Journal of Geriatric Psychiatry and Neurology

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Contemporary Review 2009: Cognitive Aging

Lauren L. Drag and Linas A. Bieliauskas
J Geriatr Psychiatry Neurol 2010 23: 75 originally published online 25 January 2010
DOI: 10.1177/0891988709358590

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 Journal of Geriatric Psychiatry
and Neurology
Contemporary Review 2009: Cognitive Aging 23(2) 75-93
ª The Author(s) 2010
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sagepub.com/journalsPermissions.nav
DOI: 10.1177/0891988709358590
http://jgpn.sagepub.com
Lauren L. Drag, MA, PhD,1 and Linas A. Bieliauskas, MS, PhD1

Abstract
This article addresses key topics in cognitive aging, intending to provide the reader with a brief overview of the current state of
research in this growing, multidisciplinary field. A summary of the physiological changes in the aging brain is provided as well as a
review of variables that influence cognitive abilities in older age. Normal aging differentially affects various aspects of cognition, and
specific changes within various domains such as attention, executive functioning, and memory are discussed. Various theories have
been proposed to account for the cognitive changes that accompany normal aging, and a brief examination of these theories is
presented in the context of these domain-specific changes.

Keywords
aging, cognition, neuropsychology

Received June 5, 2009. Received revised October 27, 2009. Accepted for publication November 18, 2009.

When our 80-year-old grandmother spends 20 minutes looking
for the eyeglasses perched on top of her head, we chuckle and
chalk it up to normal aging. However, at what point should we
start being concerned about age-related cognitive changes?
Intact cognitive abilities are needed to carry out everyday activ-
ities, such as managing the finances, remembering to take med-
ications, driving in unfamiliar environments, remembering a
grandchild’s birthday, and learning to use a new computer.
As the proportion of adults older than 60 years of age is pro-
jected to reach unprecedented numbers in the near future and
lifetime expectancy has risen to more than 80 years, it has
become increasingly important to better understand the cogni-
tive changes that accompany normal aging.
Biological Changes
Normal aging is accompanied by many physiological changes
in the brain, both structurally and functionally. Structurally, the
aging brain declines in volume, although not uniformly across
regions. The frontal cortex is most affected, declining at faster
rates than temporal, parietal, or occipital cortices.1,2 Studies
using diffusion tensor imaging have shown that age-related
changes in white matter integrity are greatest in anterior
regions,3,4 and it has been suggested that the myelinated fibers
in this region are more susceptible to breakdown, which may
be a contributing factor to age-related frontal pathology.5
Volume-based imaging studies have also shown that age-
related decline in gray matter is also greatest in frontal
regions.6 This preferential involvement of the frontal lobes has
a significant impact on cognitive processes supported by this
region, as discussed in later sections.
Aside from the frontal lobes, the hippocampus is another
well-studied region that shows structural changes in normal
aging.7 Although the extent of neuronal loss in this region has
been debated, it is commonly accepted that hippocampal atro-
phy accompanies normal aging but is less than that seen with
Alzheimer disease (AD). The hippocampus is involved in
memory processes, and cross-sectional studies have associated
hippocampal atrophy with memory loss in normal aging.8-10 In
addition, a longitudinal study by Persson et al11 demonstrated
that hippocampal volume loss over time is associated with
decreased memory performance even in healthy older adults.
Compared to the hippocampus, the surrounding entorhinal cor-
tex, an area targeted by early AD pathology, remains relatively
unaffected by the normal aging process.7
These brain volume changes are not linear across the life
span, as brain volume changes are minimal in younger and
middle-aged adults.12 The rate of age-related volume decline
accelerates with increasing age. For example, ventricular
expansion, a latent measure of brain atrophy,7 occurs at an
annual rate of 0.43% in young adults but increases to 4.25%
after the age of 70.
Beyond these structural changes, the cerebrovascular
system also changes over time. Normal aging is accompanied
1
Department of Psychiatry, University of Michigan Health System, Ann Arbor,
MI, USA
Corresponding Author:
Linas A. Bieliauskas, 2101 Commonwealth Blvd, Ste C,
Ann Arbor, MI 48105, USA.
Email: linas@umich.edu

75
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76
by decreases in resting blood flow, the metabolic rate of
oxygen consumption, and the vascular reactivity of cerebral
vessels to various chemical modulators.13 There are also
changes in functional blood flow as evidenced by neuroima-
ging studies. One finding is that older adults tend to show
increased bilateral prefrontal activation compared to younger
adults when completing the same task, leading to decreased
lateralization of function. Based on these findings, the hemi-
spheric asymmetry reduction in older adults (HAROLD) model
postulates that under similar circumstances, prefrontal activa-
tion during cognitive processes tends to be less lateralized in
older adults than in younger adults.14 These patterns of bilateral
activation have been illustrated using neuroimaging with both
simple motor tasks such as button-pressing15 and also more
complex tasks such as verbal working memory and memory
retrieval.16-18 A second neuroimaging finding is of an age-
related reduction in occipitotemporal activity coupled with an
increase in frontal activity. This posterior–anterior shift,
labeled PASA, has been demonstrated across multiple different
cognitive functions, including attention, visuospatial process-
ing, and memory (see Davis et al. for review).19
A theory of functional compensation has been proposed to
account for these age-related changes in functional activation.
This view suggests that these patterns of activation reflect the
recruitment of alternate brain regions to counteract neurocogni-
tive decline.14,20 It has been proposed that aging reduces the
already limited supply of cognitive processes, producing defi-
cits on demanding cognitive tasks.21 Thus, the aging brain
needs to engage additional brain areas to generate the same
amount of resources as younger adults. For example, it has
been suggested that the PASA pattern reflects the recruitment
of anterior regions to compensate for sensory processing defi-
cits in more posterior regions.22 Elaborating on the compensa-
tion theory, the scaffolding theory, proposed by Park and
Reuter-Lorenz23 posits that increases in functional brain acti-
vity, particularly in the frontal cortex, represent ‘‘compensatory
scaffolding.’’ They define scaffolding as ‘‘the recruitment of
additional circuitry that shores up declining structures whose
functioning has become noisy, inefficient, or both.’’ They pro-
pose that scaffolding is not a response to aging itself but is
instead a response to challenge, as even younger adults can
show evidence of compensatory activation. Although increases
in activation can reflect successful compensation as evidenced
by improved performance,18 increases in activation can also
reflect unsuccessful compensation attempts in the case when
age-related decrements are still evident.14,24-26
In addition to age-related increases in activation, functional
activation patterns also tend to be less specific in older age, and
it has also been suggested that declines in neural integrity lead
to reduced specialization, or differentiation, of task-specific
behaviors. For example, studies have demonstrated less neural
specialization (ie, less category-specific activation) in older
adults compared to young adults in posterior regions when pro-
cessing visuospatial information.27,28 The theory of dedifferen-
tiation proposes that aging is associated with declines in neural
specificity due to difficulty engaging specialized neural
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Journal of Geriatric Psychiatry and Neurology 23(2)
Probability of neuronal activation in
response to a specific stimulus in
younger adults
100
Probability of activation
Target
0
Stimulus value
Probability of neuronal activation in
response to a specific stimulus in
older adults
100
Probability of activation
Target
0
Stimulus value
Figure 1. Age differences in hypothetical activation thresholds for a
neuronal network in response to a stimulus of varying likeness to a
target stimulus.
