HDE Exam #3

uniform determination of death act

defines death (medically and legally) as the irreversible cessation of circulation and respiratory functions or when all structures of the brain have irreversible ceased to function

dying

period when organism loses vitality

medical aspects of dying

• person must have total brain death including portions that control involuntary functions

  • if person is kept alive through life support they wound not be declared dead unless the brain showed irreversible loss of functioning

• final years of life person may experience sharp declines in cognition and loss of appetite and muscle mass

  • lose mobility and spend much of time sleeping

  • in late stages person has extreme difficulty breathing

dying trajectory

temporal pattern of disease process leading to death

• has four primary trajectories

  • 1) individual is at high level of functioning until death occurs suddenly due to accidental cause of unanticipated medical event

  • 2) people who are functioning at high level until disease progressed to the point where the body can no longer sustain life

  • 3) death due to presence of one or more chronic diseases that lead to progressive failures of organs and will occur over prolonged period with series of dips and recoveries

  • 4) people who have limited physical reserves at the start of trajectory

crude death rate

the number of deaths divided by population alive during a certain time

• rarely used

age-specific death rate

crude death rate for specific age group

• only refers to the likelihood of people dying within their own age group

• calculated by dividing the number of deaths within a particular age group by the number of people in the population

age-adjusted death rate

mortality rate statistically modified to eliminate the effect of different age distributions in different populations

• useful because it is based on a weighted average of the age-specific mortality rates, eliminating the effect of different age distributions among the different populations

sociocultural perspective on death and dying

death and dying are reflections of cultural values, practices and beliefs

• people learn the social meaning of death from the language, arts and death-related rituals of their culture

death ethos

culture’s prevailing philosophy of death can be inferred from funeral rituals, treatment of those who are dying, belief in the presence of ghosts, belief in afterlife, the extent to which death topics are taboo, the language people use to describe death and representation of death in the arts

death with dignity

proposed that the period of dying should not subject the individual to extreme bodily functions

• inspired by 20th century movement by cultural anthropologist Ernest Becker who hoped to make progress against western culture’s unwillingness to face reality of mortality

• inspired efforts in medical community to humanize the dying process for patients and their families

psychological perspectives on death and dying

• toward the end of their lives, individuals may begin to shift their identities to incorporate the reality that faces them and use identity assimilation to minimize reality of death

  • when they accept that their life will be ending, the process of identity balance may start to allow them to face this face with equanimity

• the way people die can also define their identities in way that no other life changes can

legitimization of biography

steps to leave a legacy that will continue to define oneself after one is gone

• people attempt to see what they have done as having meaning and they prepare “the story of their lives” by which they will be remembered in the minds of others

awareness of finitude

when people pass the age when other people close to them had themselves died

• can trigger intense period of self-evaluation while they deal with mortality and questions related to the ending of their existence by attempting to place their lives into perspective

death anxiety

the fear of death and dying

• fears of dying process, ending of the self, watching loved ones die, being separated from loved ones, receiving potential punishments after death, wondering how others will cope and fearing the unknown

• increase sense of purpose, decrease anxiety about death

• less religious = less death anxiety, somewhat religious = high amount of death anxiety, very religious = low death anxiety

issues in end of life care

• advance directives

• medical aid in dying

• hospice care

• improving health care and mental health services to dying patients

patient self-determination act

an amendment to titles of Social Security Act (medicare and medicaid) which guarantees the right of all competent adults to have an active role in decisions about their care at the end of life

• mandated that healthcare facilities and agencies who receive medicare and medicaid funding provide patients with written information about their right to be involved in making decisions about their medical care and to document those wishes

• assents individuals express and document their preferences for end-of-life care before they need it and while they are still able to participate in decision making process

advance care planning

the process in which individuals express and document their preferences for end-of-life care before they need it and while they are still able to participate in the decision-making process.

living will

a statement that stipulates the conditions under which patients will accept or refuse treatment if they are unable to make their own decisions

