These days, people are getting older and older. Europe is the oldest continent in the world at this moment. According to research, every sixth European is 65 years or older. Scientists also predict that there will even be more older Europeans in the future. They think that every fourth European will be 65 or older in 2050. This will of course have an impact for all the citizens and societies of Europe. For example, shop owners will include more products for seniors in their assortments and public places will have to make their place more accessible to older and handicapped individuals. The finances of countries may also have change. There will be more people on a pension and so the pension schemes might need to restructure their financial basis. An increase of older people will also mean an increase in the long-term care schemes and these might also have to be changed. This change raises many questions and these questions will be answered by the scientific discipline of gerontology.

Gerontology

Gerontology is a scientific discipline that studies human ageing. The study draws from different scientific disciplines like economy, sociology, psychology, epidemiology and of course, biology. The word has its origin in Greek. ‘Geron’ in Greek means old man and ‘gerh’ means growing up or aging. The word refers to being old and also to the process of ageing. The word ‘gerontology’ was first used in the 19th century, but throughout the history, people have been interested in gerontology.

Usually when people think about old age, they think about grey hair, hearing loss, wrinkles, trouble walking and memory loss. However, old 3age is not just a biological phenomenon, it’s also a social one. It is society that influences how people see themselves, how their lives are structures and what opportunities certain groups have. An example of this is the retirement law. This law states that people around 65-67 need to withdraw from paid work. From this age, people are considered to be old. This biological and social understanding of old age went hand in hand for a long time. People around the age of 65 went in retirement and they also experienced health problems. This changed during the last decades. Some people retired earlier, but they remained healthy until an older age. Today, we don’t see the age of 65 as a marker for both retirement and health problems. Consequently, people ask then when old age starts and what its characteristics are.

There are many gerontological discussions that stress the diversity of old age. Some gerontologists state that people become old when they turn 50, others state that people become old once they reach 75 years. Researchers did find a solution for the differences of opinion and that solution is to see old age as a sequence of two separate and distinct periods of life. These periods are called the young-old age and the old-old age or the third age and the fourth age. The third age is a period in which people have a relative freedom and good health. People in this age period don’t have the responsibility for the upbringing of their children and they also don’t have to work. The fourth age is a period in which there is an accelerated decline of mental and physical health. People in this period have also losses in social relationships. Every understanding of old age has its advantages and disadvantages. Also, the usefulness of the understanding depends on the context.

Europe and old age

Europe is a great continent for the study of old age, because it’s the oldest continent in the world. In Europe scientists can encounter many older people and they can also observe how societies change when populations age. Another positive thing about studying old age in Europe, is that Europe is heterogeneous. This means that there are clear visible differences within Europe in how old people are and how people deal with old age. The differences that exist are not only between countries, but also within countries. This means that scientists need to look into between-country differences as well as within-country differences to understand how old age transforms Europe. Before doing this, one needs to know what dimensions population ageing has reached. A description of Europe’s age-profile is needed and it will be discussed in the next part.

As mentioned before, Europe is older than any other region of the world. Northern America is slightly younger than Europe. The youngest continent in the world is Africa. In 2009, the median age in Europe was 40 years. This was 12 years more than the median age in the rest of the world and 21 years more than the median age in Africa. In that same year, every sixth European was in the 65+ age group, which is 16% of the population. In that same year, every 33th African was in the same age group. In 2009, 4% of Europe’s population was in the 80+ age group, but scientists expect that group to get bigger over the next decades.

Scientists have looked at the progression of population ageing in Europe. They figured out that less than 10%of Europeans were aged 65 years or older in 1950. In 2010, this group grew to 16% of the population. Researchers think that the 65+ group might continue to increase to 27% until 2050. That means that in 2050, every fourth European will be aged 65 years or older. If their predictions are correct, then the number of Europeans in that age group will have more than doubled within a century. Scientists have also looked at the rest of the world and they found out that only 5% of the world population was aged 65 years and older in 1950. In 2010, this group grew out to 8% and researchers think it will grow to 16% by 2050. This means that every sixth person in the world would be 65 years or older by then.

The numbers just mentioned describe Europe in its entity, but the basic information also is true for the individual European countries. All European countries are ageing and in every European country the number of older people will get bigger in the future. However, the level of population ageing reached and the speed at which populations age differs across the countries. North and West Europe were the oldest regions in the 1950s and Eastern and Southern Europe were the youngest ones. Population ageing progressed relatively slowly in Northern Europe and relatively quickly in Southern Europe and because of this, the age-gradient within Europe will probably be shifted by 2050. By 2050, the oldest populations in Europe will be in the South and West and the youngest population will be in the North and East.

In Figure 1.2 of the book ‘Old age in Europe’ on page 5, the median age of the population in the individual European countries in 2010 is shown. There are three different median ages in Europe in this figure, low (35 years of below), intermediate (36-40) or high (41 years and older). Note that figure 1.2 is not correct! The text about that figure is correct! Europe has a couple of countries where the median age is below 35 years. These countries include Turkey, Ireland, Iceland, Moldova and Albania. Some of the intermediate countries are the Netherlands, Germany, Sweden, Portugal and Greece. Some of the countries where the median ages are high include Norway, Spain, Russia, Poland, France and the United Kingdom. Europe is indeed greying, but it is greying in different ways. Countries differ in how fast population aging progresses and in how far it has progressed. Also, when researchers look even deeper, they see that differences also exist within countries, because people within countries do not age homogeneously. Researchers have found some differences between population groups when it comes to how fast population ageing progresses. They found that there are more women than men in the higher age groups and that the population in rural areas ages faster than the population in cities. Factors like migration and local cultures can also cause some of these within-country differences in the population ageing progress.

Characteristics of older Europeans

According to the writers of this text, the older European does not exist. Older Europeans resemble each other to some degree, but there are many differences between them. The variation is to some degree caused by country-characteristics. There are/were many different political constellations in Europe, like the former communistic East and the liberal-democratic West. There are also different religious orientations in Europe, like the mainly catholic South and the mainly protestant North. Variations are also due to differences between the individuals within a country. Individual differences can be caused by gender, marital status, socioeconomic status, living arrangements and religious affiliation. When you take all these possible variations into account, you will see that there is a diverse group of old people in Europe.

One of the biggest differences between older Europeans is their gender. There are about as many women as men in Europe, but this ratio is different in older age groups. There are a bit more women aged 65 years and older in Europe than men. In some countries, this difference is marginal (Iceland and Macedonia), while in others two out of three older people are female (the Ukraine and Latvia). That gender difference results from two factors. The first factor is quite obvious. Women live longer than men do. Because of this, women are over-represented in the older age-groups. The second factor is that mostly men fight as soldiers in wars, so war-related deaths are particularly common among men. Another difference between old Europeans is in their social networks. These are connections with friends and kin. Connections with friends and kin are important for older people, because they enhance their wellbeing and health. Friends and kin are also supportive in times of crisis. These days kinships are looser than in the decades before, but there are differences between countries. In Norway, Sweden and Finland there is extended de-familialization. This means that friends become more important. Also, in these countries and in the Netherlands, the highest levels of memberships of clubs and voluntary work are common. In Eastern Europe and in South Europe, family ties are still very important.

Another big difference between older Europeans is their socio-economic status. The socio-economic status tells us the position a person has in society. This status is determined from wealth, occupation and educational level. The wealth of older Europeans is relatively low in Eastern European countries like Poland and the Ukraine and relatively high in continental European countries, like Belgium and France. The educational level is also higher in Continental Europe and Northern Europe, like Austria and the Netherlands than in Southern Europe, like Spain and Greece. Also, the occupational prestige of older people is higher in Continental and Northern Europe than in Southern Europe.

It seems that in Eastern Europe, the circumstances of aging healthy are the least favourable. In those countries, the level of resources for health care is the lowest and the people from those countries have the highest prevalence of smoking and obesity. By contrast, in Northern and Western Europe, people have the best health care and the lowest level of risk factors for diseases. The highest proportion of obese people in Europe are from Eastern Europe (21%) and the lowest proportion is from Western Europe (18%). Of course, there are variations within the regions. For example, the highest proportion of obese men can be found in the Czech Republic (31%), but the lowest proportion of obese men can also be found in Eastern Europe, in Moldova (10%). Every country has its own progress of aging and in the next section, three countries from Europe will be discussed.

Old people in Italy

After Germany, Italy is the oldest country in Europe. Italy is the third oldest country in the world. Because of this, researchers often look at Italy when they want to know how societies change by aging. They think that studying Italy today will give them information about the things that will happen in other European countries in the next decades. 6% of the Italian population were aged 80+ in the beginning of the 21st century. This is the highest percentage of the European countries. There are a couple of regions in Europe with a high proportion of people aged 80+ living in them and seven of the ten regions can be found in Italy. Italians think, on average, that old age starts at 68 years. This age is one of the highest named in Europe. Old people in Italy have a low level of engagement in productive activities. 37% of Italians aged 55-64 was employed and this is one of the lowest percentages within Europe. Also, older Italians don’t participate a lot in voluntary, political and religious organizations or sports clubs and social clubs. Italians say that this is because the old people want to engage more with their family and they often look after their grandchildren and therefore don’t have much time to do other things. So it’s not that they are less engaged, but they are engaged in a different context than other Europeans.

In Italy, public care services are relatively scarce and it is therefore difficult to organize care provision for older people who need it. The care services also differ across Italy and the family will have to do most of the care work. Italians often hire migrant care workers (called badanti) to support the family carers. Often, the badanti live with the person they are taking care of and they help them with their daily lives. Of course there are certain working- and migration-regulations and the badanti work for a couple of months in Italy and then have to return for several months to their home countries.

Old people in Sweden

Sweden has a great labour market situation for old people. About 70% of Swedish people aged 55-64 worked in a paid job. This is the highest percentage in Europe. Ageing in Sweden has little effect on the pension schemes and labour market. The ageing in Sweden is the European average. However, people in Sweden live longer than averages Europeans do and they also stay healthy until an old age. After reaching the age of 65 years, Swedish people can expect to spend 14 years in good health, on average and then five years in poor health. Swedes perceive old age starting at 67 years. This is relatively late, the European average is 64.

Because of their good health, Swedish old people can be active until a late age. They also tend to do this. Sweden has one of the highest shares of volunteers in the 50 years and older age group. They also are more likely to provide care and health than other older Europeans and because of this, researchers conclude that old people from Sweden are still productive. They engage in different activities to benefit society and their family. However, old Swedish people are less active than most Europeans in religious organizations. The government of Sweden also helps with old people’s productivity by providing health and social services and by providing a good pension scheme. The government also established the right to work until age 67.

Old people in Slovakia

While Italy is one of the oldest countries in Europe, Slovakia is one of the youngest. The median age in 2010 was 37 years. This is 4 years younger than the European average. Slovakia can look to older countries and prepare for what might come when the population ages. In Slovakia, the youthfulness is visible in different ways. People from Slovakia who are 65 years old can expect to live three more years in good health and then 13 years in poor health. This life-expectancy in good health is five years below the European average and eleven years below the one in Sweden. The life-expectancy in Slovakia is also 3 years below the European average. Therefore, you can see older Slovakian less often than in other European countries. Slovakians also have a more youthful understanding of old age than other Europeans. They namely think that old age starts at 58 years. This is six years below the European average and the lowest one named in Europe.