mechanisms.29,30 According to this view, age-related declines
in neuromodulation lead to less accurate information transmis-
sion, higher levels of random variability, and less distinct (and
thus more confusable) mental representations of information.
One theory proposed by Li et al30 is that dedifferentiation may
stem from disruptions in the dopamine system, which affect the
modulatory role of the prefrontal cortex. The prefrontal cortex
provides top-down modulation of goal-based information
processing in various posterior brain regions and is responsible
for enhancing the processing of relevant information while sup-
pressing irrelevant information. An age-related decline in pre-
frontal modulation can thus lead to increased neural noise and
reduced neural specificity in these posterior regions. Therefore,
older networks are less discriminant and more likely to respond
to similar but nontarget stimuli due to a lack of top-down
modulation from the prefrontal cortex. Figure 1 provides a the-
oretical illustration of how the threshold for neuronal network
activation may become less stringent and more variable with
age. It has been hypothesized that these declines in neural
Drag and Bieliauskas
specificity result in increased correlations among cognitive
processes, as abilities that are independent in young adults tend
to become interrelated in old age.31-33 However, the extent of
these intercorrelations has been subject to debate.34,35
Moderating Variables in Cognitive Aging
Albert Einstein was still writing and publishing books at the
age of 71, yet surely we do not hold all septuagenarians to this
standard. There are many variables that affect cognitive aging,
including education, intelligence, and sensory abilities. Given
the many extraneous influences that can moderate the cognitive
aging process, it is not surprising that interindividual variability
increases with age. Ardila36 reported increases in cognitive het-
erogeneity across older individuals through greater score dis-
persions on intelligence testing. These dispersions were not
uniform across all domains, as tasks assessing executive func-
tioning and attention had greater variability than those asses-
sing visuoconstruction and fund of general knowledge.
Greater heterogeneity was also shown in those individuals with
lower scores.
It has been proposed that education levels can account for a
significant portion of the cognitive variance associated with
normal aging. Studies have found positive relationships
between levels of education and performance on cognitive
tasks including block design, verbal fluency, and digit
span.37,38 Within the memory domain, education can affect
recall ability but generally has minimal effects on recognition
performance, suggesting that education primarily affects mem-
ory performance in tasks with high strategic demands. Years of
education have also been associated with lower rates of cogni-
tive decline across time39 (although this has been debated40-42),
better performance on cognitive tasks,43 lower incidence of
dementia,44 and reduced brain atrophy,37 though possibly
because a high level of education may be a proxy indicator
of cognitive reserve. Cognitive reserve is thought of as either
a passive (eg, the capacity of neurons) or a active (eg, the abil-
ity to optimize performance by recruiting alternative brain net-
works) process that allows an individual to cope more
successfully with age-related brain changes.45 This reserve
capacity, a latent construct often measured by education or
vocabulary, is thought to reflect the resilience and plasticity
of cognitive networks that protect individuals from the negative
effects of aging (or at least allow them to compensate). Similar
to the scaffolding theory of Park and Reuter-Lorenz, the more
reserve (or scaffolds) an individual has, the more he or she will
be able to successfully cope with disruptions in the aging brain.
Indices of cognitive reserve have been positively associated
with cognitive performance in multiple domains including
attention and memory46 and is thought to be a protective factor
against the expression of age-related cognitive decline. Cogni-
tive reserve appears to moderate the relation between age-
related pathology and cognitive functioning. Examining both
cognitive performance and postmortem brain autopsies in a
group of older adults, Bennett et al47 found that the relation
between AD pathology and cognitive function differed by
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77
90
High CR
Correct % performance
80
70
Low CR
60 Threshold
dementia
Age 30 40 50 60 70 80 90
Lower CR Higher CR
= age 65 = age 85
Figure 2. Dementia thresholds and cognitive decline as a function of
cognitive reserve (CR). Reprinted with permission from Bieliauskas
and Antonucci.52
years of formal education. In addition, Stern et al48 demon-
strated that in a group of individuals with AD with equivalent
cognitive symptoms, those with higher education had more
pathology, indicating that they were further along in the disease
process despite evidencing similar cognitive abilities.
While cognitive reserve may be a protective factor against
age-related decline, it may also be that individuals with higher
reserve start out with more resources and therefore take longer
to reach the critical threshold where deficits start to appear,
even with a comparable rate of decline. For example,
Tucker-Drob et al49 demonstrated that vocabulary knowledge
and years of education, 2 markers of cognitive reserve, were
positively associated with levels of cognitive performance but
not rates of decline over time in older adults. They suggested
that education positively influenced cognitive abilities in ear-
lier adulthood and that these benefits persisted throughout the
life span. Thus, high cognitive reserve can delay the onset of
clinical symptoms of dementia due to an absolute improvement
in cognitive performance, regardless of alterations in the rate of
age-related cognitive decline. In addition, because individuals
with higher reserve often have higher levels of pathology
before cognitive symptoms appear, the rate of cognitive decline
after symptom onset may appear accelerated in this group.50,51
Figure 2 illustrates how symptoms of dementia may be notice-
able at later stages of decline for individuals with high cogni-
tive reserve compared to individuals with low cognitive
reserve even given identical rates of decline.52
Education is not the only variable to affect normal aging.
Lindenberger and Baltes40,41 found that contrary to the cogni-
tive reserve hypothesis, neither education, affluence, nor cogni-
tive ability predicted age-related differences in cognitive
abilities, leading them to propose that declines were based on
biological and not social factors. They demonstrated that visual
and auditory acuity can account for a large percentage of age-
related variance across cognitive tests, including those asses-
sing processing speed, reasoning, memory, and fluency. It was
proposed that sensory function, while serving as a general
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index of neurobiological brain integrity, is also a fundamental
component of cognitive function. It is intuitive that sensory
abilities can have a significant impact on cognitive functioning.
