COPING WITH COGNITIVE CHANGE IN AGING:

PERSPECTIVES OF THE AGING INDIVIDUAL AND THE

GEROPSYCHOLOGIST

Some implications of reported findings on memory and other cognitive aspects of aging will be discussed in this section, including considerations relevant to the geropsychologist.

7.02.4.1 ªFrom Lab to Lifeº

The research literature on memory and other cognitive functions conveys the general conclu-sion that decline and change become more likely with advancing age, although the age-related sensitivity differs for various tasks. At the same time we usually find that most elderly people maintain independence and successful function-ing in everyday life even though this involves numerous tasks that require complex memory and cognitive abilities. These observations seem contradictory and address questions about the significance of reported findings on memory and cognitive changes in aging, revealed in the experimental or clinical setting. These different portrayals of aging also become evident to the geropsychologist. Salthouse (1983) suggested four explanations for the discrepancy between ªlab and lifeº: individual differences, ecological validity, cognitive demands in terms of com-plexity and difficulty, and everyday life experi-ences and learning.

7.02.4.1.1 Individual differences

The individual differences issue is a neglected aspect in the prevailing normative tradition in the gerosciences. The use of chronological age, as a proxy marker for aging, and the arithmetic mean as the typical statistic for describing performances, tends to emphasize general patterns over unique features, including that of interindividual differences.

In everyday life we may face individuals in advanced ages who show better performance than they did some years ago. The recovery from certain diseases and treatment effects are also seen in advanced ages. The normative design is, however, unlikely to show both sides of the coin, that is, while some individuals decline, others remain stable or even improve their performance over time. Besides generation and cohort differences, individuals of the same age typically manifest great differences in physical as well as psychological functioning.

Elderly people are distributed between the extremes of those who experience early physical and cognitive impairments and, at the other end of the continuum, the successful agers who maintain their performance throughout life.

This notion is important because it provides a basic frame of reference for assessment, as well as an accurate portrayal of aging.

An interindividual perspective is an essential element for the geropsychologist. The research literature provides the general norms for late-life functioning, and at best adequate norms for various tests. An assessment requires, however, detailed information about previous function-ing of the individual. Such information, or more likely assumptions about ªbaseline perfor-manceº in earlier days, should provide the ultimate points of reference for the geropsy-chologist.

7.02.4.1.2 Ecological validity

Ecological validity refers to the congruence between laboratory and clinical tests, and everyday life tasks requiring memory and other cognitive resources. Although certain experi-mental tasks may be considered as esoteric, they surely activate cognitive subprocesses and components of relevance for life outside the laboratory. The overall aim in experimental aging and cognition studies is the understanding of age-related change in those subprocesses and components. In this sense, the complexity of everyday life tasks can never correspond to requirements in the laboratory setting.

Although the range of available tests covers many dimensions of memory and cognitive functioning, it is important to remember that

Coping with Cognitive Change in Aging 45

they still represent only a sample of markers for various cognitive processes.

Another aspect of ecology relates to com-pensatory behaviors that tend to be neglected in the laboratory. In everyday life individuals can compensate for weaknesses in certain abilities by profiting from strengths in other areas of functioning. In this sense difficulties may not become manifest in natural settings. In tests, however, individuals are usually inhibited from using compensatory strategies to overcome weaknesses. Impairments are then more likely to be evinced.

The ªlab±life dimensionº represents an im-portant issue for the geropsychologist when confronted with an individual showing impaired test performance, but demonstrating relatively intact functioning in everyday life. The detec-tion of cognitive problems on certain tests may be due to disease processes (secondary aging) and provide arguments for interventions aimed at retarding or improving performance. Low performance on tests is also indicative of the cognitive expenditure that is needed to manifest ªintactº everyday functioning.

7.02.4.1.3 Complex cognitive processing The notion that cognitive demands in every-day life are less complex and difficult than that of laboratory and clinical tests deserves atten-tion. One might argue that the demands of the two situations are not identical (e.g., Baltes &

Willis, 1979). Laboratory and clinical tests of memory and cognition are usually designed in accordance with psychometrics. This means that level of difficulty is deliberately introduced as a variable for evaluating performance.

