Psych of Aging Exam 3 (pt.3)

HOSPICE + Depression

What is hospice?

Medical care for people with an anticipated life expectancy of 6 months or LESS

• Cure is not an option

• Focus on SYMPTOM MANAGEMENT

Misconceptions

• Eligibility

• Coverage

• Nursing Homes

• Hastens Death

• Opioids

• Eligibility → “You have to be actively dying.”

• Coverage → “Insurance doesn’t cover it & it’s expensive”

• Nursing Homes → “Can only be cared for at a nursing home”

• Hastens Death → “They are killing my family member”

• Opioids → “Drugs mask a person’s symptoms/ making them addicted”

What is the actual process of death like? (physiologically & neurologically)

• Person sleeps more

• Unconscious when asleep

• Only brain region working = breathing

History of Hospice

• When did it start ? → Doing what?

• When was it actually established?

• Who established it?

Start: 14th c → Caring for travelers

Official: 1967

Who: Cicley Saunders

Caregivers who are strained have a ___% increase in their mortality

63%

What symptoms do caregivers experience?

• Insomnia (not getting enough sleep)

• Stress + Depression

What are the types of patients that use hospice the most?

• AD

• Cancer

• Heart issues

Which nationality uses hospice the least?

Black & Native Americans

What impact did COVID-19 have on hospice?

• Lack of interaction (home visits)

• Less enrollment

• Lack of supplies

Misconception about nutrition during hospice

( What is the body actually doing?)

Food/Artificial nutrition DOES NOT improve health

• Body is trying to CONSERVE energy

What are common occurrences for people in the last moments of death

Hearing/Seeing things that are not there

What are some disparities seen in hospice care?

Gender identity/sexuality (minorities) experience less care

Preferences (LGBTQ+) related

more comfortable with gay/lesbian patients

NOT trans patients

Special concerns – Dementia

• How to help them

BE WHO THEY NEED YOU TO BE

• if they think you’re their mother, act like her

• provide them with the comfort

What are the 2 main symptoms of Major Depressive Disorder?

1) Depressed mood

2) Loss of interest/pleasure

(During the same 2-week period)

How often do the symptoms have to be in order for it to be categorized as depression?

“Most of the day, nearly every day”

Major Depressive Disorder is associated with ___, which is accounted by suicide…

HIGH MORTALITY

What are 2 signs of depression that don’t always fit in the DSM-5 criteria?

1) Mixed Features

2) Anxious Distress

Define:

1) Mixed features

2) Anxious Distress

Mixed features:

• Presence of MANIC SYMPTOMS

Anxious Distress:

• Presence of anxiety

LLD (define)

Late Life Depression

• Seen in older adults

• LESS acute version of MDD

LLD vs MDD

• Demographic

LLD:

• 65+

• Prevalence 1-4%

• 10-50% OAs show symptoms of depression

50% meet LLD criteria

Etiology of MDD vs LDD

MDD:

• Genetics

• Chemical imbalance

LLD:

• Inflammatory mechanism

• Neurodegenerative disease

• Genetics

What are the 4 causes of LLD?

1) Immunosenescence

• Muted immune response

2) Cardiovascular Mechanism

• Hardened arteries

3) Neurodegenerative Diseases

4) Other

• Lung disease, immune disorders

What’s wrong with the term “PSEUDODEMENTIA”?

• What does it mean?

Implies that the cognitive symptoms of dementia are NOT REAL

What’s wrong with the term “Reversible Dementia”?

• What does it mean?

Suggests that the cognitive problems are TEMPORARY & can disappear with TREATMENT

What is a better alternative to pseudo-dementia + Reversible Dementia?

Dementia Syndrome of Depression

What are the 2 factors that contribute to the causes of LLD?

1) DNAm (methylenation: Turns genes on/off)

• Manage serotonin levels

2) Psychosocial Factors:

• Loneliness

What are 2 genes critical for AD that are also associated with LLD?

1) APOE4

2) BNDF

Why can loneliness cause depression?

Causes INFLAMMATION

Identify the differences between LLD & MDD

• Age

• Symptom Profile (categories)

• Cognitive Changes (common/Uncommon)

• Medical Comorbidities (common/Less common/types)

• Etiology

• Prognosis → prediction of duration (Variable/chronic)

• Diagnosis → Straightforward/Difficult

• Treatment →

MDD:

• Any age

• Sadness/guilt

• Uncommon

• Less common

• Genetic/biological

• Variable

• Straightforward

• SSRIs

LLD:

• 65+

• Cognitive changes → Some emotional

• Common

• Cardiovascular/neurodegenerative/inflammation

• Chronic

• Difficult

• Psychosocial + Pharmacological

What is Bereavement? What does the normal process look like?

