Psychopathology – Late Life and Neurocognitive Disorders

Myths about late life

1. decline in cognition

2. decline in happiness

3. loneliness

Social selectivity with age

the tendency of individuals to become more selective in their social interactions with age

Problems in late life

physical decline, polypharmacy, research gap

Explain the problem of physical decline in late life

1. more than half of 60+ have a severely debilitating medical condition

2. quality and depth of sleep declines with age (causing cognitive, physical, and psychological problems)

Explain the problem of polypharmacy in late life

40% of elderly people are prescribed 5+ meds, clinicians not checking and patient underreporting causes dangerous interactions

Explain the problem of research gap in late life

1. researchers test drugs on younger people and overlook symptoms that are more serious in the elderly

2. more than 20% are prescribed inappropriate medication

3. STOPP/START is a screening tool that identifies them and offers alternatives

Effects in the study of aging

1. age effects → effects of being a certain age

2. cohort effects → effects of having grown up in a certain period

3. time of measurement effects → effects of being tested in a certain period

Pro and con of longitudinal experiments in developmental change

1. group differences have less effects

2. selective mortality, biased by attrition

Selective mortality

when people die before follow up

Prevalence and incidence of psychological disorders in late life

1. 65+ have lowest prevalence of all age groups

2. most disorders have earlier onset, and most with disorders in late life have had them for a long time

3. late onset is common for drinking problems

Reasons for low prevalence of psych. disorders in late adulthood

1. positive emotionality and more close-knit social circles

2. methodological errors

Methodological issues in measuring late life psychopathology

1. response bias → may be more uncomfortable discussing mental health and drug use

2. cohort effects → time period of upbringing affects prevalence

3. selective mortality → those with psychopathology die younger

Treatment considerations for elderly (while most work for all ages…)

1. some psychiatric meds can be dangerous

2. therapy may need to be adjusted for loss of senses or mobility

3. with cognitive decline the presence of a caregiver and reminders can be helpful

Dementia symptomatology

1. cognitive deterioration which causes functional impairment

2. diagnosis is based on declines in cognitive abilities

3. memory loss is most common

Neuropsychiatric symptoms of dementia

1. psychiatric symptoms secondary to the neurological disease

2. affective and motivational symptoms (depression is most common, affecting half)

3. sleep disturbance, loss of impulse control, hallucination/delusion

Dementia development

1. most forms develop slowly, first symptoms appear before impairment

2. early signs before functional impairment are called mild cognitive impairment (MCI)

Mild neurocognitive disorder DSM-V

1. modest cognitive decline based on substantial neurocognitive impairment and concerns of patient, close other, or clinician,

2. does not interfere with independence or everyday activities but may require effort and accommodation

Consideration for diagnosing mild neurocognitive disorder

1. requires low score on one cognitive test but some tests are more reliable and using multiple tests can improve reliability

2. 10% of the time cognitive decline is tied to reversible factors

3. 10% with MCI and 1% without MCI will develop dementia in one year

Major neurocognitive disorder DSM-V

1. significant cognitive decline based on substantial neurocognitive impairment and concerns of patient, close other, or clinician

2. interferes with independence and everyday activities

Main symptoms of Alzheimer’s disease

1. memory loss → most prominent, may be overlooked for years

2. apathy → common before cognitive symptoms, one third develop MDD

3. language → problems word finding

4. visuospatial abilities → disorientation

Alzheimer’s progression

1. early → lack awareness, blame others, persecution delusions

2. moderate → impaired judgment and comprehension, disorientation, agitation

3. terminal → personality loss, narrowed social involvement, oblivion

Biological causes of Alzheimer’s

1. more plaques → disrupt communication and trigger inflammation

2. more neurofibrillary tangles → disrupt cell function and trigger cell death starting in the hippocampus

Alzheimer’s late onset heritability

0.6-0.8

Genes associated with Alzheimer’s

APOE4 on chromosome 19, genes related to immune function and cholesterol metabolism

APOE4 and Alzheimer’s

causes overproduction of plaques, less beta-amyloid clearing, and less glucose metabolism in cerebral regions before symptom onset

Genes related to immune function and cholesterol metabolism in Alzheimers

1. triggers inflammation which increases risk

2. glycemia and diabetes also tied to Alzheimer’s

Lifestyle factors related to Alzheimers

exercise and intellectual engagement

Exercise in Alzheimer’s etiology

1. lower cognitive decline and plaque levels especially for those with APOE4 polymorphism

2. levels in mid-life and late-life are important

Intellectual activities in Alzheimers etiology

1. frequent engagement lowers risk

2. in those with similar levels of plaque and tangles those with higher engagement have less cognitive decline

Cognitive reserve

the idea that people can compensate for the disease by using different brain networks or cognitive strategies

Frontotemporal dementia (FTD)

1. caused by a loss of neurons in frontal and temporal regions, especially the anterior temporal lobes and PFC