• helps ensure individual’s right to choose whether heroic measures will be used to sustain life

• how, when, under what circumstances life-sustaining treatments are provided/witheld

• contract between person, medical community, close relatives

durable power of attorney for health care

names the individual who can legally make decisions should the patient be incapacitated

• known as healthcare proxy

• surrogate decision making

do not resuscitate order

directs healthcare workers not to use cardiopulmonary resuscitation if the patient experiences cardiac or pulmonary arrest

do not intubate order

specifies that the patient does not want to be kept alive through a breathing tube

do not hospitalize order

specifics that the patient does not wish do be hospitalized even if needed

medical order for life-sustaining treatment

contains orders for a physicians assistant or nurse practitioner

physicians order for life-sustaining treatment

contains orders for physician

• includes DNR, DNI and DNH orders and record the name and contact information for the healthcare proxy

medical aid in dying

gives patient to participate in decisions that would end their lives in case of developing a terminal, painful and debilitating illness

• physican-assisted suicide: physician facilitates the end of patient’s life by giving the patient the means to commit suicide

• medical aid in dying: providing a patient with the means to end life when the patient is in the terminal phase of already dying

euthanasia

the ending of a patient’s life by a physician or other medical professional

• passive - treatments are withheld from dying patient

• active - medical personnel take actions to end person’s life such as by administering lethal medications

hospice

site or program that provides medical and supportive services for dying patients

• prepare: examine feelings, plan

• family involvement: come to resolution of relationship

• patient and family have control

palliative care

care that focuses on optimizing the patient’s quality of life by providing relief from pain and other disease symptoms

bereavement

the process during which people cope with the death of another person

• can affect anyone, regardless of age but is more likely to take place in later adulthood

• takes stress on body, causes individuals to experience range of feelings including anger, depression, anxiety, feelings of emptiness, impaired attention and memory

practical aspects of bereavement

• funeral planning

  • finding funeral home, provide death certificate information, make plans for burial/cremation, plan and run memorial service or funeral

• legal/finacial

  • social security, change bank accounts, update home-related bills, change name on insurance and credit cards

• changes in the home

  • go through belongings, dispose of possessions, meals and food preparation, move if necessary

emotional aspects of bereavement

• according to study adults may experience low levels of depression, anxiety, grief and social impairment

• can persist over time over after “mourning” period has ended

attachment view of bereavement

bereaved can continue to benefit from maintaining emotional bonds to deceased individual

• survivor can hold onto at least some of spouse’s possessions because of symbolic value, hold onto thoughts and memories

• becomes part of survivors identity

dual-process model of coping with bereavement

the practical adaptations to loss are regarded as important to the bereaved person’s adjustment as are the emotional

• practical adaptations include set of life changes that accompany the death such as new tasks or functions

• loss oriented functions - involve coping with the direct emotional consequences of the death

• people adjust to bereavement by altering between the two dimensions of coping

reminiscence

review of memories

• writing, talking, telling stories

• related to erikson’s integrity vs. despair stage of psychosocial development

kubler-Ross’s stages of grief

• denial, anger, bargaining, depression, acceptance

reactions to diagnoses

• positive avoidance

• fighting spirit

• stoic acceptance

• helplessness/hopelessness

• anxious preoccupation

• positive avoidance and fighting spirit = 35% died of cancer vs. other mechanisms = 76% died of cancer

where to die

• most adults say they prefer to die at home

• most die in nursing homes and hospitals

• quality of care: other nursing vs. hospice

importance of farewells

• gifts

• signals to people that they matter

• makes death real to both parties

• helps both accept death

• may make dying easier, especially if farewell is before last moments

• may make it easier to disengage and reach acceptance

medical directive

written statement of person’s wish to accept/reject certain medical interventions