Process of mourning someone’s death

• Feeling sadness/numbness/Guilt

• SOLVES OVER TIME

Persistent Complex Bereavement Disorder

• How long?

• What does it look like?

6 months or longer

• Most of the day, every day

• Rumination of death

• Longing for reunion with the deceased

• Identity confusion

• Feeling “STUCK” in grieving process

Geriatric Depression Scale (GDS)

(Range for) 0-10+

• Normal

• Suggestive of Depression

• Clinically Depressed

Normal: 0-4

Suggestive of Depression: 5-9

Clinically depressed: 10+

How does Cornell Scale for Depression rate depression? (CSDD)

• Scoring?

Requires an interview with COLLATORAL SOURCE

• >10: Probably Major Depression

• >18: Definite Major Depression

Which test is better at differentiating MDD & LLD?

CSDD

Types (categorical) Treatments for LLD

1) Physical Activity

2) Restful Sleep

3) Medication

Why are medications less effective in LLD?

OAs might have co-morbidities

• Medications might overlap

What are the 4 most common types of LLD treatments?

1) Electroconvulsive Therapy (ECT)

• Shock treatments

• Used when not respondent to meds & other therapies

2) Repetitive Transcranial Magnetic Stimulation (rTMS)

• High strength magnetic fields to stimulate brain areas

3) CBT

4) Engage Therapy

• Mixture of many

Which of the following BEST distinguishes Late Life Depression (LLD) from Major Depressive Disorder (MDD)?

• A) LLD is always more severe than MDD and requires immediate hospitalization

• B) LLD is typically a subthreshold, longer-term condition with broad severity range, whereas MDD is more acute; LLD commonly occurs in OAs who never previously had MDD

• C) LLD and MDD are clinically identical but differ only in the age of onset

• D) LLD exclusively presents with cognitive symptoms while MDD presents with mood symptoms

B

A 70-year-old community-dwelling woman reports persistent low mood, loss of interest, and fatigue for over a year but does not meet full DSM criteria for MDD. This presentation is MOST consistent with which of the following?

• A) Major Depressive Disorder — her symptom duration confirms the diagnosis

• B) Late Life Depression — she shows depressive symptoms below the threshold for MDD, consistent with LLD's subthreshold nature

• C) Neurodegenerative depression — her age confirms a dementia-related etiology

• D) Immunosenescence — her immune suppression is directly causing her mood symptoms

B

Which of the following prevalence statistics BEST reflects the epidemiological picture of depression in older adults?

• A) 50–75% of community-dwelling OAs meet full MDD criteria

• B) LLD and MDD have equal prevalence rates in both community and long-term care settings

• C) Depression affects fewer than 1% of nursing home residents when assessed with standardized criteria

• D) MDD prevalence in community-dwelling OAs is 1–4%, but 10–50% show subthreshold depressive symptoms

D

Depression rates in long-term care facilities differ markedly from community settings. Which of the following BEST reflects this difference?

• A) Nursing home residents show lower rates of depression due to structured social programming

• B) Up to 25% of nursing home residents meet full MDD criteria, with even more (up to 50%) showing LLD

• C) Depression in nursing homes is exclusively LLD, with no residents meeting MDD criteria

• D) Long-term care residents show similar prevalence rates to community-dwelling OAs

B

How does the etiology of LLD differ from that of MDD?

• A) MDD involves inflammatory and neurodegenerative mechanisms; LLD is caused purely by genetics and chemical imbalances

• B) LLD and MDD share identical etiologies but differ only in symptom severity

• C) MDD is primarily linked to genetics and chemical imbalances expressed through sadness; LLD involves a broader set of causes including inflammation, cardiovascular factors, & more

• D) LLD is caused exclusively by psychosocial factors such as grief and social isolation

C

A researcher infuses a healthy older adult with bacterial endotoxins as part of a controlled experiment. The participant subsequently develops depressive symptoms. What etiological mechanism of LLD does this MOST directly support?

• A) Dysfunctional reward processing causing anhedonia through dopaminergic disruption

• B) The immunosenescence/neuroinflammation pathway — demonstrating that inflammation can causally induce depression in older adults

• C) Cardiovascular mechanisms — endotoxins cause arterial hardening leading to cerebrovascular depression

• D) Neurodegenerative mechanisms — endotoxins trigger amyloid accumulation causing depressive symptoms

B

An older adult suffers an ischemic stroke affecting the left prefrontal cortex. Three months later she develops significant depressive symptoms. Which etiological mechanism of LLD MOST directly explains this presentation?

• A) Immunosenescence — her muted immune response is triggering neuroinflammation

• B) Psychosocial factors — adjustment disorder following functional loss after stroke

• C) Cerebrovascular mechanisms — stroke-related brain tissue death is directly associated with post-stroke depression, affecting nearly 1 in 3 stroke survivors

• D) Neurodegenerative mechanisms — her stroke has accelerated tau deposition causing depression

C

Which of the following BEST describes the relationship between neurodegenerative disease and Late Life Depression?

