) is a stage between normal aging and dementia and involves problems with memory, language, or other cognitive functions. But unlike those with full-blown dementia, people with MCI are still able to function in their daily lives without relying on others.

Many people with MCI eventually develop Alzheimer’s disease or another type of dementia. However, others plateau at a relatively mild stage of decline and are able to live independently. Some people with mild cognitive impairment even return to normal.

It is not yet fully understood why MCI progresses to Alzheimer’s disease in some people, while remaining stable in others. The course is difficult to predict, but in general, the greater the degree of memory impairment, the greater the risk of developing Alzheimer’s down the line. According to the Alzheimer’s Association, roughly 15 to 20 percent of the population over the age of 65 experience some degree of mild cognitive impairment.

Symptoms of MCI include:

• Frequently losing or misplacing things.
• Frequently forgetting conversations, appointments, or events.
• Difficulty remembering the names of new acquaintances.
• Difficulty following the flow of a conversation.

Read: Mild Cognitive Impairment (MCI) .

Obtaining an early diagnosis of dementia is critical, especially if your symptoms appear suddenly. Some medications for dementia may be more beneficial if given early in the progression of the disease. Timely intervention may also help you better control symptoms and prolong your quality of life.

There is no single medical test used to diagnose dementia. To make a diagnosis, your doctor will assess your memory problems, changes in thinking, behavior, and function, and conduct medical tests to rule out other conditions and drug interactions that may be causing your symptoms.

While your doctor may be able to broadly diagnose dementia, determining the specific type can sometimes be challenging. Many symptoms overlap between different types of dementia, so you may need to consult a specialist neurologist or psychologist for a full diagnosis.

Coping with a diagnosis

Being diagnosed with dementia is a life-changing experience—for both you and your loved ones. It can turn your world upside down and leave you grappling with a host of conflicting emotions, from shock, anger, and grief to profound sadness and isolation.

[Read: Coping with an Alzheimer’s or Dementia Diagnosis]

While there is currently no cure for dementia, a diagnosis doesn’t mean that your life is over. There are treatments available for the symptoms. There are also steps you can take to help slow the progression of the disease and delay the onset of more debilitating symptoms, enabling you to prolong your independence and live a rich and full life for longer.

Recent research suggests that healthy lifestyle habits and mental stimulation may help prevent dementia altogether, delay its onset, or if you’ve already been diagnosed, slow the onset of more debilitating symptoms. In fact, research published in the Journal of the American Medical Association in 2019 concluded that healthy lifestyle changes can reduce the risk of dementia even if you have a genetic predisposition.

Just as physical exercise keeps you physically fit, exercising your mind and memory can help you stay mentally sharp, no matter your family history or how old you are. The following strategies can help:

1. Regular exercise. Starting a regular exercise routine, including cardio and strength training, may significantly reduce your risk of developing dementia. Aim for 30 minutes of moderate exercise on most days of the week.

2. Social engagement. The more socially active you are, the more you connect face-to-face with others, the stronger your memory and cognition is likely to be.

3. Healthy diet. Brain-healthy eating habits, such as those promoted in the Mediterranean diet, can help reduce inflammation, protect neurons, and promote better communication between brain cells. Daily servings of fruit and vegetables and weekly servings of fish may help to lower your risk for dementia. 

4. Mental stimulation. By continuing to learn new things and challenge your brain, you can strengthen your cognitive skills, stay mentally sharp, and may delay or prevent dementia symptoms.

5. Quality sleep. Getting quality sleep may help to flush out brain toxins and avoid the build-up of damaging plaques.

6. Stress management. Unchecked stress takes a heavy toll on the brain, shrinking a key memory area, hampering nerve cell growth, and worsening dementia symptoms.

7. Vascular health . Controlling your blood pressure, monitoring your cholesterol levels, and quitting smoking can have beneficial effects on both your heart and brain health.

To learn more about putting these strategies into action, see Preventing Alzheimer’s Disease—or Slowing its Progress .

Caregiver support

Call the  Alzheimer’s Association  helpline at 1 800 272 3900 or the  Alzheimer’s Foundation of America  at 1-866-232-8484.

Call the  Alzheimer’s Society  helpline at 0300 222 1122 or  find support near you .

Call the  Dementia Australia  helpline at 1800 100 500 or  find support programs .

Find an Alzheimer Society  in your area.

Call the Alzheimer’s and Related Disorders Society of India  24-hour helpline in your area .

Browse a worldwide directory of  Alzheimer associations  for information, advice, and support near you. (Alzheimer’s Disease International)

More Information

• Neurocognitive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
• Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., … Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413–446. Link
• Morris, M. C., Tangney, C. C., Wang, Y., Sacks, F. M., Barnes, L. L., Bennett, D. A., & Aggarwal, N. T. (2015). MIND diet slows cognitive decline with aging. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 11(9), 1015–1022. Link
• McEvoy, C. T., Guyer, H., Langa, K. M., & Yaffe, K. (2017). Neuroprotective diets are associated with better cognitive function: The Health and Retirement Study. Journal of the American Geriatrics Society, 65(8), 1857–1862. Link
• McMillan, L., Owen, L., Kras, M., & Scholey, A. (2011). Behavioural effects of a 10-day Mediterranean diet. Results from a pilot study evaluating mood and cognitive performance. Appetite, 56(1), 143–147. Link

More in Alzheimer’s Disease & Dementia

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What’s normal, what’s not, and when to seek help

Recognizing the symptoms and coping with a diagnosis

Stages of Alzheimer’s Disease

Understanding the 3-stage and 7-stage models of Alzheimer’s

Advice for Alzheimer’s caregivers from Patti Davis, best-selling author of The Long Goodbye

Symptoms, causes, and coping tips

Maintaining a rich and fulfilling life for longer

Types, symptoms, and treatment

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