OVERALL AGE-RELATED CHANGES IN MEMORY

Retrieval of information is an important part of daily functioning.

With normal aging, memory deficits are associated
primarily with the storage of long-term episodic memories.
Information that places little demand on attention, such as
implicit memory tasks, results in very little age-related changes
in performance. The advantage that older adults experience
on recognition tasks indicates that their memory storage and
retrieval may be much less efficient than that of younger
adults. A processing speed perspective illustrates that normal
aging is accompanied by a slowing in overall cognitive processing
and it is accepted that older adults process information
at a slower rate compared with younger adults. Salthouse19
found that after statistically controlling for processing speed,
age was only weakly related to memory. Memory functioning
in normal aging is thus mediated by processing speed.
The reduced attentional resources concept18,40 suggests that
a limited amount of cognitive resources are available for a
given task and consequently, a more complex task requires
more attentional capacity than a simpler task. It follows that
because the amount of attentional resources is reduced with
aging, the processes of encoding and retrieval of information
use a larger proportion of available resources for older adults
than for younger adults. In sum, research suggests that overall
cognitive slowing and changes in attentional ability account
for much of the change in memory functioning as we age.
Verbal Abilities
Most verbal abilities remain intact with normal aging.41
Therefore vocabulary and verbal reasoning scores remain
relatively constant in normal aging and may even show
minor improvements. The two main areas of verbal abilities
that are frequently discussed in terms of aging are verbal fluency
(semantic and phonemic) and confrontation naming.
Verbal fluency is the ability to retrieve words based on their
meaning or their sounds. Confrontation naming describes
the ability to identify an object by its name.
Two common tests used to assess verbal fluency are the
Controlled Oral Word Association Test (COWAT)42 and
the semantic fluency test.31 The COWAT is perhaps the
most widely used test of phonemic fluency. The COWA task
requires an individual to generate as many words that begin
with a specific letter as quickly as they can. The semantic fluency
task is a timed-test that requires the individual to generate
examples in a specific category (e.g., animal naming test).
The Boston Naming Test32 is a commonly used test to measure
confrontation naming ability as individuals are required
to name the object in the presented picture. Confrontation
naming is composed of several different processes; an individual
must perceive the object in the picture correctly, identify
the semantic concept of the picture, and retrieve and
express the appropriate name for the object.43 Confrontation
naming ability is associated with the tip-of-the-tongue
(TOT) phenomenon. The TOT phenomenon occurs when
an individual knows the name of a person or object and is
able to retrieve the semantic information about the object,
but cannot retrieve the name of the object.44 Although an
individual is unable to retrieve the target word, he or she will
often try to describe the term using other words.45 Throughout
all of adulthood, proper nouns comprise the majority of
TOT experiences. However, the increase in TOT phenomenon
among older adults is due to their greater difficulty in
retrieving proper nouns.44 There is not a significant age difference
in the frequency of TOT episodes for simple words.
However, older adults have significantly more TOT experiences
than younger adults for difficult words.45 Thus, wordfinding
difficulty and TOT moments are the most common
cognitive complaints of older adults.
The majority of cross-sectional studies have found that
older adults have lower scores on the Boston Naming Test
compared with younger individuals. It should be noted that
while subjective complaints of word-finding difficulties
increase with age, significantly lower performance on tasks
of confrontation naming only emerges after age 70.44 Zec
et al46 found that confrontation naming ability as measured
by the Boston Naming Test improves when individuals are in
their 50s, remain the same in their 60s, and decline in the 70s
and 80s; it should be noted that the magnitude of these agerelated
changes is relatively small. It was found that there
was an approximate one word improvement in the 50s age
group and a 1.3 word decline in the 70s age group. There is
some indication that there is an accelerated rate of decline in
confrontation naming ability with age.44
Normal aging is associated with a decline in verbal fluency.
It is important to note that the normal age-related decline
seen in verbal fluency performance may be partially mediated
by reduced psychomotor speed rather than true deficits
in verbal ability. Slowed handwriting and reading speed in
the elderly was predictive of poorer performance on verbal
fluency tests.47 Rodriguez-Aranda and Martinussen48 found
a decline in verbal fluency as measured by the COWAT
after age 60. The ability to generate words beginning with
a particular letter improves until the third decade of life and
remains constant through the 40s. Subsequently, a significant
decline occurs in phonemic naming ability and continues to
worsen gradually until the late 60s. Phonemic verbal fluency
ability continues to decline rapidly through the late 80s. Gender
and education may impact ones phonemic verbal fluency
across the lifespan. Women may slightly outperform men on
tasks of phonemic verbal fluency. Individuals with higher levels
of education (beyond high school) show greater verbal
fluency ability as measured by the COWAT compared with
individuals with lower levels of education (12 years or less).49
Executive Functions
Executive functions describe a wide range of abilities that
relate to the capacity to respond to a novel situation.16
Executive functions include abilities such as mental flexibility,
response inhibition, planning, organization, abstraction,
and decision-making.50,51 Executive function can be thought
of as having four distinct components: volition, planning,
purposive action, and effective performance.3 Volition is a
complex process that refers to the ability to act intentionally.