• preserves person’s right to determine their own treatment when they are incompetent, unable to make decisions or unable to express wishes

advance directives

decisions about medical treatment

• legally binding

• define which treatment options are acceptable before they are needed

• types: living wills, medical directives, durable powers of attorney for health care

Alzheimer’s disease

major neurocognitive disorder (dementia) in which the individual suffer progressive and irreversible neuronal death

• category of conditions

• global deterioration in intellectual abilities and physical function

• accounts for 60-80% of dementia cases

• cause and type of dementia

dementia

general term for symptoms like decline in memory, reasoning or other thinking skills which interfere with daily life

AD diagnostic criteria

types of dementia

• alzheimer’s

• vascular

• Lewy body

• frontotemporal

• huntington’s

• mixed dementia: dementia from more than one cause

AD prevalence

over 7 million Americans are living with Alzheimer’s

• less than 10% in 71-79, 20% at 80-89 and 30% at >90

AD gender differences

• almost 2/3 of Americans with Alzheimers are women

• estimated lifetime risk for AD for women

  • 19% at 45 vs. 10% for men

  • 21% at 65 vs. 11% for men

• why?

  • lower educational attainment and lower socially active job - mind not as active to minimize risk

  • hormonal differences

  • child bearing

  • women having higher rates of depression

  • chromosomal differences

  • cultural influences on men and women

AD racial and ethnic disparities

when compared with older caucasians

• African Americans 2x as likely

• hispanic Americans 1.5 as likely

• possible causes

  • racism affecting services and resources available

    • especially safety of living environment - living in industrial area

    • funding not good for school

    • under resources healthcare and systematic racism within it

  • variation and prevalences in diseases

  • differences in health behaviors

    • diet, exercise, sleep, stress

  • socioeconomic factors

    • social determinants of health

AD age differences

• 2025 stats 

  • 7.2 million total 

  • 65-74: 1.9 million 

  • 75-84: 2.8 million 

  • 85+: 2.5 million  

• Percentage of people with Alzheimer' s dementia increases with age 

  • 65-74: 5% 

  • 75-84: 14% 

  • 85+: 33%

• all age groups will have an increase in diagnosis and more people in old old group and oldest old group with AD

AD mortality

• 1 in 3 seniors died with Alzheimer's or another dementia

• Among people aged 70, 61% of those with Alzheimer’s dementia are expected to die before age 80 compared with 30% of people without Alzheimer's dementia

Dying from AD

AD noted on death certificate as the underlying cause of death

• has increased 142% from 2000 to 2022

dying with AD

AD → condition → death

AD caregiving

nearly 12 million Americans provide unpaid care for family member or friend with dementia, a contribution to the nation valued at more than $413 billion

• high percentage of caregivers who provide help with ADLs

• 59% report emotional stress of caregiving

• 38% report physical stress of caregiving

• high percentage of dementia caregivers who report having a chronic health condition compared with caregivers of people without dementia or non-caregivers

AD caregiver demographics

• 2/3 women

• >1/3 daughters

• ¼ sandwich generation

AD workforce

nearly 900,000 additional direct care workers will be needed between 2022 and 2032 (more new workers than in any other single occupation in the US)

AD economic cost

in 2025 health and long-term care costs for people living with Alzheimer’s and other dementias are projected to reach $384 billion

• Medicare paying 45%, medicaid, 19%, out of pocket 25% and other 11%

signs of Alzheimer’s disease

• memory loss that disrupts daily life

• challenges in planning or problem solving

• difficulty completing familiar tasks

• confusion with time or place

• trouble understanding visual images and spatial relationships

• new problems with words in speaking or writing

• misplacing things and losing the ability to retrace steps

• decreased/poor judgement

• withdrawal from work or social activities

• changes in mood or personality

AD stages

symptomatology

• mild cognitive impairment

mild cognitive impairment

shows some cognitive symptoms but not all of those necessary for a diagnosis of AD

brain changes because of AD

• fewer nerve cells and synapses

• senile plaque build up between nerve cells

• neurofibrillary tangles form (made of twisted strands of proteins)