• A) Depression is a consequence of dementia but never a risk factor — causality flows in one direction only

• B) Dementia causes depression through neuroinflammation, but depression does not independently increase dementia risk

• C) The relationship is bidirectional and ambiguous — depression is a risk factor for dementia AND dementia is a risk factor for depression, and they frequently co-occur

• D) Depression and dementia are unrelated conditions that happen to share similar prevalence rates in older adults

C

A 68-year-old man with type 2 diabetes, COPD, and hypothyroidism presents with persistent low mood and anhedonia. Which etiological framework for LLD MOST comprehensively explains his presentation?

• A) Genetic/chemical imbalance model identical to MDD etiology

• B) The "other illnesses" pathway — 80% of OAs have at least one chronic condition, and lung disease, diabetes, and endocrine disorders are all independently associated with depression

• C) Immunosenescence alone — his multiple conditions reflect a globally muted immune response

• D) Psychosocial factors — his chronic illness burden causes grief and social withdrawal exclusively

B

A clinician documents "pseudodementia" in an older adult's chart to describe cognitive symptoms that emerged during a depressive episode. Why is this terminology considered inappropriate?

• A) "Pseudodementia" implies the cognitive symptoms are not real, when in fact they are genuine symptoms present in both depression and dementia

• B) The term is outdated only because it was replaced by a more specific DSM-5 diagnosis

• C) The term is inappropriate because cognitive symptoms never occur in depression — only in true dementia

• D) "Pseudodementia" is only inappropriate when used in community settings, not clinical documentation

A

The term "reversible dementia" is considered inappropriate for describing cognitive symptoms in LLD. What is the PRIMARY reason for this?

• A) Dementia is by definition irreversible, making the phrase grammatically contradictory

• B) Cognitive symptoms attributed to depression rarely completely resolve even with successful depression treatment, making "reversible" inaccurate

• C) The term is only inappropriate for patients under age 65

• D) "Reversible dementia" implies a vascular etiology that is inconsistent with LLD

B

What is the PREFERRED terminology to replace "pseudodementia" and "reversible dementia" when describing the cognitive manifestations of Late Life Depression?

• A) Subcortical cognitive syndrome

• B) Depression-induced neurocognitive disorder

• C) Dementia Syndrome of Depression

• D) Affective cognitive impairment disorder

C

DNA methylation of serotonin transporters is associated with increased risk of LLD. Which broader epigenetic mechanism does this represent?

• A) Structural mutation of the serotonin transporter gene causing permanent loss of function

• B) Turning genes on or off through methylation, altering serotonin availability and increasing depression risk

• C) Copy number variation in serotonin receptor genes causing receptor downregulation

• D) Mitochondrial DNA damage reducing ATP availability for serotonergic neurotransmission

B

Two genes critical for Alzheimer's disease are also associated with LLD risk. Which genes and alleles are implicated, and why is this clinically significant?

• A) APOE ε2 and BDNF Val — these are protective alleles that reduce both AD and LLD risk

• B) APOE ε4 and BDNF Met — these "bad" alleles link AD genetic risk to LLD, and importantly represent different genetic risks than those seen in MDD in younger adults

• C) APOE ε3 and BDNF Val66Met — these alleles cause LLD through tau-mediated neuroinflammation

• D) TREM2 and APOE ε4 — these alleles cause microglial dysfunction leading to both AD and LLD

B

Up to 43% of older adults reported feeling lonely in pre-pandemic data. According to the psychosocial etiology of LLD, through which physiological pathways does loneliness increase depression risk?

• A) Loneliness reduces dopamine release, directly causing anhedonia through reward pathway suppression

• B) Loneliness causes social withdrawal that reduces physical activity, lowering BDNF expression

• C) Loneliness triggers cortisol dysregulation that methylates serotonin transporter genes acutely

• D)Loneliness increases heart rate, blood pressure, and systemic inflammation, and disrupts sleep — which itself causes further inflammation

D

A researcher argues that LLD and MDD in younger adults share the same genetic risk factors, making them biologically equivalent conditions. Which finding MOST directly challenges this claim?

• A) LLD occurs only in adults over 65, while MDD can occur at any age

• B) The genetic risk factors for LLD — including APOE ε4 and BDNF Met — are critically different from the genetic risks associated with MDD in younger adults

• C) LLD responds to the same antidepressant medications as MDD, confirming shared biology

• D) Both LLD and MDD involve serotonin transporter methylation, confirming identical epigenetic mechanisms

B

A socially isolated 74-year-old with low income and no close family network presents with persistent depressive symptoms. Which psychosocial determinants of LLD are present in this case, and what does this suggest about intervention?