Slovakia has also a distinct living situation. The average Slovakian retired at age 58 in 2009. This is one of the lowest retirement ages in Europe. The mandatory retirement age in Slovakia is 62. Retired Slovakians are less likely to volunteer than other European retired people. The low levels of engagement in work and volunteering might be a result from the early health deterioration in Slovakia. However, older Slovakians are socially integrated despite this low engagement and high health decline. Researchers from Slovakia concluded that social and health care are a central issue in Slovakian old age policies. They also said that the government has been regulating social and health care for older Slovakians throughout the last decades. But they also said that those policies did not always put emphasis on the situation of older Slovakians. Clearly, this has to change.

Gerontopsychologists look at the effects of ageing on the brain and the personality. They also look at how cognitive functions change when people age and how individuals can cope with the changes to maintain a high quality of life. One of the most important age-related cognitive changes is dementia. That is a disease that causes memory loss and capability loss. Gerontopsychology looks at the stability and changes of behaviour and experience of people in their later life. Gerontopsychology thinks that processes of development and change when one ages is not a unidirectional decline process, but a process that can be stable or multidirectional. Gerontopsychology looks at the developmental potentials of older people and at their environmental and personal resources. The research has shifted from pathological to healthy ageing.

Theories and concepts

In this section, the basic concepts of Gerontopsychology shall be discussed. The emphasis of this will be primarily on cognitive ageing. Important concepts in this are the concepts of quality of life and cognitive health. The terms look at functional concepts of competence. Cognitive health is not just the absence of disease, but also the preservation of a multidimensional cognitive structure. This structure allows older people to maintain a sense of purpose, the abilities to function independently, social connectedness and to cope with illnesses and functional deficits. Quality of life looks at a person’s resources. Somebody who thinks that his/her resources are functional to perform activities that serve goals, will have a higher quality of life. So both concepts look at the environmental and individual contexts and they also imply that characteristics of a person’s resources are not the only thing important when measuring performance, but that one also needs to look at the integration into social structures and the adaptation to different situations.

Cognition consists of multiple abilities and these abilities have different developmental courses. The level of most cognitive abilities declines differentially across adulthood. Usually, cognitive abilities are categorized into two types of intelligence. These types are fluid intelligence and crystallized intelligence. Fluid intelligence is the process speed, working memory, recall, verbal fluency and reasoning. Research has shown that there is a decline in measures of fluid intelligence when someone ages. Crystallized intelligence is the experiences and culture-dependent performances that somebody learns. In general, cognitive abilities decrease with increasing age, but some people maintain their cognitive abilities in old age and some even increase the cognitive abilities. There are individual differences in cognitive ageing and there are also differences between generations.

There are four main theories which researchers use to explain the differential age-related changes in crystallized and fluid intelligence. Salthouse’s processing speed theory suggests that age-related difference in performance are due to a general decrease in speed of performing mental operations. According to the theory, a slower processing speed is related to all aspects of cognition, even if they don’t have a speed component. Craik and Byrd argue that the age-related decline in cognitive functioning is due to reduced processing resources. Processing resources are abilities to manipulate and process information (measured by working memory tasks). Other researchers see the decline in inhibitory control as the cause for cognitive deficits. Inhibitory control is the ability to suppress currently irrelevant information or behaviour. This theory suggests that older people have more problems to inhibit prior information from working memory and that because of this, the work space for new material is reduced. Yet other researchers relate sensory functions (visual and auditory) to age-associated changes in cognitive function. Some researchers have found that auditory and visual functions together can account for a large amount of the variation in intellectual functioning. This is also called a common cause hypothesis and it states that declining sensory function will have a negative effect on all cognitive abilities. All these theories can account for age differences in cognitive abilities. All the theories just mentioned differ in the focus on basic mechanisms. Schaie thinks that most of the age differences in cognitive abilities tests result from cohort differences rather than age differences. This means that factors other than age and practice in specific skills should be used to look at the development of cognitive abilities. Some of these factors are generational differences in schooling and the use of technology.

Cognitive health and quality of life

The concept ‘cognitive health’ is getting more and more popular among scholars. As mentioned shortly in a previous section, cognitive health refers to a person’s ability to adapt their cognitive performance to changes in the environment and the ability to make the cognitive functioning stable. Most research on cognitive ageing focuses on interventions to improve impaired cognitive functioning or on the prediction of cognitive decline, but cognitive health research looks at which factors may support stable levels of cognitive functioning. Often, cognitive health goes together with the term ‘plasticity.’ When someone adapts successfully to the environment, we speak of health cognitive development. Successful adaptation of a person also leads to neuronal and behavioural plasticity. Cognitive plasticity is often defined as a person’s cognitive capacity under certain specific conditions. Cognitive plasticity is seen in neuronal and behavioural data, because there is a relationship between cognition for certain cognitive abilities and neuronal activation. However, researchers still don’t know the exact relationship between these two. There are researchers who have found that there are small or negative effects in older people between the reduction in cortical volume and cognitive performance. According to some, cognitive plasticity can exist even if the neuronal plasticity has been compromised, this is called cognitive reserve. Passive cognitive reserve sees reserve as the result of brain size and synapses and the active cognitive reserve theory argues that the brain actively copes with pathology. This means that the brain is able to use brain networks more efficiently or to acquire new brain networks. This has been seen in human beings with higher levels of intelligence and who had more education and a high level of occupation. Research has shown that people with lower intelligence show functional deficits after brain damage and people with high intelligence in the same situation maintain their performance level. Being active during the youth can build up cognitive reserve and this will result in long-term plasticity in old age.

Researchers look much at the quality of life when they study the outcomes of health-improving interventions in old age. There are many instruments that measure quality of life, but there is still no firm consensus on what quality of life exactly is. The World Health Organization sees quality of life as a meta-disciplinary construct which involves psychological, medical and sociological aspects, but that broad definition doesn’t clearly separate quality of life from similar constructs, like life satisfaction. There are two main approaches to determine quality of life in old age. The first one is the so-called sQOL which measures the subjective evaluation of a person’s life situation and quality of life and the second one is the oQOL, which looks at the quality of life of a person from the outside, like measuring health impairments. The first approach thinks that quality of life is a subjective state and that is must be measured through subjective statements. The subjective quality of life looks at the discrepancy between a person’s current life situation and his/her ideal life situation.

There are different instruments that measure sQOL and the particular instrument determines which type of quality of life (social relationships, physical health, environment) is studied. It is therefore difficult to make direct comparisons between different instruments. The second approach looks at objective measures of quality of life and sees quality of life as better the higher the given resources of an individual are. The oQOL can be determined more reliably, without a person’s report bias and without a statement from the person whose oQOL is being measured. This is a positive think, because people with dementia might not make a reliable statement. But, this approach doesn’t take into account inter-individual differences in the availability of resources to achieve goals. There is also a new model, called the fQOL model, which defines quality of life as an integration of multiple subjective representations of the functionality of a person’s resources. This model assumes that quality of life is higher, the more strongly a person represents his/her resources as being functional to perform complex activities that serve central goals. This model is different than the other two. It does use subjective assessments, but these are not satisfaction judgments, but functionality judgments.

Coping strategies

The resources of a person and the person’s ability to adopt to different situations and environments has an impact on cognitive health and the quality of life. There is a mechanism to achieve a successful and healthy personal development and also a healthy adaptation and that is the selective optimization with compensation (SOC) strategy. Choosing tasks that are of high individual importance and that match a person’s abilities is the selection part of the strategy. This selection is divided into elective selection (ES) and loss-based selection (LS). Elective selection is guided by social norms or preferences and loss-based selection is a shift in personal goals due to a loss of external or internal resources. Selection thus leads to a smaller number of alternative options and the persons can concentrate on a reduced range of achievable goals. Old people usually lose resources and their number of achievable goals will also decrease. In order to achieve a selected goal, a person has to optimize his/her strategy by refining and deploying resources (that is the O in SOC). Training, a good motivation and learning new skills can help with optimization. Compensation refers to acquisition and utilization of alternative means to reach certain goals and keeping performances at a desired level, despite the actual or anticipated decreases in resources.

A concept that looks a bit like the SOC is the concept of resource orchestration. This concept assumes that performance in complex cognitive tasks requires using multiple cognitive abilities in different degrees during the performance of the task. This means that multiple skills have to be timed and orchestrated. This means that an improvement in elementary abilities will probably not lead to large improvements in the complex behaviour. interventions of this approach look at individually meaningful goals and they focus on the orchestration process itself. This means that they help to identify the goals, the relevant abilities and to optimize decisions when to use certain strategies.

The current state in Europe

Europe has the highest median age of the population in the world. This brings a couple of challenges to societies. One of these challenges is the increase of the prevalence of dementia. Dementia causes a person to lose his/her cognitive abilities faster than they would lose it during the normal ageing process. This will result in memory loss and even the loss of physical functioning. Older people suffer more from dementia than younger people (5.9% to 9.4% of people aged 65 and up in Europe and 0.1% of younger people). 6.2% of people aged 60 and over in Europe suffer from dementia and 60-70% from these people have Alzheimer’s disease. This rate is almost the same as the rate in other developed regions, like Australia and North America, but it is higher than those of other regions, like Africa and Asia. This is actually not so strange, because the more developed regions have longer life expectancies. The number one risk factor of dementia is old age. In Europe, more people life up to an old age and there will therefore also be more people (proportionally) with dementia than in Africa and Asia. Researchers estimate that in the year 2050 the number of dementia diseases in Europe is going to double and that the number in less developed regions is going to more than triple. This is because the population of the less developed regions is going to increase in the next 40 years. In Europe only the part of the population aged 60 years and older is going to increase and other parts of the population are expected to decrease. Dementia costs Europe a lot of money and it is important to determine the factors that can help a successful cognitive ageing process and that stop the development of dementia. It is also important to arrange good care for people who already suffer from dementia. It is therefore important to look at the individual and environmental resources that can contribute to maintaining the functional level and the ability to adapt to the environment.

Stopping dementia

Not everybody will lose his or her cognitive abilities or develop dementia. Most of old people are able to maintain their functional level to a very old age. To figure out why some people suffer from dementia and others do not, one first needs to know which environmental and individual resources may support successful cognitive ageing without developing dementia. Although people have a decline in cognitive and physical resources, certain resources (knowledge and strategic skills) may increase with age. Most resources can be improved through training interventions. Researchers therefore should identify these resources and look at how they interact and look at the factors that may influence them.