• shriveling cortex → damage to thinking, planning, remembering areas of the brain

• Decreased volume; especially severe in hippocampus (helps us to make and recall long term memory) 

• Ventricles enlarge - empty space in brain (no brain cells) but allow cerebral spinal fluid to move in and out 

• Sulci becomes wider because we lost neurons 

senile plaques

form when beta-amyloid protein pieces clump together

beta-amyloid plaque

protein that accumulates outsides of nerve cells into plaques in the brain, disrupting communication between brain cells and eventually contributing to their death

• versions that are chemically stickier are more likely to accumulate into the plaques found in the brain of person with Alzhiemer’s

neurofibrillary tangles

destroy cell transportation systems made of proteins

• nutrients and other suppliers can’t move through cells

• cells eventually die

AD progression

spreads through the cortex in predictable pattern

• live average of 8 years when diagnosed with AD

  • changes happen 20 year prior even before displaying symptoms

AD stages

• early

  • affects hippocampus (learning and memory)

    • decline in episodic memory function (don’t remember recent events lively)

    • may forget words, location of familiar objects

  • affects frontal lobe

    • decision making, problem solving and purposeful behavior

• middle stage

  • Frontal lobe - more damage 

  • Trouble with speaking or understanding speech 

  • Trouble knowing where body is in relation to surrounding objects 

  • Acting in unexpected way 

  • Damage to nerve cell - difficult to express thinking or feeling and perform routine tasks

  • Being forgetful of events or personal history, unable to recall info about themselves, choosing proper clothing for season, sleep scheduled reversed, tend to wander and become lost, suspiciousness, hand-wringing, inhibition gets worse 

  • Still participate in daily activities with assistance 

    • Very important

• late stage

  • Widespread shrinkage due to cell death 

  • Lose ability to communicate, recognize loved ones and care for selves 

  • Lose recent experiences

  • Physical changes, difficulty communicating, vulnerable to infections, pneumonia, need engagement, benefit from interaction, listen to calming music and gentle touch 

early-onset AD

• affects people under 65

  • often in 40s, 50s and sometimes 30s

  • 5% of AD patients

  • often genetically inherited

  • rare

  • very severe (rapid pace of progression)

late-onset AD

• affects people 65+

• more common

• death occurs 8-10 years after diagnosis; sometimes 20 years

genetic role in AD

• 100+ genes give people great susceptibility for AD

• human karyotype

  • autosomes

  • sex chromosomes

APOE gene

gene affects protein which affects function

• APOE e2, APOE e3, APOE e4

APOE e2

possibly protective against development of Alzheimer’s

• if AD occurs it develops later in life compared to people with APOE e4

• 5-10% of people studied have this allele

APOE e3

seems to have neutral effect on AD

• most common of APOE alleles

APOE e4

increases risk for AD

• associated with earlier onset of AD compared to other alleles

• occurs in 15-25% of people

• 2 copies is associated with higher risk than 1 copy

  • 2-5% have two copies

• 40-65% of people diagnosed with AD in the US have at least one copy of APOE allele

  • causes for people without allele: heart health, brain damage, drug usage

Epigenetics

how environment affects expression of genes

APP

protein found in many tissues of the human body and is particularly present in the nerve cells of the brain

• mutations of it influences the likelihood of developing Alzheimer’s disease

• located on chrome 21

PSEN1

found on chromosome 14

• mutations in gene are most common cause for early onset AD

• influences breakdown of APP

• Certain versions leads to APP broken down → extra beta amyloid → amyloid plaques → in between synapses and influences neurons 

PSEN2

found on chromosome 1

• increase risk for early onset AD

• influences breakdown of APP

• Certain versions leads to APP broken down → extra beta amyloid → amyloid plaques → in between synapses and influences neurons 

differential risk

prevalence

in certain lineages genes for increased risk of AD may be more prevalent

• early-onset AD: less than 10% of cases

• 10-15% of early onset cases occur in people with mutation in APP, PSEN1 or PSEN2