Weale53 demonstrated that the amount of light reaching a
60-year-old retina is only one third of the amount that reaches
a 10-year-old retina, and imaging studies have demonstrated
that cortical responses to sensory inputs also decline with
age.54,55 Sensory inefficiency means that more cognitive
resources and effort need to be put toward stimulus identifica-
tion, taking these resources away from more complex, cogni-
tive operations such as memory for the stimuli.56-59 This has
implications for the clinician seeing geriatric patients, as a false
positive diagnosis of cognitive dysfunction can occur if sensory
losses are not taken into account. On a more positive note, older
adults derive more sensory benefit from supportive context than
younger adults, suggesting that compensatory processes can help
overcome some aspects of age-related sensory degradation.57,58
Intraindividual variability also needs to be taken into
account when assessing the cognitive functioning of older
adults. For example, the effects of time-of-day on cognitive
functioning have been well established with the general finding
that for older adults, cognitive abilities peak in the morning and
gradually decline over the course of the day.60,61 Older adults
tend to be more active and energetic in the mornings and show
greater medication and appointment adherence during these
hours.62 However, this is not to say that older adults should call
it a day after lunch. Ryan et al63 demonstrated that drinking caf-
feinated coffee can actually minimize this decline and lead to
improved cognitive performance in the afternoon.
Theories of Aging
Although there is no question that normal aging is accompa-
nied by changes in cognitive abilities, there is still debate about
what specific mechanisms, if any, underlie these changes.
There are several theories that have suggested a single, funda-
mental mechanism that can account for much of the decline in
cognitive function across domains. These theories range in
explanation from the neurochemical (eg, the dopamine theory
of aging) to the localized (eg, the frontal hypothesis of aging)
to the process level (eg, theories of processing speed and
inhibition). These theories are not mutually exclusive, given
that they attempt to explain different levels at which cognitive
abilities can be affected. Examples of some current theories of
cognitive aging are addressed below.
At the neurochemical level, the dopamine hypothesis of
aging posits that age-related dysregulation in the dopamine sys-
tem mediates the cognitive deficits associated with normal
aging.64 There is substantial evidence suggesting that normal
aging is accompanied by dopamine dysregulation in multiple
areas including the striatum and the frontal cortex65-69 and
fluctuations in dopamine levels can significantly affect cogni-
tion.70,71 Several studies have demonstrated that dopamine
markers are a strong predictor of cognitive performance, partic-
ularly executive functioning abilities, in normal aging.72-75
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Journal of Geriatric Psychiatry and Neurology 23(2)
Taking a more localized approach, the frontal aging
hypothesis posits that the frontal lobes are particularly sensitive
to the aging process and that declines in frontal efficiency can
account for many of the cognitive deficits associated with
cognitive aging.76-78 As will be discussed in later sections,
age-related cognitive changes in multiple domains including
executive functioning, language, and memory can be traced
to inefficiency in frontal-based processes such as strategy
initiation, retrieval from long-term memory, and effortful pro-
cessing. Although there is consistent evidence of declines in
frontal functioning with normal aging, there is still some
disagreement over whether the frontal lobes are preferentially
susceptible to normal aging compared to other regions. For
example, Greenwood79 argues that the frontal lobe is not par-
ticularly unique in showing age-related changes and suggests
that it may be more appropriate to view aging from a network
rather than localization approach. She posits that aging may not
simply affect 1 region but rather alter the dynamic of a more
complex processing network that spans several brain regions.
Addressing age-related changes in specific cognitive
processes, the inhibitory control hypothesis suggests that
decreased efficiency in inhibitory processes can explain age-
related changes in certain cognitive abilities such as working
memory.76,80 The ability to inhibit or suppress task-irrelevant
stimuli is thought to rely on the frontal lobes, and impairments
in these processes can lead to deficits on interference-sensitive
tasks. For example, if irrelevant information is allowed to enter
working memory, there is a heightened susceptibility to dis-
traction, especially when presented with multiple sources of
information (eg, following a conversation in a crowded room).
Within the memory domain, older adults show increasing sus-
ceptibility to retrieval interference compared to younger adults,
particularly when facts share the same concepts and compete
with each other at retrieval, termed the ‘‘fan effect.’’ The fan
effect, named after its conceptual likeness to a folding fan,
refers to the finding that as the number of facts associated with
a particular concept (ie, the size of the fan) increases, speed and
accuracy in retrieving these facts from memory decreases.
Thus, as the size of the fan increases, so does the amount of
interference from irrelevant information in memory. Older
adults are more susceptible to the fan effect, suggesting an
age-related decrease in the inhibitory mechanisms required to
screen out conceptually relevant but nontarget information.81,82
Many complex cognitive tasks rely on inhibitory processes to
suppress irrelevant information, clear away information that
is no longer useful, and override the production of dominant but
inappropriate responses. Inhibition is particularly important on
tasks requiring an individual to sustain goal-directed activity.
Such tasks include those involving problem solving, working
memory, set-shifting, and selective attention.
Also addressing age-related changes in processing, the
speed of processing hypothesis proposes that a large portion
of age-related variance on cognitive tasks can be accounted for
by declines in the speed in which older adults process informa-
tion.83,84 Increasing age is associated with a decrease in the
speed with which cognitive processes can be executed, leading
Drag and Bieliauskas
to impairments in various cognitive functions, including
working memory, free recall, and verbal fluency, although to
different extents depending on task complexity and domain.
Verhaeghen et al85 demonstrated that age-related slowing is
minimal for low-complexity verbal tasks but increases for ver-
bal multiplicative tasks and low-complexity visuospatial tasks.
Age-related slowing was largest for a multiplicative visuospa-
tial processing task. Processing speed effects can occur via
2 mechanisms. Slowed processing speed can lead to cognitive
deficits because time-limited processes cannot be executed
efficiently enough within a given time frame (the limited time
mechanism) and also because the relevant products of earlier
processing may be lost by the time they are needed after later
processes are complete (the simultaneity mechanism).83,84
Although there is no doubt that processing speed declines with
age, there has been debate over whether it can explain signifi-
cant variance across cognitive domains.86 While inferences
based on cross-sectional data have demonstrated up to 71%
of shared variance between age-related processing speed and
memory changes,87 longitudinal studies have suggested a more
modest role of processing speed in cognitive aging. A longitu-
dinal study by Lemke and Zimprich88 found that age-related
changes in processing speed accounted for only 37% of the
variance in age-related memory changes, which is lower than
expected based on cross-sectional data. Sliwinski and
Buschke89 demonstrated that while cross-sectional analyses
show that processing speed accounted for between 70% and
100% of age differences in various cognitive abilities, this
drops to 6% to 29% when longitudinal analyses were used.