Planning is the process and the steps involved in achieving
the goal. Purposive action refers to the productive activity
required to execute a plan. Effective performance is the ability
to self-correct and monitor ones behavior while working.
All of the components of executive functioning are necessary
for problem solving and appropriate social behavior.
Another term for executive functions is frontal lobe functions
because these abilities are localized in the prefrontal
cortex.52 The frontal aging hypothesis refers to the idea
that normal aging leads to deterioration of the frontal lobes.
Deterioration is due to a loss of volume in the prefrontal
cortex and is associated with cognitive deficits. Prefrontal
deterioration plays a key role in many of the age-related
changes in cognitive processes, such as memory, attention,
and executive function.53
Like many cognitive processes, it is difficult to assess pure
executive function as many of the measures used in its assessment
rely on other cognitive processes such as working memory,
processing speed, attention, and visual spatial abilities.
The Wisconsin Card Sorting Test (WCST)54 is a popular test
used to measure executive function. The WCST requires an
individual to sort a set of cards based on different categories.
Individuals are not informed about how to sort the cards
and must deduce the correct sorting strategies through the
limited feedback that is provided. After a particular category
is achieved (i.e., a set number of correct responses) based
on a particular characteristic (e.g., color or shape), the sorting
strategy changes and the individual must shift strategies
accordingly. Once the test is completed, the examiner is provided
with several measures related to executive function, for
example, categories and perseverative errors. A category is
achieved when a specific number of cards have been sorted
correctly based on the particular criterion such as color. Perseverative
errors occur when an individual continues to give
the wrong response when provided the feedback that the
strategy is not or is no longer correct, thus demonstrating a
lack of cognitive flexibility.
On the WCST older adults achieve significantly fewer categories
than younger adults.52 The most significant decline
in performance on this test is seen in adults age 75 and older.
Individuals of this age group achieve significantly fewer categories
and more perseverative errors compared with younger
individuals. However, changes in executive functioning as
measured by neuropsychological assessments, such as the
WCST, can be seen in adults aged 53 to 64, but adults ages
53 to 64 do not show deficits on more real-world executive
tasks.55 Thus although individuals in midadulthood may
show a decline in executive functioning on structured neuropsychological
tests, their real-world executive skills remain
intact.
Other measures used in the assessment of executive functioning
included Trail Making Test, Part B5 and the WAIS-III
subtests,4 Matrix Reasoning and Similarities. Trail Making,
Part B, is a timed visual-spatial sequencing task requiring
an individual to draw connecting lines alternating between
numbers and letters in numerical and alphabetical order.
Matrix Reasoning is an untimed task that measures ones
nonverbal analytic thinking abilities. The Matrix Reasoning
task requires an individual to identify the missing element
of an abstract pattern from a variety of choices. Wechslers
Similarities subtest measures an individuals verbal abstract
reasoning skills by asking an individual to describe how two
different objects/concepts are alike.
Normal aging is generally associated with a decline in
executive functioning.56 When reasoning and problem-solving
involve material that is novel, complex, or requires
the ability to distinguish relevant from irrelevant information,
the performance of older adults suffers because they
tend to think in more concrete terms and the mental flexibility
required to form new abstractions and concepts
declines.3 Compared with younger adults, older adults also
show a decreased capacity to form conceptual links as mental
flexibility diminishes.3 Executive functions serve as the
overseer of brain processing and are essential for purposeful,
goal-directed behavior. Deficits in executive functioning
can be seen in difficulties with planning and organizing,
difficulties implementing strategies, and inappropriate social
behavior
or poor judgment.
Lifestyle Factors Associated with
Cognitive Functioning
LEISURE ACTIVITIES
The mental exercise hypothesis refers to the notion that
keeping mentally active will help maintain an individuals
cognitive functioning and prevent cognitive decline. Many
activities, such as playing bridge, doing crossword puzzles,
studying a foreign language, and learning to play an instrument,
have been suggested to help in preventing cognitive
decline.57 The research regarding the mental exercise
hypothesis has been varied and there is currently not a
definitive answer regarding the role of leisure activities in
preventing cognitive decline.