• A) Only loneliness is present; income and social support are not psychosocial LLD risk factors

• B) Loneliness, lack of social support, and low income are all present, suggesting that social and financial interventions may be as therapeutically relevant as pharmacological treatment

• C) These are tertiary prevention factors that only matter after LLD has been formally diagnosed

• D) Psychosocial factors only contribute to LLD when combined with APOE ε4 carrier status

B

Which of the following BEST distinguishes normal bereavement from Complicated Bereavement (Persistent Complex Bereavement Disorder) in older adults?

• A) Normal bereavement lasts exactly 6 months; complicated bereavement lasts longer than 1 year

• B) Normal bereavement involves sorrow and numbness that resolves over time; complicated bereavement involves incapacitation by grief lasting 6+ months, rumination, identity confusion, and feeling "stuck"

• C) Normal bereavement only occurs after spousal loss; complicated bereavement occurs after any significant loss

• D) Complicated bereavement is diagnosed only when depressive symptoms meet full MDD criteria

B

An older adult lost her husband 8 months ago. She reports thinking about him constantly, has abandoned her previous hobbies and friendships entirely, feels her identity has disappeared without him, and cannot imagine trusting anyone again. This MOST closely represents which condition?

• A) Normal bereavement — 8 months is within the expected grieving window for spousal loss

• B) Late Life Depression — her symptoms meet full MDD criteria

• C) Complicated Bereavement (Persistent Complex Bereavement Disorder) — she shows incapacitation, rumination, identity confusion, and social withdrawal lasting 6+ months

• D) Dementia Syndrome of Depression — her cognitive symptoms suggest underlying neurodegeneration

C

Why might bereavement be particularly complex in older adults compared to younger adults?

• A) Older adults have less emotional regulation capacity and are therefore unable to process grief normally

• B) Bereavement in OAs may be compounded by multiple concurrent losses, awareness of their own mortality, and the interdependence that develops in long-term partnerships

• C) Older adults are more likely to develop MDD following bereavement because of APOE ε4 carrier status

• D) OAs have fewer social resources to draw on, making all bereavement complicated by definition

B

A clinician administers the Geriatric Depression Scale (GDS) to a 76-year-old and obtains a score of 7. How should this result be interpreted?

• A) Normal — no further assessment needed

• B) Suggestive of depression — warrants further clinical evaluation

• C) Clinically depressed — immediate pharmacological intervention is indicated

• D) Definite Major Depression — inpatient psychiatric referral is required

B

Which of the following represents the PRIMARY limitation of the Geriatric Depression Scale (GDS)?

• A) It requires a collateral informant interview, making it impractical in community settings

• B) It overweights somatic symptoms, making it inappropriate for medically ill older adults

• C) It cannot be administered to patients with any degree of cognitive impairment

• D) It only assesses current depressive symptoms without considering duration, missing an important diagnostic dimension

D

The Cornell Scale for Depression in Dementia (CSDD) differs from the GDS in which of the following important ways?

• A) The CSDD is a self-report measure while the GDS requires clinician administration

• B) The CSDD requires interviews with both the affected person AND a collateral source, and is a clinician-dependent instrument covering five symptom domains

• C) The CSDD only assesses physical signs of depression, while the GDS assesses mood and behavioral symptoms

• D) The CSDD uses a binary yes/no format identical to the GDS but with additional somatic items

B

A clinician is assessing a patient using the Cornell Scale for Depression in Dementia (CSDD). Which of the following symptom domains would NOT be captured by this instrument?

• A) Mood-related signs including anxiety and lack of reactivity to pleasant events

• B) Cyclic functions including insomnia and diurnal mood variation

• C) Ideational disturbance including suicidal ideation and mood-congruent delusions

• D) Neuroimaging findings including white matter hyperintensities and cortical thinning

D

A CSDD score of 19 is obtained for an older adult with cognitive impairment. How should this be interpreted?

• A) Probably Major Depression — score exceeds the threshold of 10

• B) Suggestive of depression — further monitoring is recommended before diagnosis

• C) Definite Major Depression — score exceeds the threshold of 18

• D) Normal for a patient with dementia — cognitive impairment artificially elevates CSDD scores

C

A researcher is designing a study to differentiate LLD from dementia in a sample of cognitively impaired older adults. Based on available evidence, which assessment tool should be prioritized and why?

• A) GDS — because its simplicity makes it more reliable in cognitively impaired populations

• B) CSDD — because it is superior to the GDS at differential diagnosis of LLD versus dementia, requires collateral input accounting for impaired self-report, and covers a broader symptom range

• C) GDS — because it assesses symptom duration, which is critical for distinguishing LLD from dementia

• D) Both instruments are equivalent for this purpose and should always be administered together

B