Genetic Role in risk for developing AD

• risk gene (increase likelihood of AD)

  • apolipoprotein E (APOE)

• Deterministic genes (directly cause AD)

  • APP

  • PSEN1

  • PSEN2

AD prevalence in people with DS

• Almost 6x higher than in people without DS 

• Why? → APP gene on chromosome 21 

  • Extra copy of APP gene 

• At least 50% of people with DS develop AD symptoms during 50s and 60s 

• 75% of those 65+ with DS have AD 

AD risk factors

• Age 

• Family history 

• Genetics 

• Modifiable risk factors 

• Certain medical conditions

modifiable risk factors for AD

• High cholesterol levels 

• High blood pressure 

• Sedentary lifestyle 

• Tobacco use 

• Obesity

healthy habits for AD

• Challenge your mind 

• Stay in school 

• Eat right 

• Manage diabetes 

• Maintain a healthy weight 

• Sleep well 

• Get moving 

• Control blood pressure 

• Be smoke free 

• Protect your head

AD diagnosis

• All age groups will have increase in diagnosis and more people in old old group and oldest old group with alzheimer's dementia 

Psychological disorder

the range of behaviors and experiments that fall outside of social norms, create adaptational difficulty for the individual daily and put the individual or others at risk of harm

• complex interaction of changes that take place over adulthood

• risk of harm

• causes difficultly in y in adaptability in daily life

incidence

percentage of people who develop a condition within a given period

prevalence

percentage of people who experience a disorder within a given period of time

• ex. everyone who developed MDD during 2025 & everyone who developed it before 2025 and is still experiencing it

prevalence of psychological disorder

• highest prevalence in 18-25 and continues to decline throughout age of 95+

risk factors for psychological disorders

depression, anxiety, substance abuse, traumatic symptoms, personality dysfunction

• mobility problems, sensory impairments, sleep disturbances

• chronic diseases and malnutrition

• prescription drugs

• traumatic experiences, abuse

• longstanding disturbances in patterns of behavior

• loneliness, ageism, COVID-19

• financial insecurity, social discrimination

diagnostic factors for psychological disorders

DSM5

a referenced used by mental health professional to diagnose people with psychological disorders and developed by American Psychological Association

ICD11

diagnostic system developed by WHO and includes all medical conditions as well as psychological disorders

• in version 11 - the recommended term of old age within category of classifying disorders and replaced use of senility (in older age and having problems with thinking which implies aging is pathological and requires a diagnosis and recognize symptoms may appear different in older adults

professional geropsychology

the application of gerontology to the psychological treatment of older adults

• field makes it possible to educate other mental health professionals on the basic principles of care for older adults

mood disorders

person loses control of their emotions which leads to distress for person

• MDD

• bipolar disorder

major depressive disorder

an extremely sad mood that lasts most of the time for at least two weeks and is not typical of individual’s usual mood

• may experience appetite, sleep disturbances, feeling of guilt, difficulty concentrating and low sense of self worth

• prevalent in people 18-25 and low percentage in people 50+

• most people experience it by 43

dysphoria

sad mood

prolonged grief disorder

persistent reaction to bereavement with death that occurred over one year ago

• person must experiment at least 3 depressive symptoms nearly everyday for a month

bipolar disorder

people who experience a manic episode with feelings of elations, grandiosity and expansiveness and a major depressive episode

• rates relatively low in older adults

manic episode

one week period in which an individual experiences atypical feelings of elation, grandiosity, expansiveness and high levels of energy

anxiety disorder

disorder in which the main characteristic includes anxiety, a sense of dread about what might happen in the future

• most common type of mental health disorder in the US

• usually begins in childhood

• highest severity in 18-29 and continues to decrease in 65+