Synopsis
[1] Introduction: Outline of Concept & Process of Aging
[2] Aging: Normal Cognitive Changes & Impairments which May Occur
[3] Clara: A Case Study: Cognitive Changes & Nursing Strategies
[4] Conclusion: Crystallisation, Equilibrium & Transcendence
References

Bibliographical Citation

NEWMAN, C.A.   (1991).  On the process of aging: cognitive changes, impairments and positive responses: discussion of the proposition that these occur normally (Wilson & Kneisl, 1983) supported by an analytic case study examining efficacy of nursing strategies based on this understanding.  Metropolitan & Eastern School of Psychiatric Nursing, Royal Park Psychiatric Hospital, Vic. [PN-I: Psychogeriatric Unit].

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SYNOPSIS

Perceptual, energic, structural and integrative changes in cognition, other than cognitive traits, are found to be normal to the aging process.  This process can be compared to 'crystallisation' in which lines of energy are analogised into mature structures in equilibrium.  Blocks to this process bring about impairments or abnormal cognitive changes.  In a case study, Clara exemplifies the cognitive needs of older people to perceive their own self-fulfilment, engrossment in reality, social involvement, and social recognition.  Only then can energy economising self-acceptance occur, cognitive illness or lifespan reducing distress be avoided, and disease, death and bereavement be faced without inducing obsession, depression or delusion.  In summary, the process involves 'post-narcissistic love of the human ego' (Erikson, 1963), or 'integrating ego along self-transcendental lines' (cf.Descartes, in Lewis, 1933: 182).
 

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INTRODUCTION: AN OUTLINE OF THE CONCEPT & PROCESS OF AGING

The concept of aging is an everyday one - we refer to things being old and mean either that they are 'near the end of their natural period of existence' (Concise Oxford Dictionary, 1964), or alternatively that they have the characteristics acquired through aging.  The latter paradoxically include being 'worn, dilapidated, shabby, feeble or obsolete' as well as positive traits such as being 'wise, experienced or inveterate' (ibid).  However 'to age' can also refer non-qualitatively to the experiencing of time, and any structural or functional alterations in this sense are variable connotations, rather than what is denoted by 'aging'.  Wilson and Kneisl at first seem to be using the expression 'aging process' in this third sense.  They are saying that changes in cognitive functioning usually occur in 'the later stages of a normal lifetime' - they are not saying that people invariably become 'wise' or 'feeble'.  However, they are also obviously saying that cognition is variably subject to a more general process of aging to which the human organism is invariably subjected.  The thesis of this paper is that this is essentially a process akin to 'crystallisation', or, to put it another way, to the 'analogical conversion of function into structure', and that this is an invariable process applying to cognition unless cognition is impaired.

Cognition refers to 'knowing, perceiving or conceiving' as opposed to motivation or affect.  There are two divergent understandings of the concept.  The empirical school, after Aristotle, defines cognition as 'all processes by which the sensory input is transformed, reduced, elaborated, stored, recovered, and used' (Neisser, 1967).  The idealist school, after Plato, which has affinities with later Gestalt and humanist psychology, defines cognition as 'acquisition of knowledge' (Reed, 1982: 2;  Flew, 1979: 61) in terms of 'transcendent realities and relations directly apprehended by conscious thought' (Flew: 254).  The common sense position which will be adopted here is to refer to the objective rather than subjective aspects of cognition, which are the same for either school.  These include 'perceiving', 'remembering' and 'thinking'.  The latter may be further subdivided into 'imagining', 'reasoning' (Chaplin, 1982: 94), and 'language' (Reed, 1982: 2; Gleitman, 1981: 166).  Reasoning in turn refers to 'decision-making' (or judging), 'problem-solving' (deduction and induction) and 'insight learning' (intuition).

Changes in perception, memory and intelligence in aging are considered separately for convenience although research tends to blur the distinctions and merge the categories into one (Vinacke, 1974: 4-30).  Cognition thus becomes more or less equivalent to an older concept of 'Reason' with thinking the active aspect, perception the passive aspect, and memory the intermediate axis of the same phenomenon.  Just as thinking is a kind of memory, and memory a kind of perception, equally 'all possible knowledge depends on the validity of reasoning' (Lewis, 1976 [1947]: 18).  '[Cognition] is just so much of the share of Reason as the state of the brain allows to become operative - it represents the bargain struck or the frontier fixed between Reason and Nature' (ibid: 43).  With the inevitable loss of force in a slowing organism, cognitive directedness must rely increasingly on accumulated structure and less on spontaneous energy to maintain that interface.  It must analogise function into structure, to maintain useful cognitive processes, integration and identity.
 