Research has shown that cognitive and intellectual stimulation contributes to a cognitive healthy ageing process and that it seems to prevent dementia. It has also been shown that education has a protective effect on dementia. However, what’s not clear is if education is able to prevent dementia or if educated people are just diagnosed at a later date because their capabilities compensate for the losses for some time. There are also physical conditions that have a protective effect on dementia. For example, the absence of diabetes has been reported to have a protective effect on dementia. However, many reported effects are based on retrospective data and causal effects actually require intervention studies. A couple of studies have looked at the effects of cognitive training and they have found positive effects for cognitive health in older adults and also in people who are in risk groups (people with mild cognitive impairment) or who are already suffering from dementia. Other studies have shown positive effects of physical training interventions on cognitive abilities. The studies have also shown that physical training improves cognitive function. Physical training may thus protect against cognitive decline and dementia. Global cognitive stimulation is more effective than concentrating on a specific functioning. It is therefore better to have an enriched environment that allows a person to engage in activities that stimulate physical, cognitive and social skills than just concentrating on one of these things. Sadly, there are only a few studies that have looked at the effect of combining physical and cognitive trainings. More research has to be done on this subject. The research should look at stimulating these things simultaneously, because in daily life, different motor and cognitive resources engage together.

Strengthening the resources is not the only thing that should be done to help older people with cognitive impairments. People with dementia also have specific care needs and require specific housing because of their disease. The environment should be adapted so that there is an optimal person-environment fit that can provide adequate care and that allows a person to life an independent life for as long as possible. However, one needs to consider the individual resources and goals of the person in order for an optimal person-environment fit. On must look at the social context situation of a person, at the general mobility and at the presence of other mental and physical diseases. The different countries in Europe have different care provisions. In certain countries, especially in Southern Europe (Italy, Spain), the family predominantly provides care. The family takes care of the relative who suffers from dementia and patients in those countries are thus less frequently institutionalized. However, this also means that these patients are not able to benefit from professional care and the family can also be burdened with the patient. This may also be a burden for the patient. In Western Europe, many people with dementia are institutionalised, but the majority of patients with dementia are cared for at home. Many countries there provide help at home or make an institution as home-like as possible. One example of this is a small-scale living or group living arrangement, which can be found in the Netherlands, Germany and the United Kingdom. These arrangements have six to eight people living in a place which has a 24/7 care and surveillance by a couple of staff members. Certain rooms are shared, like the living room and kitchen, but some rooms are private areas that have the private stuff of the patient. These arrangements provide intensive professional care and a homelike living situation. The care and treatment can be adapted to the individual needs of the patients. Care providers should provide the adaptation of the environment to the available resources of the patients and the individual needs of the person. This will result in different forms of care. Providers also need to support independence and they should let the patient feel as much in control as possible.

Scientists these days have a good opportunity to improve their knowledge about the function of the aging brain, because people live longer than ever before. In the United States, 13% of the citizens are 65 years and older. The life expectancy at birth there is 81years for women and 76 years for men. Researchers estimate that one in five citizens by the year 2030 will be seniors and they also think that the oldest old (85 years and older) will be the fastest growing segment of the population. Given these numbers, it is important for research to focus on normal and pathological ageing.

We now know and accept that that some degree of cognitive decline associated with ageing is inevitable and these declines are different for every person. There is a variation in cognitive performance in areas as fluid intelligence and memory when people age. When people age, there is an increase in the proportion of old people who show normative age-associated cognitive decline. However, there will also be an increase in the pathological cognitive decline. There are some aspects of cognition that remain relatively stable with normal ageing. Some of these are vocabulary, storage of knowledge and implicit memory. The decline that often goes together with normal cognitive ageing is a decreased efficiency in information processing in multiple areas. These areas are speed of processing, short-term memory, reaction time, verbal fluency and executive control. Visual-perception also declines with age.

Slowed processing speed is an important cognitive change in the ageing brain. Research has found that visual-motor tracking and sequencing slow with age. Older people have a slower processing speed in general and this mediates cognitive efficiency by restricting the speed at which cognitive processes can be executed. The quality of performance can also be affected by reduced processing. This is because there is a decreased quantity of information processed that is necessary for completion of the task. Also, the products of earlier processing can be lost by the time later processing happens and this makes the integration of relevant information difficult or even impossible. Reduced processing can lead to a decrease in working memory capacity, because less information can be processed in a certain amount of time.

Also, higher-order cognitive functions, like elaboration and abstraction, can be impaired. This is because the relevant information is not available anymore in the working memory or storage. Older people have a reduced inhibition of selective attention and because of this, the changes in their working memory occur. Older people show a decreased ability to suppress the processing of irrelevant stimuli. Their attention will be dis-regulated because of this and this will also have an effect on different aspects of executive performance, like suppressing responses. Cognitive ageing is also related to poorer effortful processing, but automatic processing remains relatively intact. Normal age-related changes in language function are an inefficiency in word retrieval. This means that older people have more trouble in finding words and this is also called the ‘tip of the tongue’ phenomenon.

Structural brain changes

Normal ageing goes together with a couple of changes in brain structure, like volumetric shrinkage, loss of dopaminergic receptors, more neurofibrillary tangles and plaques and a decreased white matter density. The most thinning and shrinking of the brain occurs in the hippocampus, cerebellum, caudate and prefrontal areas. Ventrical volumes increase in old age. Decreases in white matter density are most common in frontal or occipital regions of the brain. White matter changes result in cognitive slowing. This is because the function of white matter is to transport signals between different areas of the brain via myelinated axons. Myelin integrity degrades with age and the speed of cognitive processing will therefore also degrade. The loss of dopaminergic receptors contributes to attentional dis-regulation, difficulty with contextual processing and executive dysfunction. Researchers have proposed that contextual representations are housed in the dorsolateral prefrontal cortex and they are regulated by dopamine projections to this spot. Context processing plays a big role in attention, working memory and inhibition. Studies have found that old people have more neurofibrillary tangles than younger people. The most affected regions are the amygdala, entorhinal cortex, subiculum and inferior temporal regions. The orbitofrontal, midfrontal and parietal regions are less affected and occipital regions are minimally affected. Senile plaques (SP) are also found in older people these affect all brain regions equally, but the occipital cortex is the most spared region. People who were not demented at death, showed less plaques and tangles than people with mild cognitive impairment and dementia. Functional imaging techniques show that older people show more bilateral activation in older adults. This means that the older brain activates the contralateral hemisphere more to achieve greater cognitive benefits.

Theories of ageing

Researchers proposed that abilities that are relatively independent in early life (cognition, sensory ability), are more interrelated with old age. This can be seen as a decrease in neural specificity. Regions that respond selectively in younger adults change and respond to a wider array of inputs in older adults. In older adults, prefrontal activation is associated with decreased parahippocampal activation and hippocampal volume shrinkage. In younger people, activation in the parahippocampal regions is associated with learning new material, but in older adults there is more prefrontal activation and this suggests that greater frontal activity may be a compensatory mechanism for decreased activation of other regions.

Salthouse’s processing-speed theory of cognitive ageing proposes that a wide range of cognitive task performances are limited by the imposed constraints on the speed of processing. Slow processing speed can have an effect on cognition in two ways. The first is that cognitive operations are executed too slowly to be fulfilled successfully in the available time and the second is that the amount of available information that is necessary for higher-level processing is reduced. This is because early processing is not available anymore when new processing occurs. Complex operations depend on the products of simple operations and that’s why they are most affected by slow processing speed. The accuracy of performance is dependent on the number of operations that can be carried out in a given time period. Due to disruptions in the synchronization of signals, the amount of simultaneously available information may also be reduced.

According to the scaffolding theory of ageing, structural brain changes are accompanied by efforts of the neural networks to maintain homeostatic cognitive functioning in the face of these changes. So, the brain function will change through the strengthening of existing connections, non-use of faulty connections and the formation of new connections. Scaffolding is often seen as the brain’s normal response to challenge. The neural networks shift from broad and dispersed to a specific circuit of neural regions. The regions will have dominant control over functions and the initial broad networks will be minimally active and they remain available for compensatory processing. Scientists think that scaffolding maintains healthy cognitive functions, when neural degradation occurs. The circuits of scaffolding can give us complementary, new or supplementary ways to complete cognitive tasks and these circuits reside largely in the prefrontal cortex. However, scaffolding networks are less efficient and more prone to error than honed circuits, because honed circuits are highly functionally interconnected. According to the theory, this will result in the observable cognitive decline seen in older adults.

Individual factors

There is variation in cognitive performance in older people, especially in the older old. Because of this, it is important to examine the individual difference factors related to the cognitive ageing process. Research has found that factors that contribute to cognitive reserve or cognitive decline are education, physical health, occupational complexity and diet. Cognitive reserve is ‘caused’ by a couple of processes: richer connections and organization between neural circuits, changes in intracellular signalling pathways and alterations in synaptic efficiency. Physical health is an important factor when it comes to the prediction of cognitive function. Medical disorders are better predictors of neuropsychological performance than chronological age. These disorders are obesity, white matter lesions, hypertension and high cholesterol. Some other measures of biological age have also been associated with poorer cognitive functioning. Higher education has been associated with preserved cognitive performance over time, but not all studies support this claim. Occupational complexity is also associated with better cognitive functioning. This is especially the case when one works with people. Once somebody retires, the cognitive benefits received from high occupational complexity cease. Once these skills are not being practised, they have no longer an effectiveness in bolstering cognitive ability.

Mild cognitive impairment

Usually a patient or his/her family refers him/her to a doctor when they perceive a decline in cognitive ability. A neuropsychologist determines whether the patient’s/family’s complaints of cognitive decline are due to normal cognitive ageing or due to an objective impairment in cognitive functioning. Mild cognitive impairment represents a decline in cognitive performance greater than would be expected for the person’s age but not sufficient enough to meet criteria for a diagnosis of dementia. Some scientists describe mild cognitive impairment as interposed between normal cognitive ageing changes and the early changes of dementing processes. It is seen as a pathological condition. The incidence and prevalence of mild cognitive impairment vary across studies, because different samples, diagnostic criteria and assessment procedures are used. The prevalence of mild cognitive impairment within the general population ranges from 1 to 19%. The original criteria for mild cognitive impairment are:

1. Normal activities of daily living

2. Presence of a memory complaint

3. Normal general cognitive function

4. Abnormal memory for age

5. Not demented

This is useful for patients who have intact cognitive performance in every domain, except for the memory domain. Those patients with an impairment in the memory domain are labelled as having amnesic mild cognitive impairment. Other criteria were also proposed by a multidisciplinary group of experts, because mild cognitive impairment is represented heterogeneous in clinics. Some patients have only impairments in the memory area, but others have memory impairment and also another domain impairment. Some have impairments in non-memory cognitive domains. The most updates diagnostic criteria for mild cognitive impairment are:

1. Concerns regarding change in cognition: the patient’s cognitive status has changed compared to his previous level.

2. Impairment in one or more cognitive domains: there is evidence of lower performance in one or more cognitive domains. This performance is lower than would be expected for the patient’s age and educational background.

3. Preservation of independence in functional abilities: these patients usually maintain their independence in daily living without help. However, some patients have mild problems with complex functional tasks.

4. Not demented

Subtypes

Research has found several subtypes of mild cognitive impairment. One that has already been mentioned, is amnesic mild cognitive impairment (a-MCI). Some patients show an impairment in a single non-memory cognitive domain, but they perform normally in other domains. These patients will get the label of single-domain non-amnesic mild cognitive impairment (na-MCI). There are also patients with impairments in multiple domains, but who show intact activities of daily living. These patients are classified as having multiple-domain mild cognitive impairment. When a deficit in memory is present in these patients, they are given the diagnosis of multiple-domain mild cognitive impairment with amnesia (md-MCI + a). If memory impairment is not present, then the patient will receive the diagnosis of multiple-domain mild cognitive impairment without amnesia (md-MCI-a).