Everyday life is often highly predictable through recurrent tasks and events with which we have learned to cope. Tests of memory and cognition are also likely to introduce novel tasks, requirements, and a setting that is unfamiliar to the individual.

The familiarity with psychological testing differs across age cohorts. The oldest old tend to have fewer such experiences. Recommendations of ªage-fairnessº should be evaluated against this background. In addition, in real life people tend to seek those environments that fit their interests and available resources, including those that relate to cognition. This is a matching of abilities and task demands that does not occur in the laboratory or in the clinical test situation. In evaluating an individual's perfor-mance, geropsychologists have to consider how a task should be presented, how the instructions are administered, including feedback to the individual. Motivation and other noncognitive factors are also important. The importance of

instructions and practice before administering a certain task is well known to the experienced clinician. Standard tests and batteries usually allow only brief instructions. Difficulties ex-perienced by elderly people in comprehending these instructions, for example, in abstract tasks, are likely to interfere with later perfor-mance. Ensuring that the individual under-stands task requirements can therefore significantly improve performance (e.g. Baltes, Sowarka & Kliegl, 1989).

7.02.4.1.4 Everyday life experiences and learning

Although research on memory and cognition in aging typically confirms a deterioration view, the resources in most individuals are sufficient to cope with environmental demands of daily life. When the magnitude of decline exceeds the ecological demands it becomes a manifest deficit. For example, in the diagnosis of dementia, the impairment in memory and other cognitive abilities must interfere with daily life functioning according to diagnostic criteria (American Psychiatric Association, 1987, 1994). Many activities and tasks in everyday life are overlearned by their being practiced over and over again. As noted by Salthouse (1983), ªsince increased age in adulthood is generally positively correlated with experience, many highly practiced activities may be maintained at a constant level despite age-related declines in component ability because of the compensating effects of greater experienceº (p. 203).

In experimental and clinical settings, memory and cognitive tasks are typically novel and the cues and instructions provided do not necessa-rily correspond to those available in natural, everyday life. Performance is then more unlikely to rely on previous experiences. The ability for adequate everyday functioning is also affected by more or less subtle social and cognitive support systems that constitute natural ingre-dients in daily-life activities (use of a calendar, reminders, and other external aids). In addition, individuals also tend to withdraw from activities that are viewed as too demanding, using excuses such as that they have lost interest (see Baltes's model below). The geropsychologist has to consider and be aware of the mechanisms of the fit between environmental demands and cogni-tive capabilities of the individual.

7.02.4.1.5 Current knowledge and extralaboratory cognition

As pointed out by Salthouse (1983), and by recent proponents of testing memory and cognition in daily-life contexts (e.g., Willis, 1996), ªthe greatest hindrance to knowledge

about the relationships between laboratory performance and extralaboratory competence is simply lack of detailed information about the nature of real-world activitiesº (Salthouse, 1983, pp. 203±204). Clearly, more attention needs to be given to the external validity of results obtained in the laboratory or clinical setting. Improved means of evaluating everyday performances constitutes one avenue for this.

Much of the literature on aging and cognitive functions can be divided into three parts on the basis of methodology. Research is conducted in the psychometric tradition, in the experimental tradition, or in the ecological tradition. It seems clear that there are possible gains by cross-fertilization between approaches. Indeed such efforts are not absent. One approach includes bringing everyday activities such as television watching into the laboratory (e.g., Stine, Wingfield, & Myers, 1990) for subsequent tests of, for example, memory. Another logical possibility is to perform clinical or laboratory-like tasks in the subject's everyday world.

Weber, Brown, and Weldon (1978), conducted such a study where elderly residents in a nursing home were tested on spatial knowledge and memory for scenes and locations in their nursing home. An even broader approach may be warranted, taking into account such things as collaborative support provided by a spouse (Gould & Dixon, 1993; Gould, Tre-vithick, & Dixon, 1991). On the other hand, proponents of an applied approach aiming at intervention and adjustment of the environment argue that researchers have now developed sufficient understanding of older adults' cogni-tive systems to make it possible to improve the quality of life for older adults (see Park, 1992).

The latter view relies mainly on knowledge about cognitive processes, as well as documen-ted strengths and weaknesses of the elderly in a broader sense.