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AGING - NORMAL COGNITIVE CHANGES & IMPAIRMENTS THAT MAY OCCUR

The process of cognitive aging has been the subject of intensive laboratory and archival research since the 1940s, and clear results have been found in the four main categories of speed of performance, sensory and perceptual changes, memory and learning, and expressivity of personality.  Perhaps surprisingly, thinking itself, the 'active' aspect of cognition, is normally the least changed and this often as a secondary consequence.  Trends include a decline in certain kinds of 'mental agility' requiring concentration and perceptual dexterity as measured for example in typical intelligence tests, but the decline is offset partly or more than fully 'by increased knowledge gained in the course of experience' (Welford, A.T., in Gregory, 1987: 13).  Given adequate financial security, nutrition, organic health and social access, a person will normally become slower, more cautious, less energetic and adaptable, and more forgetful of recent events; but will also be more 'accurate, economical, experienced, systematic and knowledgeable' (Lowe, 1974: 243-245) and just as 'eager, alert and interested' as ever (ibid: 254: Erikson, 1959).

Central brain functions rather than peripheral organic changes are responsible for the main trends of 'performance' in early and middle old age (Welford, op.cit: 13-14).  Genetically pre-programmed organic changes affect cognitive performance in late old age.  Performance in most laboratory tasks normally becomes slower from the late teens, with effective compensation in system, accuracy and knowledge normally until the late thirties (ibid.), although peak performance may come earlier as with mathematicians, or much later as with historians and philosophers.  Such evaluation is criticised since the tasks and standards are 'appropriate for people around the age of the investigators' and pessimistic conclusions may often be no more than 'self-fulfilling prophecies' - placebo effects built on expectations enadvertently communicated or already held by the older participants (Lowe, op.cit: 246).  Against this is the common sense position, backed up by voluminous findings, that measured in terms of what we do 'in a given stretch of time, the given stretch of time seems to move faster' (Popper, 1983: 447).  Prof.Welford attributes this to the fact that 'signals from the sense organs to the brain and from one part of the brain to another become weaker, while at the same time random neural activity in the brain tends to increase' (Welford, op.cit: 13).  Popper on the other hand attributes the subjective experience of diminished time to a lessening of conscious engagement between 'self and brain' (Popper, op.cit: 447, 560).  Whichever perspective is adopted, scores on typical intelligence tests decline from the early twenties until by the age of sixty they have normally returned to their level at the age of ten (Welford, op.cit.) as in the elderly such tests tend to measure speed of performance rather than other aspects of what we ordinarily mean by 'intelligence'.  Those who have been 'intellectually and socially active in their lifetime show a minimum decrease, and in some cases an increase, in IQ scores' (Braudis, 1986, in Wilson & Kneisl, 1988: 1003).

Narrowing of the perceptual field is a normal aging characteristic, with the end result that the environment itself becomes narrowed (Alchin & Weatherhead, 1988: 123).  No other aspect of cognition is so subject to impairment or damage, and some degree of both is at least statistically normal.  Presbyopia, loss of ability to focus the eyes, is a normal process beginning in childhood by which the lens becomes less flexible until in old age it is 'virtually a fixed-focus lens set at infinity' (Wingate, 1982: 476).  While visual accuity normally declines in a parabolic curve with age, hearing deteriorates differentially against the higher pitches in linear progressions from about the age of twenty-three (Nowell Jones, in Gregory, 1987: 14-16).  The heat centre in the thalamus becomes less responsive, so that a cold environment becomes both more dangerous (Bevan, 1983: 88) and frequently more stressfully perceived.  Generally, worn out nerve cells for carrying sense-data are not replaced when they die as they are unable to reproduce themselves (Wingate, op.cit: 13): touch, pressure, pain and the chemical senses of taste and smell are diminished to some degree causing decreased pleasure and potential risks (Wilson & Kneisl, op.cit: 1004), although the rate of such physical aging 'varies tremendously among individuals' (ibid: 1000).  Some degree of sensory deprivation, at least comparatively, is normal and natural, although this is compounded by unnatural cultural factors.  Studies of sensory deprivation in Canada showed that a pattern of intellectual deficits caused by laboratory-induced deprivation in young subjects was exhibited normally in elderly persons forced by cultural patterns and perceptual limitations to spend large portions of their time in sensorily deprived environments (Zubeck, 1960; Solomon, in Howells, 1971: 249).