Thus, focusing on cross-sectional differences rather than long-
itudinal changes can lead to overestimates of shared variance.
While processing speed can account for substantial variance
in age-related cognitive functioning, other factors certainly
need to be taken into account. This is the case with all theories
of aging, as no single theory has been able to fully account for
all of the variance associated with cognitive aging across all
cognitive domains. It may be, however, that different theories
are better able to explain age-related changes in different
cognitive processes.
Although the above theories predict that cognitive decline in
normal aging is caused by a single mechanism and a common
cause, each of these theories is not necessarily mutually exclu-
sive. For example, it is possible that dopamine dysregulation is
the primary cause of age-related frontal dysfunction, given that
the frontal lobes are a main target of efferent striatal and ventral
tegmental dopaminergic pathways. Frontal-based dopamine dys-
regulation may then lead to declines in processing speed and
inhibition.72 Thus, it may be that normal aging is accompanied
by multiple physiological and cognitive changes across a variety
of levels, including any and all of the above mechanisms. This
illustrates the need for a single unifying theory that can explain
the interrelated mechanisms of cognitive aging across these dif-
ferent levels. In addition, none of the above theories makes
explicit predictions regarding functional activations, and future
models of cognitive aging will need to incorporate possible
explanations for age-related functional changes.
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79
Domain-Specific Cognitive Changes
Mental Status
A mental status measure widely used to briefly assess global
cognitive functioning in the older adult population is the
Mini-Mental State Examination (MMSE). MMSE scores
decline with normal aging, although change is relatively mini-
mal until the later decades. Score variability also increases
with age.90 Although a threshold of 24/30 is frequently used
to screen for dementia, it has been suggested that higher cut
scores are more clinically useful in detecting possible cognitive
impairment.91 Roper et al92 found that in a sample of geriatric
inpatients, a cut-off of 26 yielded the highest diagnostic accu-
racy in detecting brain dysfunction.
Education and IQ also affect MMSE and need to be taken
into account when assessing mental status scores.93 Crum90
demonstrated that in a large group of both younger and older
adults, individuals with less education tended to demonstrate
lower scores and also a wider variability in scores. In this study,
the median MMSE scores for individuals with 5 to 8 years of
schooling was 26, compared to a median score of 29 for those
with at least 9 years of school. It has been suggested that for
elderly individuals with a high school education and beyond,
a score of 26 or below warrants further investigation into pos-
sible dementia.94 In addition, given the positive correlation
between MMSE scores and IQ levels, caution needs to be taken
when interpreting low MMSE scores in certain populations, as
low MMSE scores may not necessarily reflect cognitive
decline in individuals with a below-average IQ (ie, 89 and
below).95
Given that MMSE scores can be influenced by age, educa-
tion, and IQ, it has been suggested that comparing scores over
time may be more useful in detecting dementia than a single-
point evaluation, as a score of 20 may not necessarily indicate
cognitive decline in certain populations.96 This is consistent
with more general suggestions that serial assessment is more
reliable in detecting cognitive decline (particularly in the inci-
pient stages of a neurodegenerative process) than single-point
assessments.97,98 Eslinger et al99 found that a decline of 3 or
more points on the MMSE over a 6-year period was predictive
of poorer health, depressive symptoms, and lower neuropsy-
chological scores, suggesting that declines of 3 or more may
signify a departure from healthy aging. Other studies have
examined specific subcomponents of the MMSE for use in clin-
ical practice. For example, it has been demonstrated that the
most predictive combination of MMSE subtests for cognitive
impairment in individuals 60 years and older was the summed
scores of time orientation and serial sevens.100 Those individ-
uals who had a summed score of above 7/10 were likely to
score above a 24 cut-off in the full battery, suggesting that these
2 subtests alone can be informative if time is limited. The
delayed recall portion of the MMSE may also be of interest
in those individuals with suspected memory impairment. In a
group of healthy older adults, Chandler et al101 demonstrated
that the majority of individuals remembered 2 to 3 of the
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3 words after a delay. Recall of 0 or 1 words occurred in only
3% of healthy individuals compared to 87% of individuals with
AD within the 50 to 75 age group. Thus, good recall (ie, 2 to
3 words) is the norm in most cases of normal aging and
anything below this may be indicative of memory impairment.
Attention
We are faced with situations in daily life that rely on multiple
aspects of attention, such as navigating through a grocery store
armed with a grocery list or talking on the phone while cooking
dinner. Even a short drive in an unfamiliar location requires
multiple aspects of attention, some of which may be affected
by normal aging. Sustained attention is needed over such a
10-minute drive, as is selective attention to ignore the adver-
tisements on the side of the road, divided attention to listen
to an ongoing conversation in the car, and task-switching to
shift attention from the written directions to the road ahead.
In fact, motor vehicle accident rates have been related to per-
formance on measures of attention, particularly those assessing
switching of selective attention.102 Thus, age-related declines
in certain aspects of attention may reduce the efficiency to
operate in complex situations.