7.02.4.1.6 Cognitive aging and the individual: an integrative model

A comprehensive model for the understand-ing of primary cognitive agunderstand-ing in the real-life context that integrates much of the literature on cognitive aspects of aging was proposed by Baltes (1991). The model (see Figure 6) is based on a series of propositions. These propositions, or general statements, are to some extent already covered in previous sections of the present chapter. Briefly, it is assumed that aging is characterized by much interindividual varia-bility; it is important to distinguish between pathological, normal, and optimal aging; there is much developmental reserve capacity in old age; aging is characterized by a loss of fluid

intelligence; knowledge and crystallized abilities may compensate for the losses in fluid abilities;

with aging the balance between gains and losses becomes less positive or even negative; and the self in old age continues to be a powerful system of coping and maintaining integrity.

Against the background of these general conclusions, some adaptional mechanisms were suggested for successful psychological aging.

The model focuses on the dynamic interplay among selection, optimization, and compensa-tion, all components in a general process of adaption, effective throughout life. However, because of the losses experienced in aging, whether biological, social, or mental, the model is especially applicable to elderly persons. By selection of activities from a previously more extensive repertoire of behaviours, maximizing the effort spent on maintaining certain activities by means of practice or acquisition of new knowledge, and finally fostering of compensa-tory behavior, performance may be maintained at high levels even in old age.

Without going into details, some conclusions apply to the present chapter. The model has obvious implications for the geropsychologist.

In the clinical setting, a wide variety of functions or abilities are routinely tested. Since the purpose of an investigation is usually to arrive at a diagnosis, the focus is often on deficits and weaknesses. Planning for training or rehabilita-tion, on the other hand, also requires closer examination of strengths and the potential for improvements. However, with reference to the discussion about everyday cognitive perfor-mance, it may be justifiable to include a routine for evaluation of cognitive reserves and abilities to adopt compensatory behavior. The impact of interindividual variability is strongly acknowl-edged in Baltes's model as interindividual variability in old age applies not only to behavioral functioning, but also to indicators of biomedical functioning (Costa & Andres, 1986; Rowe & Kahn, 1987). This variability may in combination with other critical compo-nents, such as expertise in some areas, produce differential patterns in aging. Hence, both strengths and weaknesses are equally critical components in a full understanding of the individual's general level of functioning.

7.02.4.1.7 Cognitive reserves and plasticity Some additional comments on cognitive reserve capacity may be warranted. Following the Baltes (1991) model, potential for cognitive improvement may be discussed in terms of baseline reserve capacity as well as develop-mental reserve capacity (see Kliegl & Baltes, 1987). Baseline reserve capacity refers to

Coping with Cognitive Change in Aging 47

variations in performance due to varying levels of task demands and support, while develop-mental reserve capacity denotes the range of performance under extended periods of devel-opment or practice. Reserve capacity is related to such diverse examples as the acquisition of expertise, testing the limits of an individual's capacity, and memory training.

7.02.4.2 General Assessment Guidelines Some guidelines in the assessment of elderly persons can be extracted from previous discus-sions. These general guidelines by no means constitute a complete coverage of all topics.

Also, advice in relation to specific diagnostic issues is not dealt with. Certain suggestions are self-evident, but nevertheless important to address explicitly.

Throughout the chapter, it has been empha-sized that the level of cognitive functioning is under multifactorial influence and that inter-individual variability is substantial in aging.

These notions have obvious implications for the geropsychologist. Chronological age has tradi-tionally been the sole stratification variable in the psychometric test tradition. Using test norms to aid in the interpretation of perfor-mance ought to be considered in this context.

Further, the distinction between primary and secondary aging requires the integration of information from several sources, including that of physical health and social life.

Before meeting the client, we would strongly recommend the geropsychologist to review

medical records. Although literature on the relation between cognition and disease is scarce for illnesses in old age other than dementia or major depression, it may be worthwhile to look for the presence of, for example, cardiovascular disease including elevated blood pressure, hyper- or hypothyroidism, diabetes, epilepsy, vitamin deficiency, previous transient ischemic attacks or stroke. The medical literature also lacks, in general, age-graded norms for the elderly, for example, age-adjusted cut-offs for laboratory tests such as the test of folic acid.

