Decreasing Mental Frailty in At-Risk Elders

Abstract

Frailty may be used to describe those older adults who are in precarious balance between their abilities to maintain health and function and their deficits that threaten the balance. Frailty often is described in purely physical terms, omitting the mental and psychologic aspects,^1–4 When the term is applied to the mental abilities of older adults, frailty is associated with memory vulnerability in the cognitive domain and depression in the psychologic domain. Compromised thinking, anxiety, and decreased confidence in memory are symptoms of mental frailty, this article examines the effects of aging on memory and the intertwining factors of depression and self-efficacy as treatable antecedents of mental frailty in older adults. The article also describes simple assessment techniques, explores memory improvement strategies, and considers nursing implications. (Geriatr Nurs 1998;19:220–4)

Forgetfulness and memory problems are especially important concerns of the elderly because they threaten independence, interfere with everyday activities, and lead to anxiety and depression. Many older people and clinicians have misconceptions and general lack of knowledge about what constitutes normal cognitive function in an old person. Beliefs often are based on the stereotype that memory automatically deteriorates as we age.

Memory ability does indeed change with age, but the changes vary considerably from one individual to another and are usually mild, fluctuating, and not progressive. Possible changes include slower learning and recall, increased interference with concentration and attention, and the use of less effective strategies for organizing information.⁵ A basic assumption that has guided memory research to date is that these changes in memory ability occur either because of normal changes as a result of aging or from pathologic causes, such as cognitive impairment and other dementias.⁶ Negative expectations of older adults’ cognitive abilities continue to flourish because of this assumption.

Most studies have tried to prove that older adults lose mental function as they age. Research has been directed toward examining changes in memory across the life span and the relationship between memory performance and self-evaluation of memory.^7,8

MENTAL FRAILTY AND DEPRESSION

Depression has a negative influence on memory performance and beliefs and exacerbates mental frailty⁹ Depression begets anxiety and forgetfulness and may lead to increasing mental frailty and dependence. To help the clinician determine who may benefit best from rehabilitation and treatment for depression, memory testing that includes an assessment of memory complaints and self-awareness of memory is necessary. From a clinician’s perspective, self-assessment of memory is important for several reasons, as noted in Table 1.

TABLE 1.

Important Reasons for Self-Assessment of Memory

Memory complaints reflect elders’ views of their cognitive ability. Self-assessment helps clinicians discriminate between dementia, anxiety, and depression. Individuals tend to underestimate their abilities when depressed. Individuals suffering from dementia tend to overestimate their abilities. Self-report instruments elucidate elders’ beliefs of underlying performance. All old people have memory problems. People simply don’t understand. Physical illness may cause cognitive problems.

In a memory training study designed to improve performance and beliefs, the presence of depression had a negative influence on results.¹⁰ Overall, participants whose depression scores were higher, as measured by the Geriatric Depression Scale, had significantly lower memory confidence or self-efficacy scores than did subjects with lower depression scores.

Two weeks after the memory improvement course, both depressed and nondepressed participants showed significant improvement in memory confidence and self-efficacy. However, people with the greatest depression showed a tendency to declining self-efficacy and memory ability. Therefore, when assessing elderly clients and formulating memory enhancement treatment plans, clinicians must consider not only the influence of anxiety and degrees of depression but also the individual’s beliefs in self-efficacy.

MENTAL FRAILTY AND SELF-EFFICACY

The concept of self-efficacy may be defined as our confidence in our ability to perform effectively in a given situation. According to Bandura,¹¹ self-efficacy is based on our judgment about how well we can organize and execute courses of action needed to deal with prospective or unpredictable situations that may be ambiguous and produce stress. As we lose confidence in memory, our anxiety increases, and our sense of self-efficacy erodes. Individuals who have less confidence may even give up trying because they doubt their ability to achieve their desired performance level. On the other hand, they may be convinced of their abilities but give up trying because of an unresponsive or punishing environment.

McDougall¹² has studied elders who perceived their memory as failing and the effect of this perception on their feelings of self-efficacy. Mentally frail elders who have a low opinion of the state of their memories and a decreased belief in their ability to remember face adverse consequences in their daily lives. Repercussions of this lack of confidence in memory ability may include a generalized negative self-concept, the perception that others have a better memory than they, and a fear of impending senility or dementia.¹³ Possible consequences of this downward spiral include embarking on an expensive and time-consuming course of seeking a physician to cure their perceived cognitive ailments, purchasing expensive medications or dietary supplements to improve memory, avoiding social interactions that involve recalling names, and losing motivation and perseverance in situations that demand memory performance.