Sustained attention is the ability to maintain attention and
vigilance over time and is considered a simple attentional pro-
cess that is relatively unaffected by normal aging.103,104 Inhibi-
tion and selective attention are also important components of
attention. As discussed previously, normal aging leads to
changes in inhibitory control, which affects the ability to focus
on relevant information while inhibiting task-irrelevant infor-
mation, termed selective attention. Selective attention can be
measured by tasks such the Stroop Interference Test, which
requires an individual to focus on task-relevant stimuli proper-
ties (ie, naming the colors of printed words) while inhibiting
prepotent responses (ie, reading the words regardless of the
color). Selective attention is generally thought to be age-sensi-
tive,105-108 although these findings are not entirely consis-
tent.109 Decreases in inhibitory control resulting in increased
disinhibition and distractibility have been associated with
altered prefrontal functioning.78,110
Older adults also have difficulty when required to concur-
rently attend to and process information from multiple sources,
termed divided attention. While this dual-tasking can have neg-
ative effects on cognitive functioning even in younger adults,
older adults are particularly susceptible to the negative effects
of divided attention and can show significant decrements in
performance on tasks such as short-term memory, associative
memory, and recognition memory under divided attention.111-
116
Although divided attention can affect even simple cognitive
processes such as tone recognition, age-related decrements are
generally more pronounced for complex tasks.106 Similar to
divided attention, task-switching is the ability to switch rapidly
among different skills or tasks and also shows age
effects.117,118 Task-switching deficits may be related to general
effects of slowing or an inability to disengage attention from
1 task and shift attention to refocus on another task.119,120
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Journal of Geriatric Psychiatry and Neurology 23(2)
Task-switching is thought to rely on control processes related
to executive functioning and has been associated with activity
in the medial and dorsolateral prefrontal cortex and frontopar-
ietal white matter tracts.121,122
Executive Functioning
Executive functioning can be conceptualized as a higher order
cognitive construct that is involved in the self-regulation of
goal-directed behavior and the effective organization and use
of large amounts of information. Executive functions are
diverse but share a common dependence on the prefrontal cor-
tex, which is in itself a heterogeneous structure with extensive
connectivity to other areas of the brain. Nevertheless, age-
related decrements are often found on tasks requiring executive
functioning processes, which is consistent with the frontal
aging hypothesis. Such tasks include those assessing planning,
inhibition, set-shifting, and verbal fluency.123-126 It has been
suggested that executive functioning decrements may be
related to a failure to implement the necessary strategies to suc-
cessfully execute these tasks.127 The self-initiation of strategic
processes is thought to rely on the integrity of the prefrontal
cortex.128-130 A failure to initiate appropriate strategies can
have significant effects on other cognitive processes (eg, mem-
ory recall) as will be discussed in later sections.
Elderkin-Thompson et al131 recently reported that prefrontal
structural volume explained variability in executive function-
ing performance better than chronological age, suggesting that
prefrontal integrity mediates age-related executive functioning
changes. Similarly, Gunning-Dixon and Raz132 demonstrated
that set-shifting ability correlated negatively with prefrontal
volume in older adults. It should be noted that in this study, var-
ious executive function tasks were associated with various pre-
frontal structures, illustrating the heterogeneity of the executive
functioning construct. Further illustrating the diversity within
this domain, Treitz et al133 demonstrated that executive func-
tioning does not decline unitarily, as normal aging differen-
tially affects executive subcomponents. In addition, this study
demonstrated that executive functioning does not decline line-
arly across the life span, as there is a sharp decline in executive
functioning abilities after the age of 60.
One area of executive functioning with significant real-
world implications is working memory. Working memory is
often confused with short-term memory, which is the mainte-
nance of information in memory over a short period of
time (eg, keeping a telephone number in mind while walking
to the kitchen phone). Working memory, in contrast, requires
the active manipulation and processing of information (eg, sub-
tracting a dollar amount from a bill total). Normal aging has a
greater impact on working memory than on short-term mem-
ory.89,134,135 This may be because working memory places
greater demands on cognitive resources, as it requires informa-
tion processing in addition to basic storage. Consistent with
this, increases in working memory task complexity magnifies
age-related decrements. For example, age differences are
more pronounced for a taxing n-back task than for a simple
Drag and Bieliauskas
digit-span task.136 Thus, an older adult may be able to write
down a simple phone message with ease but have more diffi-
culty when trying to remember and calculate prices while gro-
cery shopping. Working memory impairments can also lead to
difficulty following long and complex instructions or answer-
ing multiple-choice questions, as older adults may not be able
to remember and process this complex information as well as
their younger counterparts.
It has been suggested that age-related declines in working
memory may stem from decrements in attentional control and
inhibition that cause working memory processes to be parti-
cularly vulnerable to interference. It may be that passive main-
tenance processes are also affected by this interference but
older adults can recruit compensatory brain regions to support
performance. However, when more taxing manipulation pro-
cesses are needed, the available resources cannot meet
demands, leading to deficits in performance.137
Memory
Aging does not lead to a global memory decline but rather has
differential affects on specific aspects of memory. Memory is
not a unitary construct and can be parsed into several dissoci-
able subcomponents including explicit and implicit memory,
semantic and episodic memory, and encoding and retrieval pro-
cesses, all of which show dissociations in normal aging.
Episodic memory. Episodic memory is defined as the con-
scious recollection of experienced events, such as a 21st birth-
day party, a phone conversation from last week, or a word list
from 30 minutes ago. In general, episodic memory declines
with age,138-140 although it has been demonstrated that effortful
components of memory are more affected by aging compared
to more familiarity-based, automatic components.141
Aging can affect the encoding of new information, particu-
larly when effortful or strategic processes are required.142 For
example, younger adults benefit from levels of processing
manipulations more than older adults, suggesting that older
adults encode the meaning of new information less thor-
oughly.143 Neuroimaging has shown age-related decreases in
functional activity in the medial temporal lobes and left pre-
frontal cortex at encoding, which has been associated with
poorer subsequent memory performance.17,144,145
Retrieval of information from memory is also affected by
the degree to which effortful processes are needed. Recognition
memory, which is relatively passive and nonstrategic, is less
affected by normal aging than recollection, which requires
more effortful processing.113,146 It is not surprising that aging
differentially affects recall ability, as recall tasks require
greater processing capacity, which is already limited via the
normal aging process.147 Recall tasks require an individual to
screen out irrelevant information from memory, making the
recall process much more difficult than recognition, where the
information options are already provided. Although both rec-
ognition and recall tasks can be sensitive to normal aging, older
adults fare much better on yes-no or forced-choice recognition
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81
tasks than on recall tasks, suggesting that the information is
available in memory but not easily accessible.113,148,149 Thus,
older adults may properly encode and store information but
struggle when asked to retrieve this information. A recognition
format, such as a multiple-choice test, relies less on strategic
search and retrieval, as one can rely solely on more automatic
processes of familiarity to make a recognition decision. In addi-
tion, a recognition format provides more context compared to a
recall format, such as essay writing. When recall demands are
eliminated with a recognition format, age effects are
attenuated.
It is thought that deficits in effortful memory processes arise
primarily due to inefficiency of the frontal lobes to engage in
the self-initiation of strategic processes at both encoding and
retrieval, consistent with the frontal aging hypothesis. Episodic
memory is particularly poor when the task demands significant
cognitive resources or when cues or environmental support are
unavailable, necessitating self-imposed organization and strat-
egy.150,151 While older adults may have the capability for good
memory, they may not always initiate the necessary processes
and strategies needed to optimize their abilities.38,152 Thus, it
has been proposed that age differences in memory can be
explained by degree to which self-initiated processes are neces-
sary.21 These initiation processes are dependent on the frontal
lobes, and it has been suggested that deficits in frontal pro-
cesses (eg, working memory) mediate age-related declines in
episodic memory,9 consistent with the frontal aging hypothesis.