(For details, see the literature listed in the previous section on secondary aging.)

In the assessment setting it is also strongly recommended to check for vision and hearing.

Does the client need certain glasses or a hearing aid? Secure the use of these aids, and, when vision or hearing is poor, consider using adjusted test materials.

Testing should start with a brief interview.

During this conversation, much information crucial to later interpretation of test results may be obtained. The geropsychologist should, in addition to basic information concerning edu-cation and prior work or career, also collect data about previous and present skills and interests.

When necessary, a relative may provide valu-able information (e.g., Jorm et al., 1996). The client's general feeling of being in control of daily life as well as beliefs about their own capacity may be informative in evaluating subsequent test performance.

Motivational factors play an important role in the assessment setting. Therefore, one should explain carefully the purpose of the assessment Development and aging as a

process of specialization Aging loss in biological reserve capacities

Aging-related advances in knowledge (pragmatics of life)

Optimization Selection Compensation

Restricted but effective

life

Antecedents Mechanisms Outcome

Figure 6 Baltes's selective optimization with compensation (ªThe many faces of human ageing: Toward a psychological culture of old ageº by P. B. Baltes, 1991, Psychological Medicine, 21, p. 85. Copyright by

Cambridge University Press. Adapted with permisssion).

and make sure of the client's comprehension. At this stage, it is possible that the geropsychologist has obtained a clinical impression of the client's general level of functioning. This is important for selecting the relevant tests and for avoiding floor and ceiling effects.

When introducing tests to the client, it may be worthwile to vary task demands systematically in order to investigate reserve capacity. Also, tasks may be varied in terms of time restraints. It is generally advised that tasks be selected in terms of age-fairness.

As noted, in testing older clients, norms are often not entirely reliable. In addition to problems concerning sample selections for these norms, they seldom cover the age range above 80 years. Most studies portray, however, a continuous decline of cognitive performance in the oldest, although performance may remain at relatively high levels. In the absence of norms for the very old and the introduction of other stratification variables than age, it becomes advisable to interpret raw scores carefully.

7.02.4.3 Future Prospects and Cohorts

In the years to come, geropsychologists will meet new cohorts of elderly people who are exposed to other experiences and influences than the elderly people of today. Future clients are likely to require efforts to promote independence and growth in aging, also for aspects of life related to memory and cognition.

Future cohorts may require somewhat different diagnostic considerations than today and age-fair testing may refer to something different than today. Improvements in the educational system are likely to exert an impact on performance in new cohorts of elderly people.

Furthermore, it may be that successful medical treatments for conditions such as Alzheimer's disease are introduced. In that case, geropsy-chological expertise may require improved methods for early, preclinical, detection of the disease.

Given increasing interest in geropsychologi-cal matters, new test norms adjusted for individuals in the range 80±100 years will hopefully be available to future cohorts of clinicians. The recognition of interindividual differences may end in norms that do not apply chronological age as the sole stratification variable for differentiation within normal and pathological aging. Educational level and gender are two probable candidates among other critical variables to be considered.

The impact of education may seem somewhat far-fetched, as formal education is quite distant in time for elderly people. Education is,

however, related to verbal ability and strategy knowledge (e.g., Flavell & Wellman, 1977;

Gillund & Perlmutter, 1988), both of which are prerequisites for successful performance on many memory and cognitive tasks.

Norms adjusted for gender are, to a certain extent, already available. Generally, women perform better than men on verbal memory tasks (e.g., Larrabee & Crook, 1993; Schaie &

Willis, 1993; Zelinski, Gilewski, & Schaie, 1993). Women also appear to perform at a higher level on face recognition tasks (see Shepherd, 1981, for review). Social (e.g., McKelvie, Standing, St. Jean, & Law, 1993) as well as biological (e.g., Gur et al., 1991) explanations have been proposed for these differences.

Willis, 1993; Zelinski, Gilewski, & Schaie, 1993). Women also appear to perform at a higher level on face recognition tasks (see Shepherd, 1981, for review). Social (e.g., McKelvie, Standing, St. Jean, & Law, 1993) as well as biological (e.g., Gur et al., 1991) explanations have been proposed for these differences.