Prognosis

There are not only subtypes, but also multiple etiologies for mild cognitive impairment. Petersen thought there were four main etiologies: degenerative (Alzheimer’s disease), psychiatric (depression), vascular (cerebrovascular disease) and traumatic (head injury). There are also other potential etiologies that can be considered, like medication side effects, infection or toxic factors. Some subtypes are more common associated with certain etiologies than other. Patients with a-MCI are more likely to get Alzheimer’s disease than patients with na-MCI. Patients with impairments in non-memory domains, like executive functions, are more likely to get dementia with Lewy bodies. One study showed that there is a rate of progression from mild cognitive impairment to dementia of 12% per year. After six years, approximately 80% of mild cognitive impairment patients have progressed to dementia (in one study). Other studies have found rates of 10-19% per year from mild cognitive impairment to Alzheimer’s disease. 1-2% of the general population develops Alzheimer’s disease per year and this means that mild cognitive impairment places a person at increased risk for future dementia. In one study, people with a-MCI were found in one study to have a fourfold greater risk than non-cognitively impaired individuals to develop Alzheimer’s disease. However, there are also many people with mild cognitive impairment that remain stable with their diagnosis or even revert to normal. In one clinical study, 41% remained stable over time and 17% returned to normal cognitive status. This means that for some people mild cognitive impairment is an intermediate point on a continuum from normal cognition to dementia and for others, mild cognitive impairment is a transient period of cognitive decline that resolves with time.

Pathophysiology

Neuroimaging data shows that mild cognitive impairment is a unique diagnosis, different from dementia and normal cognitive functioning states. With the help of neuro-imagining techniques it was found that the retention of Pittsburgh compound B, PIB (used to image beta-amyloid plaques), in patients with mild cognitive impairment is higher than that of normal controls but lower than in in Alzheimer’s Disease patients. The patients who converted to Alzheimer’s Disease within the 2-16 month follow-up period had higher PIB retention rates than patients with mild cognitive impairment who remained stable. Other studies have also shown that patients with mild cognitive impairment who progressed to Alzheimer’s Disease, had greater volume loss than stable mild cognitive impairment groups. Studies that looked at the increase of ventricular volume have shown that the greatest volume increase is found in Alzheimer’s Disease patients, followed by patients with mild cognitive impairment and the smallest change is seen in cognitive normal.

Assessment

The referrals for mild cognitive impairment as a diagnostic consideration may come from different sources. Referrals might come from the primary care physician, psychiatrist, neurologists and self-referral. Usually, the patients or relatives of the patient prompt the consultation for memory loss. Many patients are first seen by neurologists who then give a neuropsychological referral for a more comprehensive evaluation. Cognitive impairments often involves a question of Alzheimer’s disease pathology versus other causes, like vascular cognitive impairment or Parkinsons’s plus syndrome (for example, Parkinson’s disease with Lewy body dementia). There are common differential diagnosis for mild cognitive impairment. Some of these are normal cognitive ageing, many forms of dementia, like Alzheimer’s disease, vascular dementia and Parkinson with Lewy bodies dementia and depression. Another issue that may be relevant to referring physicians, is the beginning with a cognitive enhancing medication or with a drug that treats mood disorders. The evaluation is often called for in order to track the trajectory of cognitive decline.

Clinical interview

It is important to obtain an accurate picture of the emergence of cognitive symptoms and functional difficulties when assessing people with mild cognitive impairment. It is therefore important to have an informant present at the interview so he or she can provide his or her insight into the patient’s behaviour and functionality. The informant is usually a spouse, sibling, child or other close relative or friend who knows about the patient’s history and who can tell more about the changes in functional and cognitive status. An important diagnostic criteria of mild cognitive impairment is the presence of a cognitive complaint. This complaint is subjective. Sometimes the patient complains about the his/her memory and the informant agrees, other times the informant’s report is the only evidence for subjective cognitive change. It is important to receive a thorough history of the emergence of cognitive symptoms. The evaluation of functional abilities is also important when considering the diagnosis mild cognitive impairment. Functional independence is the most important factor in the differential diagnosis of mild cognitive impairment and early dementia. People with mild cognitive impairment have intact basic activities of daily living. So, when making an assessment, the patient should be asked about his/her ability to take care for his/her basic needs (hygiene, feeding oneself) and instrumental needs (financial management, driving).

Patients and their informants should be asked about changes in behaviour or personality. These are usually early indicators of a primarily behavioural dementing process. Some of the behaviours to consider are apathy, disinhibition and behaviours that are not ordinary for that person. Also, irritability often goes together with symptoms of cognitive decline. Also, patients should be questioned about emotional symptoms and psychiatric history in order to see whether there is an increase in symptoms of depression or anxiety. Many patients with mild cognitive impairment have at least one neuropsychiatric symptom. The most commonly endorsed symptoms include depression, apathy, agitation and anxiety. Symptoms of depression that are often reported in mild cognitive impairment patients are poor concentration, pessimistic thoughts, reduced sleep, inability to feel, inner tension and reduced appetite. It is therefore important that patients are screened for clinical and subclinical symptoms of anxiety, depression, irritability and apathy. The clinician should receive a medical history and assessment of the patient’s current health status. It is also important to obtain results from neurodiagnostic studies (MRI, EEG), in case a differential diagnosis should be made. It is also important to have an assessment of the patient’s sleep quality. Also, the current and recent medications and the chronology of the patients should be reviewed, so a clinician could see whether medication has induced cognitive changes. Least, family history of dementia should be assessed.

Functional impairment

When a clinician looks at the carrying out of activities of daily living by a patient, he or she needs to know the history from the patient in order to figure out if something has changed. History from the patient should be obtained and ideally, also some information from the informant. A detailed interview is best to pick up subtle changes in functioning. According to research, patients with mild cognitive impairment report some degree of decline in their ability to handle daily tasks. They feel that they are more forgetful, have more trouble with planning and that they are less able to multitask. The ability to learn, perform higher-order executive skills and retain new information is dampened in persons with mild cognitive impairment. This usually results in less efficient daily functioning. People with mild cognitive impairment make errors in performing tasks accurately, but they are still able to complete tasks. People with mild cognitive impairment also show subtle declines in driving abilities. Some decline in functioning is observed in mild cognitive impairment patients, but it is not so severe as the decline in patients with dementia.

Cognitive impairment

Not only are self-reports and family reports about cognitive decline used to diagnose mild cognitive impairment, but objective measures of deficits in cognitive functioning are also used. There is not an exact cut-off score for what constitutes mild impaired, but mild cognitive impairment groups perform on average, 1.5 SD below normal-ageing people. The consensus criteria for scores on cognitive tests for patients with mild cognitive impairment is typically 1 to 1.5 SD below the mean for age and education. However, these are guidelines and not cut-off scores. The clinician should evaluate whether he thinks if somebody has mild cognitive impairment. For the assessment a detailed neuropsychological assessment is needed to improve the reliability of the diagnosis. The neuro-cognitive domains should be sampled and multiple measures of memory are needed. Different areas have to be assessed to determine etiology. Mood-functioning assessments should also be included.

Neurocognitive deficits

There are certain neuropsychological impairments that can be seen in patients with mild cognitive impairment who ultimately convert to Alzheimer’s Disease. One of them is a decline in episodic learning and memory early on. Patients with mild cognitive impairment show clearly defined memory impairments and only mild impairments in other domains. Patients with a-MCI show some difficulty in planning and problem solving and md-MCI patients show the most severe impairments. It is unclear why that is the case. Research has shown that patients with MCI show poorer performance than controls on tasks of semantic memory. The patients with MCI who convert to Alzheimer’s Disease show poorer immediate serial recall and divided attention than patients with MCI who do not ultimately convert to Alzheimer’s Disease. Once the diagnosis of MCI is established, the subtype of MCI needs to be selected. This is based on the results of the neurocognitive profile.

Recommendations

When a clinician reports the diagnosis of MCI to a patient and family, he or she needs to clearly explain the nature of the diagnosis. The clinician needs to convey that the patient is at increased risk for converting to dementia in the future, especially patients given an amnestic MCI diagnosis. The patients need to be told what the implications of the deficit will be, but the cognitive strengths should be highlighted in order to develop compensatory strategies for dealing with deficits and difficulties. Recommendations with a follow-up with the neurologist can also be made, to discuss the beginning of anti-dementia medication. Management with risk factors associated with cognitive decline should be recommended. Patients should also be encouraged to participate in an approved exercise regimen and maintain a healthy diet. Actively monitoring of anxiety, depression and other psychological factors is necessary. Patients should also be encouraged to maintain socially and cognitively active. Patients and relatives should also be told to monitor the functional status constantly. It is also important to schedule a follow-up appointment. However, it is difficult to determine what the best time for this is. One must looks at the severity and number of domains impaired and one must also look at the patient’s functional status. Patients with more severe cognitive impairments are further in their disease progression and patients with multiple impaired domains may reach a dementia diagnosis sooner. Therefore, these patients should receive a follow-up more sooner than patients with just one small impairment. The safest follow-up retest is a 1-year-follow-up period. However, when the family and/or patient notices a significant decline in cognitive ability or functional status, he or she should return sooner.

Studies have shown that depression in older adults has a prevalence rate between 3 and 14% in that population. One in 15 older adults may experience major depression over the course of one year. This late life depression is associated with negative outcomes, like disability, functional impairment, increased medical symptoms and increased use of health care services. Depression also has economic costs. Because of unexplained somatic complaints and functional impairments, older adults with depression use more medical services. One study showed that depressed older adults incurred 50% higher medical costs than non-depressed people of the same age. Most of these costs went to diagnostic visits, emergency room visits, pharmacy costs and primary care visits. A small part went to mental health care. Late-life depression can place a big burden on patients, the health-care system and caregivers. It is therefore important to assess the illness adequately and to treat the disorder.

Pseudodementia

Late-life depression can be accompanied by cognitive impairments. These changes look a lot like those associated with dementia. In the history, a psychiatric illness that mimicked dementia symptoms was referred to as pseudodementia. The cognitive symptoms of pseudodementia were assumed to be related to transient mood symptoms. Because of this, they were thought of as reversible with adequate psychiatric treatment. Because of this, the term reversible dementia was also used to describe depression-induced cognitive impairments. Wells was one of the first clinicians to popularize the term reversible dementia. He observed his patients with pseudodementia and saw that they had complaints of memory loss that were not apparent to their examiner. They also highlighted their failures and talked much about their disability. However, they functioned well and better than they said they can. This is different from patients with dementia, because patients with dementia often lack insight into the extent of their dysfunction and they tend to minimize their symptoms because of that. He also noted that patients with pseudodementia often responded ‘don’t know’ to close-ended questions, while they were able to provide detailed responses on open-ended questions. Patients with depression-related deficits also have recent and remote memory deficits. Wells also said that demented individuals often try to rely on calendars and notes, but depressed individuals do not attempt to compensate for their difficulties.