Conventionally, memory and learning are said to deteriorate in aging because of: the normal, irreplaceable loss of nerve cells; oxygen starvation due to normal atheroma; increased chance of having minor strokes; weaker signals and signal extinction from one part of the brain to another; and a tendency for random neural activity in the brain to increase.  For all these reasons, coupled with perceptual frailty, 'symbol isolation' due to diminished 'practice' opportunities, and lack of interest in new data with accompanying failure to use mediating cues (Wilson & Kneisl: 1004), short term memory is normally affected to a mild degree (Lowe, op.cit: 245).  More significant is a loss of efficiency transfering material from short term to long term memory due to blurs and errors - 'some of the material is lost, and the traces of what is transferred are weaker' (Welford, op.cit: 14).  However, the conventional account is negatively biased.  Long term memory is actually normally enhanced (Lowe, op.cit.); what is called learning impairment is due mainly to a lack of interest in remembering and consequent failure to use mnemonic devices (Wilson & Kneisl, op.cit.), rehearsal, or adequate 'retrieval cues' (Atkinson et al., 1990: 289-317); and the normal extent of memory and learning deficit is exaggerated.

Wilson and Kneisl maintain that overall 'memory, learning, intelligence, coping, adaptation and personality remain relatively stable as individuals age' (1004).  This is generally true with respect to personality or cognitive traits, with tests showing almost no significant trends (Welford, op.cit: 14), and if anything a tendency for cognitive traits that have always been latent causal factors to become manifest (ibid).  However, cross-sectional research, to rule out extraneous variables, has established normal though small changes with respect to three traits: extraversion declines slightly; neuroticism declines more markedly; and psychoticism shows a distinct curve of increase either way from age thirty-six (Eysenck & Eysenck, 1969: 69-76).  According to the 'stability model', these are second-order changes which do not imply a discontinuity in the primary variables or factor relations of thinking over the life-span (Hampson, 1982: 222).  Longitudinal studies give limited support to Erikson's 'change model' but ignore situation variables and are based on subjective data.  A satisfying solution to the research paradox would be to admit that whilst cognitive tendency remains stable, we have less energy, less 'subjective environment', more cognitive structure, and a 'different set of cognitive tasks' (Hampson: 245).  The sense of change in ourselves is subjectively true, but objective cognitive traits exhibit only slowing, systematisation, and second-order changes that are dependent on situation or developmental task rather than on age.  To evaluate these and other perspectives, it is instructive to examine their predictive and strategic usefulness with respect to a particular care plan in the psychogeriatric ward.
 

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CLARA - COGNITIVE CHANGES & NURSING STRATEGIES

Clara demonstrates the natural ability of people to continue to cope very effectively with daily cognitive tasks into old age; the impairment of normal cognition that occurs when new developmental situations are not accepted; the remarkable stability of cognitive traits against many situational variables and nursing interventions; the need of nurses to accept trait stability in cognition when planning, implementing and evaluating intervention strategies; and the importance of the roles of regression, developmental crisis and structuralisation in an aging process.

Clara is a seventy-two year old Hungarian who presents as being extravert, emotionally labile, expansive, generous and talkative.  She was refered to Royal Park by the Alfred Hospital after 'management problems arising from seductive behaviour, poor dietary intake, high levels of distress and agitation, and the voicing of paranoid delusions about being poisoned' (Alfred Hospital, Nursing Notes).  She has had one short previous psychiatric admission eighteen years ago suffering from psychotic depression, which included a somatic delusion that a recent vaccination had 'altered the shape of her face' (ibid).  Despite these acute cognitive abnormalities, she has steadily maintained superficial but broad social contact, a high level of efficiency in basic activities of daily living, and employment in occupations requiring a high level of adaptive functioning, including hairdresser, actress and nurse aide.

