Keep in Mind Situational Factors When Assessing Changes in Mental Status

Normal changes in memory and cognition that may occur with aging can be exacerbated by a number of situational and health factors. Following are some changes in memory that occur most commonly with normal aging:

• It becomes more difficult to pay attention to more than one thing at a time.
• It takes greater effort to learn something new.
• It is increasingly difficult to access familiar names and vocabulary words on demand.
• It takes longer to recall information from long-term memory.

These normal memory changes can be exacerbated by factors that negatively influence memory, such as:

Attitude and Effort
Problems with paying attention
Negative expectations
Inactivity
Lack of organization in daily life

Problems with Mood
Depression
Loss and grief
Anxiety
Stress

Health Status
Physical illnesses
Medications
Vision and hearing problems
Fatigue
Alcohol
Poor nutrition

If providers recognize the presence of any of these factors, efforts can be made to address the problems with appropriate interventions.

The following three cases illustrate common situations and the interventions that were used in each case to improve memory.

CASE 1

Situation: Mr. Polanski is 88 years old and lives alone with no relatives nearby. He has diabetes and heart problems. He is uncomfortable and fearful when away from home, and only goes to the grocery store once a month. Mr. Polanski’s neighbor, Sue, who has been friends with him for many years, takes out his trash each week and is surprised at how few remains there are from food products. She also notices that Mr. Polanski is getting more forgetful. He rarely knows what day it is and doesn’t know the date of his next doctor’s appointment. He says, “My memory is so terrible. I can’t remember anything any more.” When Sue notices an ulcer on Mr. Polanski’s foot, she offers to call the doctor’s office and accompany him to the appointment. Sue uses this opportunity to express concern to the doctor about Mr. Polanski’s ability to live alone.

Factors Involved: In thinking about this case, one can see several factors that may be affecting Mr. Polanski’s memory. He is socially isolated and has an infection from his ulcerated foot. He has given up trying to stay mentally and physically active. He no longer makes an effort to remember anything new. Since he shops only once a month, poor nutrition could be an issue in his failing memory.

Intervention: The doctor orders a visiting nurse to treat and monitor his ulcerated foot, along with a home health aide three times a week to provide homemaking services. After a few weeks, Sue notices that Mr. Polanski seems more alert and always remembers what day it is, since he looks forward to the aide coming on Monday, Wednesday, and Friday. The aide prepares enough food for two days, and his appetite has improved with the home-cooked meals. The interaction with the aide has improved Mr. Polanski’s memory for recent events, as they share information about daily living and current events.

CASE 2

Situation: Pauline, age 77, recently moved from Collinsville, Illinois, her lifelong hometown, to an assisted living residence near her son’s home in Chicago. She has severe arthritis and has had trouble maintaining her home since her husband’s death three years earlier. She had mixed feelings about moving. In Collinsville, she had many friends and was familiar with her environment. She regularly attended an exercise class for people with arthritis and went out to lunch after church with the same group of people. Even so, she decided it would be best to move to an apartment near her son and his family. The move was stressful because she had to reduce the belongings of a family home to a one-bedroom unit. She spent many weeks making decisions about what to take and how to get rid of unwanted belongings. By the time she arrived in her new living situation, she was too exhausted to organize things well. She misses her friends at home and finds it hard to meet new people and get involved in new activities. She finds herself sad and somewhat hopeless about creating a satisfying new life in Chicago. For the first time, Pauline begins to question her memory. She can’t find her address book, she got lost driving back from the library, and she let the bathtub water run over. She says to herself, “What is happening to me? Maybe I’m getting Alzheimer’s disease.”

Factors Involved: In thinking about this case, one can see several factors that may be affecting Pauline’s memory: she is grieving the loss of her husband and her lifelong home; she has decreased her activity level; her move was extremely stressful and exhausting; the organization of her home developed over a lifetime has not yet been duplicated in her new surroundings; and depression is setting in as she feels more and more hopeless about ever again having a satisfying life.

Intervention: Pauline makes an appointment with a geriatrician and expresses her fears about her memory. Dr. Velez reviews her recent history and does some tests. He assures Pauline that she doesn’t have Alzheimer’s disease, explaining that her recent experiences could temporarily affect her memory. In addition, he recommends that she see a social worker for counseling. The social worker provides grief counseling and helps her understand the effects of the many changes on both her mood and her memory. Gradually, Pauline learns about her new community and finds an exercise class for people with arthritis. She sees a flyer for a three-session memory improvement class at the local senior center. In this class she learns about normal changes of memory with age, and she recognizes the many factors in her life that have been affecting her memory. Pauline begins using the new strategies she learned and feels more hopeful about the future.

CASE 3

Situation: Ms. Kirk, age 72, has recently developed some minor memory problems. The members of a thrift shop, of which she was the treasurer, noticed that she can no longer accurately keep records and pay bills. However, she and her family feel that she is adequately caring for herself and her home. When she falls getting out of her car, she breaks her ankle, and goes to a long-term care facility for rehabilitation. The nurses notice that she is confused and disoriented. She can’t remember how long she has been in the facility and has lost interest in hearing about her granddaughter. She says to her son, “I’ve always been so healthy and independent. I can’t believe this happened to me. And I can’t sleep because my roommate snores!”

Factors Involved: There are several factors that can be affecting Ms. Kirk’s memory. Her medication for pain may be causing confusion. She may be exhausted from the effort of working hard in rehabilitation and lack of sleep. She is depressed by the sudden change in her physical ability and her environment. Although she has manifested minor memory changes that interfere with her ability to do complex tasks, she now exhibits more serious signs of possible dementia.

Intervention: At Ms. Kirk’s weekly care conference, the staff decides to move her to a room with a quiet roommate. The social worker suggests that Ms. Kirk may benefit from counseling, allowing her to express her frustration and worry. She also recommends a current events group to keep her involved in what’s going on in the world. As her pain subsides, Ms. Kirk is able to decrease her pain medication. By the time her rehab is finished, Ms. Kirk’s memory has returned to her baseline status, and she is able to go home with appropriate support.

These three cases demonstrate how situational factors can affect existing memory states. By keeping in mind the many factors that can affect memory, providers can more thoroughly assess changes in mental status and implement appropriate interventions to foster improvement.

Suggested Reading

Fogler J, Stern L. Improving Your Memory: How To Remember What You’re Starting To Forget. Baltimore, MD: The Johns Hopkins University Press; 2005.

Glenner JA, Stehman JM, Davagnino J, et al. When Your Loved One Has Dementia. Baltimore, MD: The Johns Hopkins University Press; 2005.

Gordon B. Intelligent Memory: Improve the Memory That Makes You Smarter. New York: Viking; 2003.

Small G. The Memory Bible: An Innovative Strategy for Keeping Your Brain Young. New York: Hyperion; 2002.