Neuroimaging evidence also supports the role of the frontal
lobes in age-related memory changes as reduced functional
activation in prefrontal regions has been associated with poorer
memory performance in older adults.144,153,154
Semantic memory. Semantic memory, often referred to as
crystallized intelligence, refers to the store of factual know-
ledge in memory. Examples of information that can be stored
in semantic memory include definitions of words, historical
facts, and the names of all 50 state capitals. Semantic memory
actually increases with age as individuals accrue knowledge
over their life span,155-159 although it may decline in the very
later decade.160,161 This is in contrast to fluid intelligence,
defined as active problem solving ability in tasks in which solu-
tions cannot simply be derived from formal training or prior
knowledge.162 Fluid intelligence is age-sensitive.32,163 Seman-
tic memory does not show age-related decline and actually
increases with age. Park et al164 demonstrated that while fluid
processes such as working memory, processing speed, and
memory recall decline with age, world knowledge as measured
by vocabulary abilities actually increases across the life span.
Figure 3, adapted from Park et al, illustrates how semantic abil-
ities such as vocabulary increase with age while more fluid
abilities such as working memory and processing speed show
a reverse pattern. This increase in semantic memory is associ-
ated with the accumulation of factual knowledge over the life
span. Thus, a lifetime of experiences gives older adults the
important advantage of increased wisdom over their younger
counterparts. While semantic knowledge can often appear
81
82
Cognitive changes associated with
normal aging
Standard scores
20−29 30−39 40−49 50−59 60−69 70−79
Age (in years)
Vocabulary Long−term memory
Processing speed Working memory
Figure 3. Differential effects of normal aging on processing intensive
tasks and verbal knowledge abilities. Adapted with permission from
Park et al.164
impaired in older adults at first glance due to difficulties with
word finding and name retrieval, these difficulties are associ-
ated more with problems retrieving this information rather than
an actual semantic deficit.
Autobiographical memory. Related to episodic memory, auto-
biographical memory is memory for one’s own life events in the
past. There is some debate regarding whether autobiographical
memory and episodic memory are synonymous, as they both
involve conscious recollection of an experienced event.165
However, it has been suggested by some researchers that auto-
biographical memory is characterized by greater personal rele-
vance, emotional content, and a longer period of time between
encoding and retrieval.166,167 Another difference is that episodic
recollection involves reexperiencing the personal event, whereas
autobiographical memory is primarily defined by the content of
the memory (ie, memories involving the rememberer) but does
not necessitate the same reliving of the past as episodic mem-
ories do.167 Compared to semantic information (eg, knowing that
Paris is the capital of France), autobiographical memories (eg,
remembering a summer vacation in Paris) are more sensitive
to normal aging.168,169 Compared to younger adults, older adults
tend to recall autobiographical memories that are more semantic
in nature and contain factual information rather than episodic
and time- and place-specific details.169,170 This is consistent with
the findings that episodic but not semantic memory declines with
age. Autobiographical memory retrieval has been associated
with bilateral hippocampal activation in older adults, compared
to left hippocampal activation found in young adults,171 consis-
tent with age-related delateralization.
Implicit memory. Implicit memory is a form of memory in
which a previous experience indirectly influences an
82
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Journal of Geriatric Psychiatry and Neurology 23(2)
individual’s behavior without intentional retrieval or conscious
recollection of this experience.172,173 For example, asking an
individual to recollect what he or she ate for dinner requires
an active search through memory. By contrast, one can swim
backstroke without consciously recalling what he or she has
learned in swim lessons, illustrating a type of implicit memory
termed procedural memory. Implicit memory is relatively unaf-
fected by aging compared to explicit memory.138,139,174,175
Although some age-related implicit priming deficits have been
demonstrated (more so for perceptual than conceptual
priming), these age-related effects are much less than what is
found for explicit tasks.176,177
80−89
Familiarity. Familiarity is a feeling of recognition in the
absence of contextual details. For example, you may recognize
a person as familiar but may be unable to recall specific details
about who he or she is or where you met him or her. This is in
contrast to recollection, which is the effortful retrieval of spe-
cific contextual information.178 Familiarity thought to rely on
the entorhinal cortex is relatively unaffected by the aging pro-
cess compared to recollection, which is thought to be more
hippocampal-dependent.179-183 In addition, while prefrontal
and parietal regions are involved in both familiarity and recol-
lection, within these general brain regions, distinct subregions
have been shown to be functionally specialized for each pro-
cess.184,185 Typically familiarity and recollection processes
work together to support recognition memory; however, older
adults may tend to overrely on their feelings of familiarity
when they are experiencing recollection failures, which can
have detrimental effects (eg, false memories). Reliance on
familiarity as a compensatory mechanism for poor recall has
also been supported by neuroimaging evidence.186
Flashbulb memory. Flashbulb memory, a special type of auto-
biographical memory, is a vivid recollection of an emotionally
salient event that is generally more durable than memory for
everyday experiences. For example, people frequently claim
to have vivid memories for events such as the assassination
of John F. Kennedy and the Challenger explosion. Flashbulb
memories by definition are stable over long periods of time
(ie, 5 decades or more) and differ from other memories in the
amount of personal importance attached to the events and the
amount of rehearsal.187 Flashbulb memories are unique from
other remote episodic memories for everyday events in that the
ability to recall flashbulb memories is relatively unaffected by
aging and is not related to frontal functioning.188 In addition,
memory for the source of news in flashbulb memories is
relatively impervious to the aging process.189,190
False memory. In general, older adults are more susceptible to
false memories than their younger counterparts.191 This may be
because older adults counteract recollection failures with an
overreliance on familiarity or gist-based memory, which is less
vulnerable to aging than recollection.192 An inability to recall
specific episodic details (eg, memory of seeing the word on the
computer screen) to counter these feelings of familiarity leads
Drag and Bieliauskas
to higher rates of false memories in older adults.193 For exam-
ple, Dywan and Jacoby194 demonstrated that older adults are
more susceptible to the false fame effect. In false fame para-
digms, nonfamous names evoke a sense of familiarity because
they have previously been presented. Without a specific recol-
lection of this exposure, this familiarity can mistakenly be
attributed to fame (eg, that name sounds familiar, he or she
must be famous). Behavioral evidence has suggested that false
memories are mediated by frontal functioning,195 perhaps via a
more liberal response bias and an impairment in frontal inhibi-
tory processes. Neuroimaging has also shown that areas of the
middle and superior temporal gyrus are associated with false
memories in older adults, which suggests a tendency to rely
on gist-based process mediated by this region.196,197
Source memory. Source memory is thought of as memory for
the spatial, temporal, or social characteristics of the specific
conditions or context under which a memory is acquired. Mem-
ory for contextual details is affected by normal aging more so
than memory for gist or content.198-200 For example, you may
easily recognize the woman standing in line in front of you in
the grocery store, but it is much more difficult to remember
whether you know her from church or from the library. When
only simple recognition is required, older adults can rely on
familiarity and gist; however, when more contextual informa-
tion needs to be recalled, memory often fails. In a study by
Schacter et al,201 older adults could adequately remember new
facts over a delay but often forgot where they had learned them.