EFFECTS OF SELF-EFFICACY ON METAMEMORY

The self-evaluation of memory (metamemory) has been described as perceptions of memory, memory complaints, memory monitoring, and memory awareness. Metamemory, however, is the most widely used term in the literature and is used in this article to encompass all aspects of memory self-evaluation. The metamemory construct has two conceptual underpinnings: developmental and clinical. The developmental emphasis is on information about the memory system, which includes a person’s perceptions, beliefs, and knowledge about memory function and the development of memory mechanisms and content. The clinical perspective emphasizes memory problems, such as the frequency of forgetting in specific domains, and memory failures, such as decreased use of the most helpful strategies for remembering.^12,14

Poor assimilation of memory system information, along with concern and anxiety about memory problems, may lead to depression that, in turn, further deteriorates memory. A vicious cycle may be initiated if the developmental and clinical aspects of memory are not addressed with a clinician’s help.

One study determined that healthy elders without major chronic illness or depression who were attending adult education programs had a decreased sense of self-efficacy when they compared themselves with younger students.¹³ This flawed perception led them to believe their memory capacity was decreased, that stress interfered with memory, that memory decreased with age, and they could do little about the situation. However, people who view memory ability as a skill that can be developed may increase memory capacity. Therefore researchers are beginning to realize that exposing the elderly to methods that improve their self-efficacy or confidence in their memory are just as important as the traditional approach of teaching memory aids, strategies and mnemonic techniques.

ASSESSING METAMEMORY

Early attempts to assess memory complaints in a clinical interview consisted of asking single questions, such as, “Do you have any trouble with your memory?” The assessment of memory self-knowledge and cognitive awareness has evolved considerably. More sophisticated memory questionnaires have been developed to investigate the importance of memory beliefs in memory tasks, and these surveys provide a viable method of determining an individual’s perceived memory performance in everyday situations. To determine self-assessment of memory in groups of elders, the metamemory in adulthood (MIA) questionnaire¹⁵ is recommended. Table 2 outlines the strategy subscale. This nonthreatening instrument does not emphasize memory problems and failures but positively solicits information about memory and is conducted by means of face-to-face interviews. Clinicians may use quantitative and systematic methods, such as the MIA, to examine not only metamemory but also the person’s emotional and cognitive states as an aid in determining appropriate rehabilitative activities.

TABLE 2.

Metamemory in Adulthood Internal and External Strategy Questions

INTERNAL STRATEGIES	EXTERNAL STRATEGIES
Rehearsal	List
When you are looking for something you have misplaced recently, do you try to retrace your steps to locate it? Do you think about the day’s activities at the beginning of the day so you can remember what you are supposed to do? Do you consciously attempt to reconstruct the. day’s events to remember something? Do you mentally repeat something you are trying to remember?	Do you keep a list or otherwise note important dates, such as birthdays and anniversaries? Do you write shopping lists?
	Note
	When you have not finished reading a book or a magazine, do you somehow note the place where you have stopped? Do you post reminders of things you need to do in a prominent place, such as bulletin or note boards? Do you write yourself reminder notes?
Elaboration
When you try to remember people you have met, do you associate names and faces? When you have trouble remembering something, do you try to remember something similar? Do you try to relate something you want to remember to something else hoping this will increase the likelihood of your remembering later? Do you make mental images or pictures to help you remember?
	Place
	Do you routinely keep things in a familiar spot so you won’t forget them when you need to locate them? When you want to take something with you, do you leave it in an obvious, prominent place, such as putting your suitcase in front of the door?
	Someone
Effort	Do you ask other people to remind you of something?
Do you try to concentrate hard on something you want to remember?	Calendar Do you write appointments on a calendar to help you remember them?

The MIA has been in use for approximately 15 years, is reliable, and has been validated.¹⁶ The MIA is neither difficult nor threatening, and studies show the questionnaire is easily completed by the elderly; however, it may cause fatigue because of its length. To avoid tiring the respondent, each subscale can be administered separately.

The MIA, an assessment of the memory components of knowledge, belief, and affect,¹⁴ consists of 108 statements with responses rated on a five-point Likert scale. The seven subscales measure strategy, task, capacity, change, anxiety, achievement, and locus, each of which has 15 or 16 questions and is defined in Table 3.

TABLE 3.

Metamemory in Adulthood Questionnaire Subscales

Each of the following MIA subscales is independent and can be administered separately.