Pseudodementia was initially popular among clinicians, but now clinicians debate about the use of this term and the term is not really used anymore in current practice. The term was important, because it encouraged clinicians to evaluate every patient carefully and to look at alternate causes of cognitive decline other than dementia. However, this term has drawbacks. It implies a mutually exclusive process and this may lead the clinician to focus on whether someone is demented or depressed and the possibility that both conditions could be present is excluded. This term also implies complete reversibility. Research has found that in some older adults with depression and cognitive impairment, executive functioning did improve after an antidepressant treatment, but it failed to reach normal levels of performance. Other studies have also found that the treatment of depression may initially lead to improvements in dementia-related symptoms, follow-up shows that true reversibility of dementia is uncommon.

Depression as symptom of dementia

Although late-life depression can reflect a psychiatric disorder, it is more often the case that depressive symptoms are early manifestations of an underlying progressive dementing illness. High rates of depression and psychiatric symptoms are found across various neurodegenerative disorders, like vascular dementia, Parkinson’s disease and Alzheimer’s disease. Studies found that half of all individuals with cognitive impairment or diagnosed with dementia exhibited at least one psychiatric symptom. People with cognitive impairment or mild dementia most often have depression as a psychiatric symptom. In many studies, depressive symptoms appear to be highly prevalent in individuals with dementia. Depression can’t be solely attributed to a reaction to the disease itself. There is also no strong support for an association between severity of dementia and depression. Symptoms of depression can be equally prevalent across disease stages. There is a high comorbidity between depression and dementia and research has shown that depressive symptoms may be an early sign or risk factor for subsequent dementia or impairment. One study found that people baseline depression were more likely to develop dementia compared to non-depressed counterparts and they are also more likely to develop dementia earlier. It may be that depression is a risk factor for dementia, but it is also likely that depression is a behavioural manifestation of the dementia process itself. More research is needed into this subject.

Clinical assessment

Neuropsychologists play a big role in the assessment and treatment of dementia and depression. Many clinicians, like psychologists and neurologists often refer older adults for neuropsychological evaluation to better clarify a patient’s cognitive and psychiatric complaints. Neuropsychological evaluation can help diagnosis, management and treatment of the symptoms better.

It is important for the neuropsychological evaluation of a patient with depressive symptoms to gain qualitative and quantitative understanding of the symptoms. However, it is often difficult to assess depression in older adults. This can result from the fact that symptoms of depression are sometimes confounded by the effects of age and medical disorders. A loss of interest in activities and changed in appetite, libido and weight are common to medical illnesses, effects of aging and depression. For example, somebody may have a decline in social activities, but that should not mean that this person is depressed. He or she might no longer be able to drive and doesn’t have friends or relatives nearby. Also, a preference to stay home might be fatigue because of medical conditions rather than symptoms of depression. Older adults may also be more likely to underestimate their depressive symptoms. Older adults may have lower functional expectations for themselves, because of their increasing age and they may therefore dismiss their depressive symptoms due to the ageing process or declining health. Also, older adults are less likely to report dysphoric mood than younger people. Older people rather present vague symptoms, like fatigue or trouble sleeping. Given the fact that older adults are less likely to report dysphoric mood, clinicians need to look to subtle indicators of depression. These subtle indicators can be social isolation, headaches, changes in appetite, fatigue or delayed recovery from medical procedures. A careful evaluation must be performed. This basically suggests that all older adults who complain of cognitive problems should be screened for depression.

There are psychometric instruments that have been developed to screen for depression. Some of these are the Hamilton Depression Rating Scale (HDRS) and the Geriatric Depression Scale (GDS). The last scale specifically targets symptoms common to depression in older adults. There are also rating scales that have been developed specifically for use in patients with dementia. There are rule-out diagnoses to consider when a patient present with reported changes in both mood and cognitive functioning. Some disorders should be considered, like depression, bipolar disorder and anxiety. Symptoms as depression, apathy and irritability are also common across many of the dementia subtypes, like Alzheimer’s disease and Lewy body dementia. Changes in mood can also be associated with strokes. Many medications used to treat medical illness in older adults can cause depression-like symptoms. Beta-blockers and other drugs can affect both cognitive and mood functioning. Clinicians should also consider that depression may be a secondary reaction to a chronic medical illness. Digestive disorders and heart disease are also associated with an increased rate of depression symptoms. This is probably the case because people perceive a lack of control over medical symptoms.

Difference between dementia and depression

The psychiatric and cognitive symptoms associated with dementia can differ from those associated with a primary depression. Depression is usually associated with a more acute onset of symptoms (days or weeks), while the impairments associated with dementia can progress over years. This means that a gradual onset and progression of mood and cognitive symptoms will more likely reflect a dementing process and an acute onset is typically associated with depression. Also, depression often goes together with subjective cognitive complaints. Older people with depression are more likely to complain more about their cognitive difficulties than individuals with dementia. These complains may be out of proportion to the person’s actual level of functioning. A patient may complain of severe memory deficits, but still independently manage his or her finances. A lack of insight into symptoms is common in dementia and these people will more likely minimize their cognitive difficulties.

The presence of apathetic symptoms can be important when differentiating between dementia and depression. Apathy can be seen as a loss of motivation and is manifested as a lack of interest, low social engagement and an empty emotional response. Apathy can be a principal symptom of depression, but it can also reflect an independent syndrome and as distinct from the dysphoric symptoms of depression. Apathy is often seen as indifference and dysprhoric symptoms are often seen as guilt, sadness, hopelessness and self-criticism. Apathy is a feature in many neurodegenerative disorders, like Parkinson’s disease and Alzheimer’s disease. Apathy symptoms are more prevalent than dysphoric symptoms in people with Alzheimer’s disease. This means that apathy may be an early marker of preclinical Alzheimer’s disease and dysphoric mood may be more indicative of a depressive disorder.

There are also other depressive symptoms that are associated with dementia. Depressive profiles can differ between primary depression and dementia and because of this, a new set of diagnostic criteria has been proposed. The new criteria require the presence of three symptoms and these symptoms are similar to the symptoms in major depressive disorder. Social isolation and irritability are added to these. Decreased positive affect or a depressed mood is required. These symptoms don’t have to be present every day (like they are in primary depression). Clinicians should also take the age of onset of depressive symptoms into consideration. There are difference between early-onset and late-onset depression, so these might be distinct entities. Late-onset depression has a first onset between 45 and 60 years of age. Pathogenic brain contributions are different for these two different onsets. Some researchers suggest that there are cognitive difficulties associated with an initial onset of depression and that these are based on neurological disease. Some studies have found that high-intensity lesions and atrophy have a connection to late-onset depression. Others have found a correlation between findings on neuroimaging and cognitive changes with depression. Loss of interest has also been found to be greater in late-onset depression. So, depression with a late age of onset is more likely to be associated with neuropathology or the early stages of dementia. When it comes to sleep patterns, depression and dementia can also differ. Alzheimer’s Disease is associated with poor sleep and with frequent night awakenings. The onset sleep is also later and goes together with difficulty awakening in the morning. Older adults with depression have difficulty falling asleep, wake up early in the morning and have an impaired sleep continuity. So people with depression have difficulty staying asleep in the morning, while people with Alzheimer’s disease have difficulty waking up in the morning. Increased REM sleep is more characteristic of depression than dementia and this might help distinguish depression from dementia. However, clinicians don’t have this sleep information ready available. They first have to request a formal sleep study.

Neuropsychological profiles

Neuropsychological testing is important and may help distinguish dementia from depression. The cognitive changes in dementia are more severe than those in depression. So there is a difference in severity, but there are also qualitative differences. Cognitive symptoms associated with dementia are progressive, but cognitive deficits related to depression should stabilize or improve with good management of the psychiatric symptoms. So there need to be repeated neuropsychological evaluations. Other differences are those in effortful processing. Cognitive changes in depression lead to difficulties on tasks that require a high degree of cognitive resources, but performances on tasks that are more automatic require less effort the complete. The deficits in dementia result in the impairments that are independent of the degree of effortful processing. This hypothesis might be useful, but it may be overly generalized and has not been supported fully by research.

Late-life depression is associated with cognitive deficits in the domain of attention, memory and executive functioning. Especially the executive functioning difficulties are most prominent in depression. These difficulties can mediate the cognitive difficulties found in other domains, like memory. Alzheimer’s disease is characterized by a prominent memory deficit. Depression and dementia can both impact performance on immediate and delayed memory tasks, but delayed retrieval tasks can differentiate between the two. Alzheimer’s disease goes together with fast forgetting of information and this results in poor delayed recall and recognition performance. Alzheimer’s Disease affects the hippocampus and this area is critical to memory encoding and storage. Depressed people may have difficulties with delayed recall, but their performance can improve when they are given cues. Research has shown that old people with depression perform poorly on list learning tasks, but when they were given semantic cues, their memory improved to normal levels. These cued recall tasks did not improve the memory of people with dementia and so these tasks can be used to distinguish Alzheimer’s Disease from depression.

Recognition tasks can also help distinguish between dementia and depression. Recognition tasks minimize the need for strategic and effortful retrieval and depressed people show adequate performance on these tasks, while patients with Alzheimer’s Disease do not. Serial position effects can also be informative. People with Alzheimer’s Disease show poorer overall recall on word lists compared to depressed people. Alzheimer’s Disease individuals recalled words from the end of the list better than the words from the beginning of the list. This is consistent with difficulty retaining information in memory over time. Depressed people recalled words from the beginning and end of the list better than words from the middle of the list. This poor middle-list performance distinguishes depressed people from healthy ones. There are also some other differences between these two. Patients with Alzheimer’s disease have more difficulty performing dual tasks than patients with a depression. Dementia is also more associated with impairments on task of naming, visuopercentual processing and ideomotor praxis (inability to mimic hand gestures) than depression is. So, dementia and depression can differ in quantity and quality of cognitive deficits. Alzheimer’s Disease is typified by a prominent memory disturbance and also with deficits in praxis and language. Depression shows a frontal mediated pattern deficit, that leads to executive functioning deficits which can have its effects on other cognitive domains, because of the lack of initiation or strategic processing.

When people get older, the risk of cerebrovascular disease increases. Approximately 70% of individuals over the age of 70 exhibit evidence of vascular lesions on MRI-scans. These lesions can have different clinical profiles. Some small lesions can result in little to no cognitive impairment and other lesions are so severe, that they result in clinical dementia. Vascular cognitive impairment was introduced as a term to describe all forms of cognitive impairment causes by cerebrovascular disease. The type of impairment associated with vascular cognitive impairment depends on the location and amount of damaged tissue. This in turn influences the severity of behavioural, cognitive and psychiatric features. Early identification of vascular dementia is important, because many of the risk factors for vascular disease are modifiable. At the mildest end, with vascular cognitive impairment is called a vascular cognitive impairment no dementia (VCIND). At the severe end, with vascular cognitive impairment is referred to as vascular dementia and it is one of the more common types of dementia among older adults after Alzheimer’s Disease. Approximately one-third of individuals will develop dementia within one year after a stroke. When a stroke affects a very large vessel, or is strategically located, the result is likely consistent with the concept of dementia due to stroke. Clinical symptoms with associated with stroke are very variable and depend upon the area impacted. Impairment due to large vessel or strategic stroke is most commonly tied to the concept of vascular dementia, but it is not the most common expression of the disease. Vascular dementia has a more insidious onset and a slow and gradual decline. Mixed dementia between vascular cognitive impairment and vascular dementia is common, but it is controversial in the field.