One hypothesis is that age-related source memory deficits stem
from a failure to spontaneously bind contextual details with
other content components of the memory.202 When individuals
are oriented to the relationship between an item and its context
at encoding, source memory improves.203 Thus, source mem-
ory deficits may arise from an inability to self-initiate the nec-
essary encoding strategies to bind contextual details to memory
for the item itself, consistent with the frontal aging hypothesis.
Source memory deficits have been associated with reduced
recruitment of frontal and hippocampal regions during encod-
ing.204 Further illustrating frontal involvement in source mem-
ory, correlations between source memory and performance on
measures of frontal functioning have been reported in older
adults.203,205,206
Prospective memory. We rely heavily on prospective memory
in everyday life to remember to carry out events in the future
such as sending a birthday card to a friend or remembering to
send an email after finishing a conversation with a coworker.
Prospective memory can be time-based (eg, remembering to
take medications at noon) or event-based (eg, remembering
to take medications with lunch). Age-related declines in pro-
spective memory have been widely demonstrated.138,207-209
Prospective memory requires significant self-initiated retrieval,
as one needs to ‘‘remember to remember’’ and with age, inter-
nal cues and self-initiated processes become less reliable.
When external cues are limited (such as in the laboratory
setting) or when multiple actions must be kept in memory
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83
(eg, remembering to take the toast out of the oven and the
scrambled eggs off the stove), older adults have increased sus-
ceptibility to prospective memory errors.210 Prospective mem-
ory deficits are thought to reflect a problem remembering to
carry out a task when it needs to be done rather than a deficit
in planning or an inability to carry out the task itself.211 Older
adults’ prospective memories often fare better in naturalistic
settings outside of the laboratory, perhaps because they have
learned to set up external cues and rely less on their own mem-
ory abilities. For example, older adults are better than their
younger counterparts when asked to mail a postcard, log in to
an electronic organizer, or attend an appointment.212-214
Maylor215 demonstrated that older adults perform better on a
prospective memory task when it was conjoined with another
routine event, suggesting that mnemonic strategies like leaving
evening medications by a toothbrush will help with prospective
memory abilities.
Language
Although specific language abilities are relatively unaffected in
normal aging, language difficulties may arise due to changes in
frontal or sensory processes. Most language problems are due
to retrieval difficulties rather than a loss of semantic informa-
tion.216,217 For example, while older adults may have more dif-
ficulty finding the right word they want to use, their semantic
knowledge of linguistic rules does not decline.218,219
There is some evidence of mild declines in naming abilities,
although again this is typically thought to be related more to
word-finding difficulties rather than a loss of semantic infor-
mation.217,220,221 During natural discourse, older adults tend
to demonstrate more word-finding difficulties, as evidenced
by filled pauses (‘‘um’’), ambiguous references, and word
retrieval errors.222 Oftentimes, older adults experience word-
finding problems despite certainty that they know the word,
commonly called a tip-of-the-tongue experience (TOT).216,223
Tip-of-the-tongue experiences are thought to reflect a deficit
in phonological retrieval rather than access to lexical informa-
tion.224,225 Specifically, conceptual representations of the
meaning of words and sentences are well preserved with nor-
mal aging, but older adults have difficulty accessing the phono-
logical information necessary for word retrieval.226-229
Because of this phonological deficit, providing phonological
cues or phonologically related words will be more helpful to
resolve TOTs than providing semantic cues.230 Thus, an older
adult may fail to retrieve the name of the mountain with car-
vings of the presidents, but it is expected that phonological cue
such as ‘‘ru-’’ should help resolve the TOT experience more so
than a semantic cue such as ‘‘South Dakota.’’ It has been
demonstrated that TOTs are greater for proper names more
so than other types of words.231,232 Imaging has suggested that
age-related increases in TOT are associated with atrophy of the
left insula, an area of language system important for phonolo-
gical production.233
Other language changes accompanying normal aging are
thought to reflect frontal inefficiency rather than pure language
83
84
deficits. For example, older adults tend to produce more off-
topic speech during natural discourse.234,235 This tangentiality
has been related to performance on an inhibition task, suggest-
ing that it may stem from an inability to inhibit salient but irre-
levant topics.236,237 Verbal fluency is also age-sensitive, and
again this is thought to reflect a frontal-based strategy deficit
rather than a specific language deficit.238,239 Sentence compre-
hension and text recall may decline with age, more so for text
with greater syntactic complexity.157,240,241 These deficits are
thought to reflect an inability to retain text in working memory,
leading to comprehension and recall deficits.242
Visuospatial Functioning
In general, visuospatial abilities decline with age disproportio-
nately to verbal abilities.243-247 For example, compared to their
younger counterparts, older adults demonstrate poorer perfor-
mance on performance subtests than on verbal subtests of the
Wechsler Adult Intelligence Scale.248 Measures of visuospatial
abilities can be heterogeneous in nature and can include visuos-
patial attention, visuospatial memory, and visuospatial orienta-
tion, all of which can show age-related effects.249-254 Other
visuospatial processes affected by aging include mental rota-
tion,255 visuospatial construction,256 complex figure copy,257
and visuospatial processing speed.252 In contrast, there is no
evidence of age-associated visual neglect.258,259 It is unclear
whether visuospatial information itself is more sensitive to nor-
mal aging or whether visuospatial information itself tends to be
more complex (and thus vulnerable to age effects) than verbal
information.