It is suggested that engaging in leisure activities, especially
ones that are cognitively demanding, maintains or improves
cognitive functioning.58 However, there is also evidence
that individuals with high levels of intellectual functioning
engage in more cognitively demanding activities, making it
difficult to discern the exact role of mental activities in preventing
cognitive decline. This line of research suggests that
it is not the activity per se that is responsible for maintaining
cognitive functioning, but rather specific lifestyles and living
conditions.58
Although there is not conclusive evidence regarding
the protective factors of leisure activities, several research
studies59,60
have shown that leisure activities reduce the risk
of dementia in the elderly. Reading, playing board games,
learning a musical instrument, visiting friends or relatives,
going out (i.e., to movies or a restaurant), walking for pleasure,
and dancing are associated with a reduced risk of
dementia.59,60 Such leisure activities have been shown to
protect against memory decline even after controlling for
age, sex, education, ethnicity, baseline cognitive-status, and
medical illness. Participation in an activity for 1 day per
week was found to reduce the risk of dementia by 7%.59 Individuals
who participated in many leisure activities (i.e., six or
more activities a month) had a 38% less risk of developing
dementia.60
It has been also hypothesized that leisure activities reduce
the risk of cognitive decline by enhancing cognitive reserve.
A decrease in activity results in reduced cognitive abilities.61
Engaging in leisure activities may also provide structural
changes in the brain that protect against cognitive decline
given that certain areas of the adult brain are able to generate
new neurons (i.e., plasticity). Stimulation, such as engaging
in social, intellectual, and physical activities, is suggested
to promote increased synaptic density. Enhanced neuronal
activation has been proposed to hinder the development of
disease processes, such as dementia.60 However, research has
also shown that changes in cognitive reserve are more likely
to occur early in life; it is primarily the early experiences of
education and intellectual activity that increases cognitive
reserve the most.11 Despite the varied findings,
people should continue to engage in mentally
stimulating activities because even if there is
not yet evidence that it has beneficial effects
in slowing the rate of age-related decline in
cognitive functioning, there is no evidence that it
has any harmful effects, the activities are often
enjoyable and thus may contribute to a higher
quality of life, and engagement in cognitively
demanding activities serves as an existence
proofif you can still do it, then you know that
you have not yet lost it.57
PHYSICAL ACTIVITIES
It has been hypothesized that engaging in physical activities
may enhance cognition and prevent decline in late life
as physical activities enhance blood flow to the brain and
oxygenation, processes which are known to slow biologic
aging.11 Physical activities reduce cardiovascular and cerebrovascular
risk factors, which may reduce the risk of vascular
dementia and Alzheimer disease.62 There is also evidence
that physical activity may directly affect the brain by preserving
neurons and increasing synapses.63
Moderate and strenuous physical activity is associated
with a decreased risk of cognitive decline. Moderate activity
includes playing golf on a weekly basis, playing tennis
twice a week, and walking 1.6 m/day. Research has found
that long-term regular physical activity, such as walking, is
associated with less cognitive decline in women.64 The benefits
of walking at least 1.5 hr/wk at a 21 to 30 min/mile pace
are similar to being about 3 years younger and are associated
with a 20% reduced risk of significant cognitive decline
SOCIAL ACTIVITIES
Social support has also been suggested to serve as a protective
factor in cognitive decline. Social support may serve as a
buffer against stress and may lead to decreased cortisol production
in the brain. Lower levels of cortisol result in better
performance on tests of episodic memory.65 Interacting
with others may also prevent cognitive decline by providing
an individual with increased mental stimulation66 and
may also protect an individual from depression, which has
been shown to negatively impact cognition.67 Depression
and mood disorders are associated with an accelerated cognitive
decline as people age.68 Processing speed, attention,
and consequently, memory may all be affected by depression.
In addition, a lack of social interaction also impacts an
older adults well-being. It has been found that individuals
who live alone or have no intimate relationships are at an
increased risk of developing dementia; those individuals
who are classified as having a poor social network are 60%
more likely to develop dementia.69 Individuals in their 70s
who report having limited social support at baseline show
greater cognitive decline at follow-up assessments.67 On the
other hand, individuals with greater emotional supports have
better performance on cognitive tests.67 Rowe and Kahn70
proposed a model of successful aging as being composed of
three main components: avoidance of disease-related disability,
maintenance of physical and cognitive functioning,
and active engagement in life. Active engagement with life
involves maintaining interpersonal relationships and it has
been found that social environment and emotional supports
may be protective against cognitive decline and result in a
slower decline in functional status.