Clinical presentation

With vascular cognitive impairment, clinical preconceptions of disease expression and progression are not realized, because heterogeneity is the rule. Patterns of abrupt onset and stepwise decline in function are less common than a slow and progressive disease course. With this disease, executive dysfunction may predominate, but the neuropsychological presentation will be driven by the extent of diffuse and focal vascular injuries in the brain.

Vascular cognitive impairment, no dementia

VCIND refers to vascular lesions that can be seen on MRI, but that cause impairment too mild to impact activities of daily living. The most common types that can be visualised on MRI are lacunes (small cerebrospinal filled cavities in the white matter) and subcortical hyperintensities (vascular-related damage). It is not uncommon for a person to have this type of vascular damage and show normal neuropsychological abilities. VCIND may be a prodromal stage for vascular dementia, VaD. Because of this, modifiable risk factors may be important in reducing the progression of the disease. One study showed that half of the VCIND cases progressed to dementia over a 5-year period in time. People who have VCIND and frontal white matter hyperintensities are less likely to revert back to normal cognitive function after 1 year as compared to people with VCIND who do not have frontal white matter hyperintesities. Modifiable risk factors may play an important role in determining the progression of VCIND to VaD. The current pharmacological treatment options for VaD are relatively ineffective at arresting disease progression, so there is a need for early identification and clinical intervention. There is not a consistent neuropsychological profile that is predictive of advancement from VCIND to VaD, but people with VCIND often display poor performance on tests of cognitive flexibility, psychomotor speed and learning. VCIND may also increase the incidence of depression, but it is not known if vascular damage is the cause of depression or a result of the deficits.

Vascular dementia

VaD results from extensive white matter lesions and lacunar infarcts due to small vessel disease, it can also result from one or more strokes to the main cerebral arteries, or the combination of the two. The most common impaired domains of function in VaD are learning, delayed memory, executive function, with intact recognition memory. The deficits in executive function are most typically found on tests of verbal fluency, response inhibition and mental flexibility. Episodic memory deficits are found on tests of recall and list learning. Recognition may stay intact if the structures of the medial temporal lobe are not damaged. Depression is the most common behavioural feature associated with stroke. 20% of people with strokes also exhibit depression. The strongest predictor of depression is reduction in the ability to carry out activities of daily living. However, this may be confounded by stroke severity. Increased depression is associated with greater cognitive impairment and increased mortality. Depression can’t explain the cognitive deficits found in patients with VaD. There are a couple of VaD criteria proposed. The most used criteria is memory deficit. The criteria for VaD from the DSM are:

1. Multiple deficits manifested by both

   1. Memory impairment

   2. At least one of the following:

      • Apraxia: motor activity impairment

      • Aphasia: language disturbance

      • Disturbance in executive functions (planning, organizing)

      • Agnosia: not recognising objects, despite intact sensory function

2. The deficits just mentioned cause impairment in occupational and social functioning and the functioning must show a decline from previous functioning

3. Focal neurological signs and symptoms or laboratory evidence for cerebrovascular disease

4. The deficits must not occur exclusively during the occurrence of a delirium

Risk factors for VCI

There are a couple of variables associated with increased risk for stroke. Strokes can occur in younger people (with sickle cell anemia), but they are most common among older people. The greatest risk factor associated with VCI is age. Other unmodifiable risk factors for stroke are male sex, atrial fibrillation, weight, race (African American) and ethnicity (Latino). There are also a couple of deterministic genetic factors that increase the risk of vascular disease. One of these is cerebral autosomal dominant arteriopathy with subcortical infarcts leukoencephalopathy (CADASIL). CADASIL is a rare autosomal disease and it is associated with a Notch3 defect that causes infarcts in the deep white matter, brain stem and basal ganglia. The average onset of a stroke is 45 years, but many individuals with CADASIL will experience migraine with aura with an average onset at age 30 years. People with CADASIL develop dementia by the sixth decade of life and they die by the seventh decade. The cognitive deficits of CADASIL patients impact organizational abilities, executive functions and attention. A susceptibility gene for vascular disease is angiotensinogen. This gene is involved with the development of subcortical ischemic disease. Cerebrovascular disease is the underlying cause of VCI, so the risk factors related to the development of VCI overlap with those related to cardiovascular disease. The improvement of risk factors underlying overall cardiovascular health lowers the risk of stroke. Studies have shown that stopping with smoking and lowering of hypertension result in reduced stroke risk in advanced age.

Differential diagnosis

When a clinician evaluates older adults for VCI, he/she may considerate other diagnoses. Some of these are Alzheimer’s Disease, Lewy body dementia, frontotemporal dementias and normal pressure hydrocephalus (NPH). NPH is quite similar to VCI, as both conditions share frontal symptoms, but NPH more frequently includes urinary urgency and gait disturbance. When these two are present, the likelihood of NPH as the appropriate diagnosis increases. Frontotemporal dementia presents with more unique symptoms than VCI, like aphasia or personality abnormalities. The age of onset for VCI is often older than what is typical for frontotemporal dementia. It is difficult for the clinician to rule out Alzheimer’s Disease. First, clinicians thought that the neuropsychological patterns of Alzheimer’s Disease and VCI and the decline of these were disease specific, but this position has been challenged. Autopsy shows that AD and vascular neuropathology frequently coexist. This means that many patients exhibit some degree of shares disease presentation during life. It is still not clear whether both conditions develop independently or whether one condition develops first, followed by the other.

Clinical evaluation

The model of vascular-mediate brain injury has evolved more than other neurodegenerative conditions over the last few decades. Beliefs about the course of decline, the neuropsychological pattern and the utility of MRI-defined vascular burden have shifted the approach and accuracy of the neuropsychological evaluation. The clinical evaluation should follow a patient-oriented approach. A clinician also needs personal, medical and neuropsychological information.

Interviews

The clinical interview is important for the assessment for vascular disease. Many patients have good insight into their cognitive deficits, but not all patients have full insight. Patients need to pay attention in order to describe their symptoms. Often, patients will confuse concepts or misinterpret the MRI report regarding cortical versus subcortical vascular disease. The access to medical records will clarify these issues, but some clinicians work in independent practice and the records may arrive after the patient has been evaluated. During the interview, a clinician can also observe language skills and potential aphasic abnormalities. The clinician can also see if the patients can recall information correctly. Sometimes patients may describe memory failure as a tip of the tongue phenomena, rather than outright amnesic failure, but during the interview, the clinician can see whether this is the case or not. During the interview, the clinician can also extract apathy and mood constructs from the patient.

Clinicians have difficulty to differentiate between a progressive and stepwise decline. The VCI literature has characterized the decline in physical and cognitive status associated with stroke as stepwise, while the insidious and progressive decline is part of Alzheimer’s Disease. When the partner or family describes a repetitive pattern of sharp decline followed by stabilization, the stepwise pattern was confirmed and vascular etiology would be considered more likely than a diagnosis of AD. This description of decline is appropriate for many infarcts, but the pattern does not hold for small vessel disease. Clinicians should not rely on the course of decline as a pathogenic sign of vascular disease and they need neuropsychological data and neuroimaging results.

Neuropsychological assessment

Some screening measures, like the mini-mental state exam, lack sensitivity to vascular-related impairments. The Montreal Cognitive Assessment (MoCA) was introduced to provide more coverage of executive processes in the screening of dementia. The MoCA is not specifically developed for VCI and it is unclear whether the task demands capture mild to moderate cognitive impairments associated with cerebrovascular disease in a good way. A couple of years ago it was suggested that a brief 30-min and a more comprehensive 60-min neuropsychological battery for VCI should be done. The 30-min battery is limited to psychomotor speed, verbal memory and verbal fluency. The 60-min battery represents all major cognitive systems like attention, working memory, processing speed, language and mood. For memory, it is critical to use measures that capture learning efficacy across trials, recognition and delayed retention. This can help to differentiate between AD and VCI. It is also recommended to measure both letter and category fluency, because people with VCI score poorer on letter fluency, while people with AD score poorer on category fluency.

Neuroimaging

Sometimes, it is tempting for clinicians to rely too heavily on neuropsychological data alone to determine the etiology of cognitive impairment. It will be the most problematic to the clinician in the case of VCI. However, when there is no obvious data present of neuropsychological impairment for VCI, it is important that neuroimaging results are integrated into the case conceptualization to reach a more whole diagnosis. The neuroimaging abnormalities that are associated with a stroke can be identified on high-powered MRI, using a fluid-attenuated inversion recovery (FLAIR) scan. Vascular disease on these images is characterized by lacunes in white and subcortical grey matter. Neuropsychologists are often not trained to review films independently, so the degree of vascular burden must be gleaned from the radiologist’s report. However, this has some problems, because radiologists do not use standard metric systems for determining the level of pathologic burden as neuropsychologists do. Cerebrovascular disease is common among the general population after age 65 years. So, this may cause some difficulties for the MRI interpretation, because there might be some vascular burden to be seen on the MRI-scan, but this might not be sufficient enough the account for the cognitive difficulties.

Worldwide, millions of individuals provide support to midlife and older adults, for example to their own husband or wife who is chronically ill. These caregivers are often affected by physical, mental and psychological health problems, such as late-life depression, geriatric suicide, social isolation and caregiver burden. The current paper focuses on the latter: caregiver burden. The paper is a review and 1) emphasizes the clinicians responsibility to recognize caregiver burden, 2) provides tools for assessing caregiver burden and 3 ) provides insight into interventions that prevent or mitigate caregiver burden.

What is caregiver burden?

In the International Classification of Diseases (ICD-10), there is no official definition or code for caregiver burden. A useful definition is given by Zarit and colleagues (1986): ‘The extent to which caregivers perceive that caregiving has had an adverse effect on their emotional, social, financial, physical and spiritual functioning’.
This definition emphasizes two important aspects of caregiver burden: 1) the multidimensional toll it exacts on caregivers 2) the highly individualized experience: what for one person may result in a caregiver burden, can be expressed much less stressful for another person.

What is the epidemiology of caregiving?

Around 90% of in-home long-term care for adults is provided by unpaid family or informal caregivers. Many of these family caregivers are untrained and often feel not well prepared to take on these (medically skilled) tasks. Most caregivers are female, and spend on average 20.5 hours per week providing care. In 2009, 43.5 million individuals in the United States provided care for an adult older than 50 years of age. Approximately 32% of caregivers reported high caregiver burden, and 19% reported medium caregiver burden.

What are risk factors for caregiver burden?

Risk factors for caregiver burden are: female, low education, living with the care recipient, depression, social isolation, financial stress, higher number of hours spent caregiving, and lack of choice in being a caregiver.

What did prior studies focus on?

Many studies focused on caregiver burden are limited by an emphasis on homogeneous diagnostic groups. For example, they focus only on caregivers who take care for patients with Alzheimer disease, cancer or a stroke. An advantage of this homogeneous approach is that it may provide insight in symptoms or the degree for that specific disease: some diseases may result in more caregiver burden than others. A disadvantage however is that it limits the generalizability and identification of features that are common across diagnoses.