One visuospatial task commonly used to estimate visuomo-
tor abilities, visuoconstruction, and planning in older adults is
the clock-drawing task. Aging has been associated with an
increased number of errors on this task.260,261 Older adults
often have problems placing the figures on the clock face and
differentiating the clock hands correctly. Omission errors are
rare on this task and may suggest abnormal aging. As a caveat,
clock-drawing ability has also been positively associated with
level of education,262 so caution should be taken when using
this task with individuals with low education levels.
It has been suggested that visuospatial deficits on more com-
plex tasks stem from age-related changes in frontal functions,
such as working memory, consistent with the frontal aging
hypothesis. Libon et al263 demonstrated that visuospatial tasks
requiring integrative mental processes such as problem-solving
and mental transformation were more sensitive to age than
other nonintegrative tasks such as complex figure copy. Perfor-
mance on these integrative visuospatial tasks was associated
with executive functioning. Not surprisingly, visuospatial abi-
ities can have important functions for daily activities. For
example, Baldock et al264 demonstrated that visual attention
and visuospatial memory predicted driving performance in
older adults. Older adults are also slower at personal orientation
tasks such as map reading, which can have negative effects on
way-finding abilities.265,266
84
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Journal of Geriatric Psychiatry and Neurology 23(2)
Practical Applications and
Recommendations
Understanding the normal aging process can have important
real-world implications. Although most information is gathered
through artificial studies designed in the laboratory, it has been
found that these laboratory measures can predict performance
on real-life tasks, such as managing finances and medications
and using a pay phone.267
Although practitioners often rely on self-report to assess
functional abilities, the use of objective cognitive assessment
is also important. Studies have demonstrated a poor correlation
between self-report and objective memory abilities.268,269
Mendes et al270 found that older adults were more likely to
complain of memory problems than their younger counterparts,
and that subjective memory ratings were not associated with
objective cognitive performance. They suggested that older
adults with intact memory were more likely than younger
adults to rate their memory as poor. It has also been suggested
that self-report measures do not adequately assess decrements
in daily functioning ability.271 Kempen et al272 found that when
daily functioning is objectively measured, older adults tend to
overestimate functional ability. Thus, caution should be taken
when relying on self-report to assess cognitive abilities and
daily functioning in older adults, and objective tests should
be used whenever possible. Measures of executive functioning
have been associated with daily functioning and can serve as
objective screening measures when trying to assess functional
decline.
Although some degree of decline is invariably associated with
normal aging, recent evidence has demonstrated that there may be
certain factors that have positive effects on cognitive functioning
in older age. For example, physical activity and fitness have been
associated with faster reaction times, better cognitive perfor-
mance, lower rates of cognitive decline over time, and a lower risk
of cognitive impairment or dementia273-277 suggesting that cardi-
orespiratory fitness may serve as a buffer against age-related
declines. Healthy eating may also improve cognition, as 1 study
found that reducing caloric intake by 30% improves scores on
memory tests.278 Even engaging in leisure activities has been
associated with slower rates of age-related cognitive decline.279
In addition, exercising the mind can also have positive effects.
Engagement in cognitively stimulating activities has been associ-
ated with higher levels of cognitive functioning280-282 and a lower
risk of dementia.283 However, there is debate regarding whether
engaging in mental activity actually protects against age-related
decline or whether individuals who are mentally active have
higher absolute levels of cognitive performance (possibly due
to lifelong patterns of intellectual engagement that carry into older
age) but show equivalent rates of decline.284-286 Regardless of this
debate, if there is an absolute threshold where functioning begins
to decline, mental exercise, similar to cognitive reserve, should
improve an individual’s baseline cognitive abilities and thus pro-
long the time until that critical threshold is reached (see Figure 2).
Research illustrating the benefits of mental engagement
would suggest that targeted cognitive training may be one way
Drag and Bieliauskas
to improve cognitive functioning in older adults. Cognitive
interventions have been shown to have positive effects on cog-
nitive abilities with these effects observable at follow-up even
after a number of years.287-289 However, these improvements
are generally limited to only the trained abilities with little
transfer to other tasks (eg, reference 289), suggesting that these
interventions do not enhance general cognitive functioning.
Cognitive training also has less effect for older adults than their
younger counterparts,290 even if older adults are given addi-
tional training.291 Thus, while general mental activity may be
associated with increased cognitive performance, the utility
of specific, targeted cognitive training may be minimal.
Older adults can also mitigate age differences using envi-
ronmental support. For example, writing down information that
is likely to be forgotten, providing prompts at retrieval, and
providing memory cues and contextual information at encod-
ing can all improve memory abilities,292,293 suggesting that
older adults can be successful when encouraged to develop
mnemonic strategies and rely on external aids.
Conclusions
The field of cognitive aging is a comprehensive, multidisciplin-
ary field that includes findings from research neuroscience,
neuroimaging, and neuropsychology. This review intends to
provide a brief overview of selected key topics in the current
cognitive aging literature. The aging brain is characterized by
both structural and functional changes, the latter of which may
reflect attempts to compensate for age-related inefficiencies
and/or dedifferentiation. With regard to cognitive abilities, nor-
mal aging is not associated with global cognitive decline. In
fact, semantic memory actually increases with age, coinciding
with the accumulation of factual knowledge and wisdom over
the life span. Age-related cognitive decline tends to be specific,
even within domains, and are more pronounced when greater
burdens are placed on cognitive resources. For example, tasks
requiring strategy initiation and effortful processing, such as
recall, tend to be more age-sensitive than more automatic pro-
cesses such as recognition. Conversely, other abilities, such as
language and implicit memory, remain relatively stable over
the lifetime. Research has shown that certain variables such
as education, mental engagement, and physical activity can
have positive effects on cognitive performance in later life.
As cognitive aging affects cognitive abilities in a number of
distinct domains, it remains to be seen whether these domain-
specific deficits reflect a general phenomenon or multiple dis-
tinct phenomena. The frontal lobe hypothesis has proposed that
a single mechanism (ie, changes in frontal functioning) may
underlie most of these changes. For example, the self-
initiation of strategy is a frontal-based process that has been
shown to be important in multiple aspects of cognitive func-
tioning including free recall, source memory, prospective
memory, and verbal fluency. This may be due to a failure to
self-initiate the strategies necessary to successfully carry out
these processes. Changes in inhibitory control, the dopamine
system, and processing speed have also been suggested as
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85
possible underlying causes of age-related cognitive changes.
Despite the general debate in the literature, these processes are
not necessarily mutually exclusive, illustrating the need for a
single unifying theory that can explain the mechanisms of cog-
nitive aging across different neurochemical, anatomical, and
behavioral levels.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/or
authorship of this article.
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