In her later life, Clara has been at various times beset by complex cognitive impairments which relate to cognitive processes originating in past environments and contexts, and in particular to stored pain and resulting cognitive disconnection (see, Janov, 1978 [1971]: 42, 52-56).  To elucidate these processes and impairments, it is necessary to take a detailed history, a painstaking process over weeks or months, which in the context of active listening is itself therapeutic.  Both parents were Hungarian Jews born into wealthy families, and Clara describes having had a 'very happy childhood'.  This changed abruptly when her father was killed in the war as a result of German occupation and the policy of genocide.  After a period of hiding and deprivation which marked her wartime experience, Clara decided to emigrate alone to Australia.  She says this decision was made 'on the spur of the moment' because she had an 'adventurous, independent disposition'.  By 1957 she had saved up enough money to lend financial assistance to her mother, sister and a friend to join her here.  Marriage to the friend ended in divorce two years later when, desperately homesick, her sister and husband returned to Hungary.  Her mother died shortly afterwards in Melbourne, leaving Clara with no close relatives except the sister in Hungary with whom she still regularly communicates by letter, and who wishes Clara to return to live with her.  Since 1959 her life has been a series of apparent contradictions until her retirement, with 'itinerant', 'employed', 'solitary' and 'social' phases.

Her first psychiatric admission was in 1973, presenting with major depression and the somatic delusion described, after what Clara describes as a 'feeling of abandonment and wretchedness'.   This illness was short-lived, and Clara was able to return to full-time employment 'as if nothing had happened'.  Despite this, she describes suffering from increasing but transient attacks of panic and depression as she grew older, culminating in the last major depression and psychiatric admission to the Alfred four months ago.  At that time, despite overt symptoms, she was resistant to the idea of being psychiatrically ill.  Assessed on admission as being 'well oriented', with 'no memory impairment', and 'in good physical health' (Alfred Team Notes), she was nevertheless 'distressed and agitated, with paranoid delusional ideation' relating to people 'poisoning her food' (ibid).  A personality inventory included reference to 'solitary', 'seductive' and 'nuisance' behaviours.  Diagnosed as suffering from 'a paranoid psychosis', Clara was prescribed Stelazine (10 mg.b.d.) and Artane (2 mg.b.d.).  Whilst nursing notes state that she was 'clean, ordered, with no sign of neglect' (ibid), a nursing care plan identified seven areas for practical intervention:

1.  paranoid ideation;
2.  suicidal ideation;
3.  poor appetite;
4.  absconder risk;
5.  poor sleep pattern;
6.  lack of insight;  and,
7.  behavioural problems.

It is only fair to say that Clara's cognitive achievements are as noteworthy as impairments.  She has been subjected to less than normal narrowing of perceptual field, with good hearing and sight for her age, and her problem solving skills in basic daily living are more than adequate.  Social worker and community nurse reports show that she is 'imaginative', 'independent' and 'resourceful' with respect to all the necessary living objectives of personal hygiene, housekeeping, shopping, banking, meal preparation and the like.  It is true that they show that she tends to be socially tolerated rather than accepted, due to her isolation from mainstream cultural attitudes, intrusiveness, and demands for affection in return for dramatic, public acts of affection or generosity.  However, these may well be underlying cognitive traits that are normally exposed as a result of the loss of cognitive energy in aging.  With an increase in systematic rather than spontaneous cognition accompanying the lowering of energy levels due to physical aging, there is a comparable lessening of the ability to use spare energy to hide cognitive traits (Welford, 1987: op.cit.).  The use of masks or a false persona is an everyday activity of social intercourse, but one which requires cognitive dissonance to be maintained at the expense of a vast amount of nervous energy (Vinacke, 1974: 496).  In the elderly, who have reduced energy reserves, the masks tend to be swept away.  This is a normal cognitive change and not a sign of illness.

On the other hand a number of Clara's cognitive changes have been abnormal and pathological.  The successful nursing strategy against these changes implies the validity of the 'developmental task' perspective adopted (Erikson, 1963; Lowe, 1974: 243-260), and that the changes did relate to a refusal to accept tasks related to developmental phase.  This perspective predicts that non-acceptance of age-dependent developmental theme leads to bizarre, fanciful thinking and regression to non-adaptive, earlier modes of functioning due to presence of a strong, interfering mental set (ibid).  In old age particularly the integrity of the person is beset by the accumulated cognitive dissonances of a lifetime, yet less energy is available for active problem-solving, which must instead rely on a process of referral to acquired, structured and systematic knowledge.  Thus not only Clara's unresolved life experiences of disruption and bereavement, but also because of failure to come to terms with or prepare for 'age situation', delusional and suicidal ideation arose.  These specifically relate to 'lack of post-narcissistic love of the human ego' (Erikson, 1963: 268), and regression to childlike 'incorporative reactions' (Freud, 1905, 1940, in Gleitman, 1980: 456-476).

