Borders Candace, Sajjadi Seyed Ahmad
Department of Neurology, University of California, Irvine, CA USA.
Neurology and Pathology, University of California, Irvine, CA USA.
Curr Treat Options Neurol. 2021;23(3):10. doi: 10.1007/s11940-021-00665-5. Epub 2021 Mar 26.
The fastest-growing group of elderly individuals is the "oldest-old," usually defined as those age 85 years and above. These individuals account for much of the rapid increase in cases of dementing illness throughout the world but remain underrepresented in the body of literature on this topic. The aim of this review is first to outline the unique contributing factors and complications that must be considered by clinicians in evaluating an oldest-old individual with cognitive complaints. Secondly, the evidence for management of these cognitive concerns is reviewed.
In addition to well-established associations between impaired cognition and physical disability, falls, and frailty, there is now evidence that exercise performed decades earlier confers a cognitive benefit in the oldest-old. Moreover, though aggressive blood pressure control is critical earlier in life for prevention of strokes, renal disease, and other comorbidities, hypertension started after age 80 is in fact associated with a decreased risk of clinical dementia, carrying significant implications for the medical management of oldest-old individuals. The oldest-old are more likely to reside in care facilities, where social isolation might be exacerbated by a consistently lower rate of internet-connected device use. The COVID-19 pandemic has not only highlighted the increased mortality rate among the oldest-old but has also brought the increased social isolation in this group to the forte.
Differing from the "younger-old" in a number of respects, the oldest-old is a unique population not just in their vulnerability to cognitive disorders but also in the diagnostic challenges they can pose. The oldest-old are more likely to be afflicted by sensory deficits, physical disability, poor nutrition, frailty, and depression, which must be accounted for in the assessment of cognitive complaints as they may confound or complicate the presentation. Social isolation and institutionalization are also associated with impaired cognition, perhaps as sequelae, precipitants, or both. Ante-mortem diagnostic tools remain particularly limited among the oldest-old, especially given the likelihood of these individuals to have multiple co-occurring types of neuropathology, and the presence of neuropathology in those who remain cognitively intact. In addition to the symptomatic treatments indicated for patients of all ages with dementia, management of cognitive impairment in the oldest-old may be further optimized by use of assistive devices, augmentation of dietary protein, and liberalization of medication regimens for risk factors such as hypertension.
老年人群中增长最快的群体是“高龄老人”，通常定义为85岁及以上的人群。这些人在全球痴呆症病例的快速增长中占了很大比例，但在关于该主题的文献中所占比例仍然较低。本综述的目的首先是概述临床医生在评估有认知主诉的高龄老人时必须考虑的独特促成因素和并发症。其次，回顾针对这些认知问题的管理证据。
除了认知障碍与身体残疾、跌倒和虚弱之间已确立的关联外，现在有证据表明，数十年前进行的锻炼对高龄老人有认知益处。此外，尽管积极控制血压在生命早期对于预防中风、肾病和其他合并症至关重要，但80岁以后出现的高血压实际上与临床痴呆风险降低有关，这对高龄老人的医疗管理具有重要意义。高龄老人更有可能居住在护理机构，在那里，互联网连接设备的使用率持续较低可能会加剧社会隔离。2019冠状病毒病大流行不仅凸显了高龄老人死亡率的上升，也使该群体中日益增加的社会隔离问题备受关注。
高龄老人在许多方面与“年轻老人”不同，他们不仅在易患认知障碍方面，而且在可能带来的诊断挑战方面，都是一个独特的群体。高龄老人更容易受到感觉缺陷、身体残疾、营养不良、虚弱和抑郁的影响，在评估认知主诉时必须考虑到这些因素，因为它们可能会混淆或使症状复杂化。社会隔离和机构化也与认知障碍有关，可能是后遗症、诱因或两者兼而有之。生前诊断工具在高龄老人中仍然特别有限，尤其是考虑到这些人可能同时存在多种神经病理学类型，以及认知功能正常者中也存在神经病理学。除了对所有年龄段痴呆患者进行的对症治疗外，使用辅助设备、增加膳食蛋白质摄入以及放宽对高血压等危险因素的药物治疗方案，可能会进一步优化高龄老人认知障碍的管理。