Strategy. Use of internal strategies, such as elaboration and rehearsal, and external strategies, such as notes, calendars, and lists, to assist with remembering

Task. Understanding of memory processes common to most people, such as remembering interesting facts more easily than boring ones

Capacity. Performance capacity for names, facts, etc.

Change. Perception of memory stability or expectation of decline over time

Anxiety. Self-rating of the influence of anxiety and stress on memory ability

Achievement. Importance of having a good memory and performing well on specific memory tasks

Locus. Extent of belief in personal control over maintaining remembering abilities

The MIA strategy scale assesses two types of memory strategies: internal and external. Nine questions are related to the use of internal strategies, such as rehearsal, elaboration, and the effort used to remember. Rehearsal usually involves repeating the names of items in an ordered list or copying, underlining, or highlighting material to be learned. An example question about internal rehearsal strategies is, “Do you consciously attempt to reconstruct the day’s events to remember something?”

Elaboration strategies for basic learning tasks include forming a mental image or sentence relating the items in one category to those in another. Elaboration methods also include paraphrasing, summarizing, or relating new information to existing knowledge. An example elaboration strategy question is, “When you try to remember people you have met, do you associate names and faces?”

External strategies in the MIA are assessed by asking nine questions related to such devices as calendars (“Do you write appointments on a calendar to help you remember them?”), lists, and notes (“When you pause in reading a book or magazine, do you somehow note the place where you have stopped?”). Questions related to enlisting the help of others and keeping things orderly include, “Do you ask other people to remind you of something?” and “Do you routinely keep things in a familiar place so you won’t forget them when you need to locate them?”

MEMORY IMPROVEMENT INTERVENTIONS

Given the cognitive and memory changes likely to occur in normal aging, an ongoing interest exists in all types of memory aids, ranging from self-help books and adult education classes to vitamin and herb supplements¹⁷ Memory training programs designed for elderly people operate on the assumptions that elders with impaired or less-than-optimal performance will benefit from intense exposure to memory aids and that participation in a such program will increase the appropriate and spontaneous use of these memory aids. Recent research has shown that memory classes that focus on helping older adults learn memory strategies can facilitate their ability to remember.^{10–12,18,19} Folger and Stern²⁰ have developed an effective memory training system that includes a book, Improving Your Memory: How to Remember What You’re Starting to Forget, and an instruction manual that serves as a course outline for memory training classes or individual use.

Most memory programs rely on mnemonics, any mental strategy or technique that uses extraneous or seemingly irrelevant thoughts to aid in learning desired material and future recall. Specifically, linking systems, peg-words, and visual imagery may be used. The training often includes practice in mental rehearsal, visual im agery construction, visuomotor behavioral rehearsal, patterning, and psyching up through mental practice.

A comprehensive memory training program or cognitive-behavioral intervention ideally would contain four components: memory training, memory self-efficacy, stress inoculation through imagery, and health promotion. Although cognitive-behavioral interventions originally were developed for and applied to emotionally based disorders, such as depression, phobias, impulsiveness, and evaluation-anxiety, cognitive factors are likely to play an important role along the health/illness continuum. Therefore cognitive-behavioral strategies have been found useful far beyond their initial focus and hold great promise for improving mental and emotional frailty in older adults.

Memory training programs traditionally have emphasized the components of mnemonic strategy and stress inoculation. More recently, some programs have incorporated self-efficacy elements to improve the sense of individual mastery and to combat the belief that reduced cognitive capacity is inevitable and the sense of fatalism that sometimes results.^10,19

IMPLICATIONS FOR NURSING PRACTICE

Overall, studies to date show a distinct correlation between depression, anxiety, self-efficacy erosion, and mental frailty in the elderly. Assessment of metamemory and memory complaints can indicate the elder’s perception of his or her memory handicap and potential for rehabilitation. Clinicians must assess their clients for depression, memory self-efficacy, and awareness of memory processes to design individualized treatment plans.

Nurses are in an ideal position to examine memory awareness and memory performance of elders and the affective state, particularly the presence of anxiety and depression as they relate to mental frailty. Nurses working with elderly clients can be instrumental in enCouraging them to participate in suitably challenging and demanding activities within their ability. Activities beyond their abilities will result in agitation, anxiety, withdrawal, refusal to attempt even manageable challenges, decreased confidence, and further progression of memory problems.

Efforts must be made to help the older client improve his or her cognitive abilities and prevent any mental frailty from progressing. In addition to training in specific memory strategies, elderly people often need help developing confidence in their skills and memory performance ability. Such confidence can be expected to increase their feelings of self-efficacy and belief in personal control, resulting in reduced depression and anxiety and stabilized mental frailty.