How to improve diagnosis and assessment of caregiver burden?

According to the authors, physicians need to interact with family, and in particular with primary caregivers (the invisible patient). Little attention has been paid to how clinicians should relate to family caregivers. The following approach in recommended by The National Consensus Development Conference for Caregiver Assessments:

1. Identify the primary and additional caregivers

2. Incorporate the needs and preferences of both the care recipient and the caregiver in all care planning

3. Improve caregivers’ understanding of their role and teach them the skills necessary to carry out the tasks of caregiving

4. Recognize the need for longitudinal, periodic assessment of care outcomes for the care recipient and family caregiver

The present article provides topics and questions that a clinician can ask to assess caregivers (step 2). It also provides suggested openings to initiate conversions with a caregiver.

Which interventions for caregiver burden exist?

Finally, the present study reviewed several meta-analyses and reviews to provide insight into present interventions for caregiver burden. Several interventions are developed in different domains: for example psychosocial, psychoeducational and pharmalogical. Most interventions showed weak (0.2) or moderate effect sizes (Cohen’s d). Even with small or modest effect sizes, many interventions decreases symptoms of caregiver burden and are warranted.

Some practical interventions for clinicians to reduce caregiver burden are given:

• Encourage the caregiver to function as a member of the care team: be transparent, proactively include the caregiver in the care team.

• Encourage caregivers to improve self-care and to maintain their health (as often caregivers tend to neglect their own health).

• Provide education and information: educate caregivers about the illness and specific needs of the care recipient. For example, teach them proper techniques for lifting and transferring the care recipient.

• Use the support of technology, such as emergency response systems. For example, install an intercom system so that the care recipient can call for help when the caregiver is not at home.

• Coordinate for Assistance with care. Many caregivers are not aware of assistive services, such as medical adult day programs, meal delivery services and volunteer programs. Coordinating such care may lower the experienced burden of caregivers.

• Encourage caregivers to access respite care. For example, the care recipient can stay a brief period of time in an PACE program (Program of All-inclusive Care for the Elderly) to relieve the caregiver.

In our society, there is a big emphasis on autonomy and mobility. It is therefore not so surprising that our society is dependent on automobiles and recent studies have shown that individuals maintain active driver status and stay on the road later into life. There are more drivers over the age of 65 than ever before, and this number will probably keep growing. A high age and age-related cognitive conditions negatively affect the visual, cognitive and physical abilities that are necessary for safe driving. Clinicians are often called upon to comment on an older patient’s ability to remain active drivers. Ceasing driving can have negative ramifications on everyday activities, like social activities and getting to work. It also has a negative effect on the sense of autonomy and it’s also associated with poo health and depression. It’s difficult to evaluate the safety of the older driver in society, while trying to balance the person’s need for mobility and quality of life.

Driving research

According to research, the relationship between driving performance and driving outcome can be conceptualized as a triangle or iceberg. At the top of the iceberg are driving errors that produce accidents, like running a red light. The bigger middle part consists of less obvious driving errors. These driving errors can increase crash risk or result in near crashes. The bottom of the triangle or iceberg is the optimal driving section. There are two main areas of driving research that have evolved in investigating driving errors. The first tries to figure out the relationship between specific driving errors of different severities and crash involvement. The second tries to understand driver characteristics that are related to a high likelihood of committing driving errors. For clinicians who deal with older people, it is important to understand how age and cognition contribute to these driving errors.

In driving research, it is important to look at the variability in how driving outcome or driving performance is defined in the laboratory. This behaviour is often not defined in the same way. Most studies define driving performance in the following way: behind the wheel examination, performing on driving simulators, performance on instrumented vehicles, self-reported driving behaviours, documented crash involvement or crash statistics. There are significant differences across these methods. The behind-the-wheel examination is the most clinically useful method of evaluating driving performance. It is an on-road evaluation conducted by a driving specialist in a dual-controlled vehicle. Together with the driving specialist’s off-road clinical evaluation, it compromises a clinical driving evaluation. Behind-the-wheel examinations vary, because there are no mandatory rules or guidelines. In most of the cases, the person being evaluated is guided through identified routes and his/her driving behaviours are observed. There are two types of studies done in driving research. The first type are the studies conducted with a clinical focus and the second are studies conducted with a transportation research focus. These two areas should inform each other, but they often don’t. most of the research is done by transportation researchers and it is typically not published in journals that are accessed by clinicians.

Characteristics of health older drivers

There is a misconception about older drivers and the misconception is that older drivers are more often involved in automobile crashes compared to other age groups. However, empirical data does not support this claim. Some studies even show that older drivers have lower crash rates than all other age groups. What research did find, is that crash risk increases as driving exposure (annual miles driven) decreases. Older people who drive less than 2000 miles annually, which is approximately 13% of the older drivers, have one of the largest crash rates. Older adults are also more likely to be involved in certain types of crashes compared to younger and middle-aged drivers. Studies show that drivers aged 65+ are more likely to be involved in crashes at stop signs, intersections, changing lanes and while turning.

Driving errors

Studies have shown that high crash rates at intersections controlled by a stop sign were noted in older drivers (age 65-80) and younger drivers (18-21) who were more likely to run stop signs, compared to middle aged drivers. Older drivers seem to show a dangerous braking profile compared to middle age adults. The older adults brake suddenly. They begin breaking closer to the stop sign and progress faster from the initial brake press to maximum breaking. This results in a short stop. Errors in judgment and/or attention are also related to increased crash risk in older drivers while changing lanes. According to studies, crashes that occurred when the driver field to yield the right of way increased with age and they occurred more often when the driving was turning left. Many old drivers fail to evaluate the correct speed of the oncoming vehicle. The oldest drivers fail to see some vehicles.

Studies show that different cognitive abilities are associated with different driving performance measures in healthy older people, who do not have a cognitive impairment. Research has shown that older adults make certain errors more often than other drivers, such as speed control, lane changes, parallel parking and starting the car and pulling away from the curb. Older adults also committed more high crash-risk driving errors than middle-aged drivers. Older drivers often fail to check for traffic before changing lanes. Older adults are also more susceptible to distraction. Many studies have also shown that when the executive functions of the older adults are intact, they are less likely to make driving errors.

Driving in older adults with neurological diseases

Early work suggested that older people with Alzheimer’s Disease had an increased risk of crashes compared to age-matched controls, but recent studies have found no relationship between dementia and crash risk. Crash rates may not differ between health older people and people with Alzheimer’s Disease, but these two groups differ on driving errors committed. One studied showed that people with Alzheimer’s Disease only made more errors in lane changes. One big study that tested drivers with the behind-the-wheel examination, showed that increased age, greater severity of dementia and lower education were associated with higher rates of behind-the-wheel failure. Only 22% of people with Alzheimer’s Disease failed the exam. So, despite the evidence that older drivers as a group commit more high crash-risk driving errors than health people do, many older drivers with Alzheimer’s Disease are able to maintain safe routine driving over several years. However, the ability of drivers with Alzheimer’s Disease to adapt to novel driving situations is compromised compared to older adults without this neurocognitive condition. Other studies have found that cognitive performance, working memory and verbal fluency are related to crashes. People with Alzheimer’s Disease were also found to be more likely to engage in sudden vehicle slowing, which increases the risk of being struck from behind. Sudden slowing was associated with multiple cognitive abilities, but executive functioning was associated with the greatest increase in risk of unsafe behaviour.

Drivers with Parkinson’s Disease

Evidence suggests that older adults with Parkinson’s Disease are more likely to commit certain driving errors than healthy older adults. These errors involve lane changes, backing out of space, not checking the blind spot, indecisiveness at intersections and reduced use of rear- and side-view windows. Drivers with Parkinson’s Disease committed more errors than healthy people when turning, maintaining lanes or at stop signs. They also committed more safety errors according to a big study, but they did not commit more high-crash risk errors. Most people with Parkinson’s Disease are able to pass clinical driving evaluations. The drivers with Parkinson’s Disease do not limit their driving and they make as many miles a week and drive as many times as healthy adults do. When looking at cognitive measures, the drivers with Parkinson’s Disease who are seen as safe, do not differ cognitively from healthy drivers. Drivers with Parkinson’s Disease who were seen as marginally safe, performed worse on measures of verbal learning and memory, working memory, finger tapping and visuospatial ability than healthy drivers did. These results show that working memory and visuospatial abilities are important for safe driving. Studies have also shown that disease duration and severity have a negative impact on driving performance (longer duration and severity, more errors). Also, contrast sensitivity (the ability to see objects that do not stand out from the background) has a negative effect on driving safely (lower sensitivity, more errors).

Older drivers with mild cognitive impairment

There is not so much research on the driving performance of older people with mild cognitive impairment as is on drivers with Alzheimer’s Disease and Parkinson’s Disease. One looked at older drivers with mild cognitive impairment and five error types: steering steadiness, turning, gap judgment, lane control and maintaining proper speed. There was also a control group of healthy adults. The results showed that the overall mean errors did not differ between adults with mild cognitive impairment and cognitive healthy older people. The drivers were also judged by a driving specialist and when the groups were compared on the ratings of this specialist, a higher proportion of adults with mild cognitive impairment were judged as showing not optimal performance on left turns, overall driving performance and lane control. The driving performance of people with mild cognitive impairment was less than optimal, but these individuals are not impaired. There were no drivers who were seen as unsafe drivers. The researchers of this study suggest that drivers with mild cognitive impairment don’t perform optimal, because their executive functions are slightly impaired.

Application to clinical neuropsychology

Clinical neuropsychologists are often asked to comment on the driving abilities of older adults. It is quite a responsibility to decide whether somebody is able to drive or has to stop driving. It is difficult for clinicians to translate the statistically significant relationships between cognition and driving into clinically meaningful outcomes for older people. There are no guidelines as to what constitutes a sufficient assessment battery for determining driving fitness. Researchers urge clinicians to consider risk factors for decreased driving ability and to use informant report as an important method in determining the risk of the older patient with dementia. The writers think that neuropsychological assessment can make a great contribution to clinical driving evaluations. Also, if it’s possible, a cognitive assessment should be included in the driver evaluation process. The clinical driving evaluation is the gold standard for driving assessment. Driving simulation is of great use, but it’s not really a good clinical tool. It is important to remember that what constitutes a sufficient clinical neuropsychological evaluation may not constitute adequate neuropsychological assessment in driving ability. Research needs to provide direction for the selection of neuropsychological measures that need to be administered. Some domains associated with driving performance have been identified in the literature and some of these are attention, reaction time, judgment, inhibition, working memory and spatial perception.

Changes in the ageing of populations means that more and more drivers will have to face with the fact that they might have to give up driving due to health or functional limitations. Many studies in different countries have shown that many people after the age of 80-85 should rely on alternative modes of transport. Studies have shown that there are negative social and psychological consequences of driving cessation. For many older people, the feeling of being able to drive to being an ex-driver goes together with a sense of lost independence, depression and social isolation. Mental health and social integration is important for the general wellbeing and it is also important for the prevention of dementia and other health problems when people age. It is therefore important to have interventions that address the negative consequences of driving cessation. There have only been a couple of interventions that target older drivers and most of these programs aim to promote safety. This article is a review in which two areas of research are surveyed. Some studies that are reviewed are about the implications for intervention programs designed to promote safety for older adults. Other studies that are studied are studies about reducing the negative consequences of driving cessation, when safe driving is not an option anymore.