2. usually begins in late 50s and progresses rapidly, causing death within 5 years of diagnosis

3. <1%

FTD symptoms and diagnosis

1. emotional dysregulation linked to inappropriate behavior

2. loss of sympathy and emotional responsiveness linked to damaged relationships

3. often misdiagnosed

FTD etiology

presence of pick bodies and high levels of tau protein

Vascular dementia

1. caused by cerebrovascular disease

2. most commonly caused by strokes

3. symptoms depend on stroke location

Vascular dementia risk factors

same as cardiovascular disease

Lewy bodies

1. abnormal protein deposits in the brain found in DLB and Parkinsons

2. interfere with signaling and transmission

Lewy body dementia pathology

1. lewy bodies initially form in the olfactory bulb and brainstem

2. cognitive symptoms appear as they spread

3. affect regions for movement, memory, and perception

Dementia with lewy bodies symptoms

1. cognitive decline

2. motor symptoms

3. hallucinations

4. fluctuating attention and alertness

5. vivid dreams with movement and vocalization

6. severe sensitivity to antipsychotics

Diagnostic challenges in dementia with lewy bodies

1. often misdiagnosed as alzheimers or parkinsons

2. requires careful observation of fluctuations and hallucinations

Two most common medicinal dementia treatments

cholinesterase inhibitors, memantine

Cholinesterase inhibitors in dementia treatment

1. slow memory decline by preventing ach breakdown

2. do not restore lost memory and often cause nausea leading to discontinuation

3. donepezil

Memantine in dementia treatment

1. regulates glutamate (involved in memory) showing modest benefit for alzheimers

2. small effects

Medicinal treatment to manage psychological symptoms of dementia

1. antipsychotics offer some relief but increase death risk in early dementia

2. antidepressants reduce agitation but show mixed efficacy for depression symptoms

Vascular dementia treatment

1. controlling hypertension and cardiovascular health

2. may also slow alzheimers progression in those with hypertension

Past approach: Removal of beta-amyloid plaques

1. plaque accumulates years before symptoms so the treatment was often too late

2. sometimes worsened symptoms

Current approach: Early Prevention & Intervention

1. targeting early biological markers like plaques or tangles

2. prevent MCI from progressing

3. studying people at risk before symptoms appear

Emerging approach: electrical stimulation

may enhance memory recoding but is not yet approved for MCI or dementia

Psychological/Lifestyle Dementia Treatments

1. supportive psychotherapy

2. behavioral intervention

3. exercise and cognitive training

4. lifestyle intervention

Supportive psychotherapy in dementia treatment

therapist offers accurate information, home care strategies, and realistic coping approaches to prevent catastrophic thinking and foster confidence in management

Behavioral interventions in dementia treatment

1. memory aids compensates for memory loss

2. music therapy reduces agitation and disruptive behaviors

3. psychotherapy reduces depression

4. pleasant activities reduce depression and increase engagement

Exercise and cognitive training in dementia treatment

1. exercise moderately improves cognitive function in healthy elderly and those with MCI

2. cognitive training shows domain-specific improvements

3. meta-cognitive training shows broader cognitive improvements

4. more effective before development, especially for healthy older adults or those with MCI

Lifestyle interventions in dementia treatment

program of diet, exercise, and cognitive training may improve executive function

Delirium symptom categories

disturbed awareness/attention, cognition, and emotion/behavior

Delirium disturbance in attention and awareness

1. deficits in focus and attention

2. wandering thoughts and difficulty holding conversation

3. alternation between lucidity and confusion

4. sleep-wake cycle disturbance

Delirium cognitive disturbances

1. disorientation

2. memory impairment

3. incoherent speech and disorganized thinking

4. misinterpretation of environment

5. delusions and sometimes visual hallucinations

Delirium emotional and behavioral changes

1. mood swings

2. erratic behavior

3. fluctuations in motor activity (hyperactive to hypoactive)

4. sundowning (heightened agitation at night)

Delirium drug related etiology

drug intoxication or withdrawal, most common

Delirium and medical conditions

infections, metabolic or nutritional imbalances, post-operative stress

Delirium and neurological factors

head trauma, seizures, dementia

Delirium and environmental factors

dehydration, immobility and use of physical restraints

Older adults’ vulnerability to delirium

1. age-related physical decline

2. higher susceptibility to chronic diseases

3. polypharmacy

4. increased drug sensitivity

Medical treatment of delirium

1. address underlying causes

2. atypical antipsychotics

3. recovery time is 1-4 weeks but longer in elderly

Preventative care of delirium

1. ensure proper sleep-wake cycle and reduce sleep disruption

2. ensure proper hydration and nutrition

3. use re-orientation aids and restore use of glasses and hearing aids ASAP

Special considerations in treatment and diagnosis of delirium

1. delirium can be mistaken as dementia progression

2. families should be educated on delirium symptoms and recognize them as reversible with timely care