HEALTH FACTORS
Several medical conditions are associated with cognitive
decline. Hypertension is the most prevalent vascular risk factor
in the elderly.71 Chronic hypertension has been shown to
result in deficits in brain structure including the reduction of
white and gray matter in the prefrontal lobes, atrophy of the
hippocampus, and increased white matter hypertensities.72
Research has found that uncontrolled hypertension can lead
to cognitive decline that is independent of normal aging,71,73
aside from posing a risk for stroke. Older adults with hypertension
have mild but specific cognitive deficits in the areas
of executive function, processing speed, episodic memory,
and working memory.73
Diabetes mellitus has also been associated with cognitive
decline.74,75 Lipids and other metabolic markers may play a
role in the relationship between diabetes and cognition.76
Diabetes may also impact cognition through confounding
factors such as hypertension, heart disease, depression,
and decreased physical activity.76 Individuals with type 1
diabetes display a slower processing speed and a decline
in mental flexibility.75 Type 2 diabetes is also associated
with cognitive decline; longer duration of type 2 diabetes
results in greater cognitive decline.77 Elderly women
with type 2 diabetes have a 30% greater risk of cognitive
decline compared with those without diabetes, with a 50%
greater risk for individuals with a 15-year or greater history
of diabetes.
Dietary factors and vitamin deficiencies have also been
associated with cognitive decline in the elderly population.
Individuals with cognitive decline associated with normal
aging should be investigated for B12 deficiency. Research
has demonstrated that vitamin B12 injections may improve
executive and language functions in patients with cognitive
decline, but will rarely reverse dementia.78 Low vitamin
B levels may be associated with impaired cognitive
performance through several possible mechanisms including,
multiple central nervous system functions, reactions
involving DNA, and the overproduction of homocysteine
that could potentially damage neurons and blood vessels.79
Low levels of vitamin B12 and folic acid result in poorer
performance on tasks of free recall, attention, processing
speed, and verbal fluency.80 Overall, research suggests that
the effects of vitamin deficiency are most likely seen on
complex cognitive tasks that demand greater executive
functions.
Conclusion
Cognitive decline is a natural part of aging. However, the
extent of decline varies across individuals and across the
specific cognitive domain being assessed. The cognitive
reserve perspective maintains that individual differences
with regard to cognitive aging are related to an individuals
reserve built upon early life factors (i.e., educational and
intellectual experiences).9
Although cognitive reserve can be increased in later life, it
is more amenable to change in early life. Although cognitive
decline is inevitable, all areas of functioning do not
change equally. It is well established that older adults process,
store, and encode information less efficiently than
younger adults. The cognitive functions related to fluid
intelligence, such as the ability to solve novel or complex
problems, tend to decline with aging, whereas cognitive
functions related to crystallized intelligence, such as
school-based knowledge, vocabulary, and reading, generally
remain stable throughout life. Processing speed and
attentional capacity are particularly vulnerable to aging,
especially on more challenging tasks, and mediate multiple
areas of cognitive functioning. For example, a memory
problem is often, more accurately, a problem with poor
attention and/or slowed speed of processing information.
KEY POINTS
Normal Cognitive Aging
Variability exists across individuals in their ability to compensate
for cognitive changes as they age.
An active, engaged lifestyle, emphasizing mental activity and educational
pursuits in early life, has a positive impact on cognitive
functioning in later life.
In normal aging there is typically a decline in sustained attention
and selective attention and an increase in distractibility.
Older adults response time is approximately 1.5 times slower than
younger adults.
Most verbal abilities remain intact with normal aging.
Normal aging is generally associated with a decline in executive
functioning.
Memory deficits associated with normal aging are primarily
related to the storage of long-term episodic memories.
Implicit memory tasks, results in very little age-related changes in
Performance
Although research has found cognitive decline in the
areas of attention, processing speed, episodic memory,
and executive function, research has also shown that older
adults have cognitive (or brain) plasticity and may benefit
from cognitive training and other mental activities.81 However,
the results of cognitive training with normal aging
adults has been varied; although improved performance on
a specific task can be found, there is a lack of generalizability
to daily functioning in the long term.82 Nevertheless,
maintaining an engaged and healthy lifestyle (social,
physical, and intellectual) improves ones quality of life and
may add to successful aging. One problem is the assumption
that successful aging means that there is no discernable
change in memory and overall cognitive functioning from
ones previous level of functioning. Changes in cognition
are a normal part of aging and not something that is necessarily
a cause for concern or precursor to dementia. Older
adults need to adjust their idea of normal aging to a more
realistic standard.
ACKNOWLEDGMENT
Material in this chapter contains contributions from the previous
edition, and we are grateful to the previous author for
the work done.
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