Interventions for driving safely for longer

Although we know that there are issues associated with older driver safety, there have only been a couple of studies conducted to evaluate the effectiveness of existing intervention programs. These studies describe approaches to interventions that fall into two categories. The first one is the cognitive speed-of-processing intervention. These are designed to improve aspects of visual processing and attention. The second category is the educational intervention. This is designed to promote effective self-regulation and good adaptation of driving behaviour.

Cognitive interventions

Studies have shown that cognitive abilities are important factors when it comes to safe driving. Visual-processing speed and visual selective attention are important aspects of cognition for driving. These things have been assessed among older drivers by using the so-called ‘useful field of view test,’ UFOV. The UFOV looks at to which extent older adults are capable of extracting visual information without movement of they head or eyes. The testing process sometimes requires localization, detection or identification of certain targets. Studies have showed that older drivers with UFOV impairments have more at-fault crashes and driver simulator crashes. These studies have also shown that with the appropriate training (speed-of-processing training) performance on the UFOV can improve. This suggests that the driving capacity of older adults could be improved, or maintained at acceptable levels. Of course, this could only be done through interventions that give speed of processing training.

Some studies have looked at the impact of speed-of-processing training on driving outcomes. One study looked at individuals with high-risk scores according to the UFOV. Some of these people received speed-of-processing training and others received traditional driver training. There was also a low-risk control group. The results showed that the group that received speed-of-processing training improved on the UFOV task to a level that looked like the level of the low-risk group. The group that underwent traditional driver training did not show an improvement in UFOV performance. Speed-of-processing training also had a beneficial effect on driving performance. Other studies have also shown that the UFOV might be of particular use for improving the driving outcomes of people who have an impaired speed of visual processing. The ACTIVE trial is a large-scale randomized controlled trial of cognitive training interventions with older adults. It has looked at the effects of speed of processing training on cognitive tests and functional activities. This trial has also shown that speed of processing training had a positive effect on the cognitive measures of an old person. So it seems that studies have found results that have positive implications for clinical interventions for older drivers’ cognitive capacity. With these interventions, they can drive more safely and longer. But, more research is needed to determine whether there is a certain age at which those interventions are most beneficial. Research should also look at whether benefits of training in preventing decline are ‘better’ than benefits for improving performance. Studies must also examine what the most effective mode is of delivering the cognitive training. It could be the case that there are other techniques that can enhance the driving ability, and not just the ones based on UFOV.

Educational interventions

There are a couple of studies that have looked at the education-based driving interventions and outcomes. One such study gave older drivers a driving decision workbook. This is a self-assessment tool which asks older drivers to identify potential problems faced in the domains of driving attitudes, driving ability, health and behaviour. This book also provided the older adults with feedback as to how certain problems might be addressed. The results of the study showed that the people who completed the workbook indicated that the exercise increased their awareness of age-related changes that could affect driving and they also indicated that is served as a reminder of issues that relate to road-safety. This study was limited because of the sample and a lack of follow-up data, but it does show that using a workbook has promise. Another study shows that older drivers have the ability to improve on a driving task that they had familiarity with. Both the group that received educational training about the driving environment and driving performance as well as the control group that just underwent the on-road testing without the educational intervention improved.

The most comprehensive designed educational program for older drivers is the Knowledge Enhances Your Safety (KEYS) project. This intervention was developed to improve the safety of older drivers who have visual impairments. These older individuals are at high risk of accident involvement. The project used the social-cognitive theory and models that emphasize motivation, knowledge and self-efficacy for adaptive behaviour change. The older adults received a one-on-one session with a health educator. The educator told them about the implications of visual impairment for driving, strategies for avoiding hazards and he/she thought them more about the development of skills and build their confidence up. The project was evaluated and it revealed that drivers who had received the KEYS showed a greater awareness of their visual limitations and they also reported a higher degree of self-regulation of driving behaviour. However, another study that evaluated the KEYS found that older drivers that received educational training from KEYS did not show less crashes than the control group. This suggests that educational interventions may have only limited value in promoting older driver safety.

Other studies also looked at a model which saw vision and physical functioning as important for improving the capacity of driving safely. This model saw cognition as playing a crucial role in enabling driving capacity and effective self-monitoring. Many interventions also try to improve the cognitive abilities of older people. These interventions often use speed-of-processing training (UFOV) to enhance basic driving skills. Educational interventions try to promote better understanding of issues and difficulties associated with driving. Some studies suggest that educational interventions for older people benefit the people by facilitating the discussion of issues related to driving cessation with family members. This suggests that education programs might be more effectively targeted at helping older drivers to prepare for life after not driving anymore and not enhancing safety.

Clinical interventions for driving cessation

The most effective methods for reducing negative consequences of driving cessation are applied to the population level. These include improvements to existing transport services, to make them more accessible for older adults. Also, there are community-owned transport services that provide for the needs of older adults who don’t drive anymore. There are different interventions to address adverse psychological consequences of driving cessation. Social cognitive theory seems to offer a promising theoretical framework for interventions. People see giving up driving often as lost independence. The social cognitive theory focuses on self-efficacy, control over the environment and self-regulation and it helps older adults to re-evaluate what remains achievable in terms of mobility after driving cessation and to get a sense of control over the environment. Ceased drivers often face depression which results from reduced mobility, social isolation or threats to self-concept. This might also be lessened by interventions informed by social cognitive theory. Especially the promotion of self-efficacy has been identified as an important element for success in interventions to reduce depressive symptoms in older adults. So, social cognitive theory addresses threats to the self and independent mobility by promoting efficacy and knowledge about availability of alternative transportation.

It is important to have interventions informed by appropriate theory, but practical considerations are also important in the creation of approaches that address negative outcomes associated with driving cessation. One important approach that fits with the social cognitive theory framework is the active planning for driving cessation while people remain capable of driving. Strategies that can be used to plan for life after driving might include familiarization with transport alternatives, like public transport. They also include considering housing relocation when transport alternatives are not available and also initiating conversations of transport arrangements with family and friends. These activities provide benefits and also reinforce efficacy beliefs and allow older adults to adapt emotionally better to cessation. When you expect a negative event as part of a normal transitional process, you will more likely better adjust to it than experiencing a sudden loss. There are some interventions that have used educational approaches that help assist older adults to plan for driving cessation. Residents of the Australian Capital Territory (ACT) are given an educational booklet that addresses safe driving practices and techniques for self-evaluation when they turn 70. When these people 75, they receive another booklet that provides strategies in planning for driving cessation.

Future studies

Interventions that directly address problems like social isolation and reduced mobility are needed to help individuals who have already ceased driving and are experiencing a reduction in quality of life because of it. Problem-solving treatment is in line with the principles of social cognitive theory and could address the mobility, psychosocial and emotional difficulties. Psychosocial symptoms are a result of everyday problems and problem-solving treatment therefore equips people to better deal with current difficulties. This is done by outlining a problem-solving framework within the person identifies the problems, identifies achievable solutions and also identifies the mechanisms for attaining those solutions. This framework emphasises on people using their own skills and resources to solve problems and it will therefore enhance efficacy. This approach can also be administered by health professionals who did not have had psychotherapy training. This approach has also been found to be effective in improving depression outcomes for older adults. Interventions that try to reduce the negative consequences of driving cessation will probably also benefit from the involvement of supportive family and friends of the older person. Former drivers often rely on family and friends for the maintenance of mobility. This reliance can be associated with feelings of lost independence and because of this people may be reluctant to ask for help with non-essential trips. The educational intervention could stimulate discussion and family counselling could also provide an effective approach. This is probably best initiated while the older person is still driving.

Interventions for former drivers should be flexible, because they should be tailored to the specific needs of the older adult. Interventions should take into account where somebody lives (urban, regional or isolated areas) , the availability of public transport, the availability of residents willing to provide transport and the subjective experience of driving cessation. Interventions should also be different for older people who are still driving and older people who aren’t driving anymore. Someone who just stopped driving might be feeling distressed because of a loss of independence, while somebody who hasn’t been driving for a couple of years could be depressed because of social isolation. These people should receive different intervention programs. In the United States, a project was formed from a range of backgrounds like medical practice, seniors advocacy groups and traffic safety administrations. This project is called the Older Drivers Project and it’s goal is developing an improved approach to manage issues related to older drivers at a policy level. This project promotes the safety of road users and helps older adults to drive safely for as long as possible. This projects want to optimize the health status of drivers and it wants to create a safer driving environment through improvements to roads and traffic control devices. This project and other interventions should be explored really well, because the negative consequences of driving cessation for older adults are inevitable for a proportion of older road users.

Two types of dementia

Dementia is a disease which causes cognitive impairment. There are two typical types of dementia: Alzheimer’s dementia (AD) and vascular dementia (VD). AD is associated with cortical atrophy, and is called a cortical dementia. Memory impairments arise because of degeneration of mesial temporal structures, particularly entorhinal cortex and hippocampus.

Risk factors

Widespread, cortical neurotic plaques and neurofibrillary tangles are other important characters. Risk factors are being a woman, advanced age (60>), Down’s Syndrome, hypertension, and the presence of apolipoprotein E e 4.

Vascular dementia can result from an ischemic stroke, hemorrhagic stroke, and Binswanger’s Disease. Attenuation of periventricular white matter (leukoaraiosis), often observed in VD, is able to cause cognitive dysfunction. Risk factors are advanced age, history of hypertension, heart disease, hypercholesterimia, smoking, being a man and diabetes mellitus.

Diagnostic tools

DSM-IV is the most frequently used diagnostic tool for VD and AD. Also differentiations between subcortical/cortical and degenerative/non degenerative can be made. A problem with this is that a definitive diagnose of AD can only be established post-mortem. Another problem is the heterogeneous character of VD. To be diagnosed with VD or AD, according to DSM-IV, memory impairment plus another form of cognitive impairment and social or occupational impairment (compared to former functioning) should be found, but a delirium must be ruled out. To diagnose AD conditions of the central nervous system (Parkinson/Huntington/cerebrovascular disease), systemic conditions, substance-induced conditions and other Axis I disorders (for example major depression) should be ruled out.

Diagnostic challenges

Evidence of cognitive impairment is an important diagnostic feature, so standardized cognitive measures are needed. But there is no consensus found yet about this because of variability of participant inclusion criteria. Despite this there are two general findings: AD patients show more long-term memory impairment and VD patients show greater executive functioning impairments. Consino et al. found also that AD patients had significantly less leukoaraiosis and VD patients significantly more histories of hypertension and heart disease.

Because of these findings a new diagnosing system is proposed, based on neuropsychological test findings, neuroradiological findings, and vascular risk factors. It is very important that convergent date should be used to diagnose AD or VD. Cognitive profiles, medical information and neuroradiological information should all be used for discrimination between these two forms of dementia.