Clara was encouraged to critically ventilate and examine feelings related to past work role, somatic fixation and ego-preoccupation, in the context of 'growth themes' of differentiation, integrity and transcendence, and was given positive feedback to join social activities in the ward.  Isolative behaviour and suicidal ideation gradually subsided and were resolved.  On discharge, Clara was still lacking insight into reasons for her hospitalisation, but paranoid ideation had disappeared due to a 'clear, concise nursing approach' and positive feedback to clear thinking (Carter, 1981: 307-308).  An orientation away from the body, contribution to the well-being of others, and esteem for activities and attributes other than work role were promoted as vital 'tasks of aging' which Clara was able to accept (Peck, 1955, in Papalia & Olds, 1978: 426-428).  The therapeutic and predictive value of the cognitive developmental model was supported by the outcome.

An important observation is that Clara's basic cognitive and motivational traits such as expressivity, impulsivity, optimism, dissociation, hypersensibility, fantasy, intrusiveness and excitability ultimately persisted.  Over time, they have shown resilience against all situations variables, age and nursing interventions.  This supports the trait stability theory of personality (Welford, 1987; Eysenck & Eysenck, 1969; Hampson, 1982), which in turn probably explains the apparent non-resolution of 'lack of insight' despite resolution of bizarre thinking.  This argues for the need to accept basic trait stability such as dissociative [or hysteroid] tendency in cognition when planning and evaluating practical nursing interventions.  Clara's nursing history suggests that, for her, 'disengagement' rather than either skilled activity or cognitive trait alteration, was at some moment crucial in cognitive adaptation to a new life situation, and that this was brought about by social-cognitive development rather than by functional or physical change.  Regression, developmental crisis, and structuralisation of cognition all played a role in partial realisation of ego-integrity in an aging process which in Clara's case permitted stable cognitive adaptations to a changing social environment.

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CONCLUSION

The integration of discrete experiences to solve a problem by inference is a behaviour that normally increases with age (Vinacke, 1974: 293).  On the other hand aging also results in a narrowing of perceptual fields and loss of environment (Alchin & Weatherhead, 1988: 123).  Changed thinking is subjectively perceived, yet objective cognitive traits exhibit only slowing, systematisation, and second-order changes dependent on age-situation or developmental task rather than on age-time.  Such changes really represent the fact that ego strength [energy] is exchanged for ego integrity [structure].

Socialisation, essentially an environmental process, continues to offer challenges throughout the lifespan, the final challenge in old age being a cognitive challenge: the acceptance and structuring of life meaning and integrity over despair and disintegration during a phase of energy reduction (Erikson, 1963).  Theories relating success in aging to activity or disengagement (Cumming, 1961) are person and situation dependent, as exemplified in the case of Clara, where developmental and social situation, as well as intentionality (Bühler, 1968), are clearly more relevant than these or biological factors to cognitive changes during aging.  Significant memory loss, disorientation, confusion, paranoid ideas, or loss of judgment are abnormal cognitive impairments that often accompany depression or loneliness (Alchin & Weatherhead: 120ff.).  These may be due to failure to test the reality of one's own lifetime or to actively accept social and developmental goals relevant to aging.

The normal process of aging can be compared to the process of 'crystallisation' in which lines of energy are analogised into mature structures in equilibrium.  Clara exemplifies the cognitive needs of older people to perceive their own self-fulfilment, engrossment in reality, social involvement, and social recognition.  Only then can energy economising self-acceptance occur, cognitive illness or lifespan reducing distress be avoided (Arehart-Treichel, 1980: 202), and disease, death and bereavement be faced without invoking obsession, depression or delusion.  In summary, the process involves 'post-narcissistic love of the human ego' (Erikson, op.cit.) or, 'integrating ego along self-transcendental lines' (after Descartes, in Lewis, 1978 [1933]: 182).  Wilson and Kneisl are accurate insofar as they portray perceptual, energic, structural and integrative changes in cognition, other than cognitive traits, as normal to the aging process.
 

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Title:  On the process of aging.
Sub-title:  Cognitive changes, impairments and positive responses/ Clara: a case study.
Author:   NEWMAN, Campbell Alexander
Psychiatric Nursing Phase I

Posting Date: 25 March 1991

Metropolitan & Eastern School of Psychiatric Nursing
Royal Park Centre /Royal Park Psychiatric Hospital
Tutor:  FAHEY, Aidan;   Supervisor:  HEATON, David.
Phase I:  Psychogeriatric Unit

1. Psychiatric Nursing;   2. Psychiatry: Psychogeriatrics.

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