Psych 360 Chapter 14
- Aging
o Elderly = over the age of 65
§ Arbitrary point set largely by social policies
o In less than 200 years, life expectancy has almost doubled in Western world
o Gender differences in social judgments about aging-related changes in physical appearance
o Cultural variation
§ In some cultures, elders are revered
- Myths about late life
o Aging involves inevitable cognitive decline
§ Severe cognitive problems do not occur for most
· Mild declines are common, particularly in fluid abilities
o Older adults are unhappy
§ More skilled at emotion regulation
§ Attend more to positive
§ Display less psychophysiological response to negative emotion
o Late life is a lonely time
§ Interests shift away from seeking new social interactions to cultivating a few close friendships (social selectivity)
- Common problems experienced in late life
o Physical decline and disabilities
o Sensory acuity deficits
o Loss of loved ones
o Social stress of stigmatizing attitudes towards elderly
o Cumulative effects of a lifetime of stressors
o Decline in quality and depth of sleep
- Problems experienced in late life: polypharmacy
o Prescribing multiple drugs to a person
§ 40% of elderly persons are prescribed at least 5 medications
§ 20% prescribed dangerous medications
§ Increases the risk of adverse drug reactions
§ Most research has tested drugs on younger people
- Research designs
o Special considerations in the study of aging
§ Age effects
· Things that happen specifically due to age
§ Cohort effects
· “boomers” differ from “gen-z” in experiences during each stage of life
§ Time-of-measurement effects
· Social/historical influences present at time measurement is made (e.g., pandemic)
o Similar to considerations in studies of child development
o Cross-sectional studies
§ Researcher compares different age groups at the same point in time on a variable of interest
· E.g., how quickly can people press a button?
· Compare older people to younger people
· Assumption is that associations with age are due to aging
§ Fails to provide information about how people change over time
o Longitudinal studies
§ Researcher retests the same group of people with the same measures at different points in time
· May extend over several years or decades
· Can see how people change over time (compared to themselves at younger ages)
§ Attrition can lead to biased sample
· Selective mortality—no longer available for follow-up because of death
· People with the most problems are likely to drop out from a study
- Psychological disorders in late life
o DSM criteria are the same for older and younger adults
§ Some criticism of this approach – e.g., substance use may create more physical problems when older vs. younger
o Particularly important to rule out medical explanations
§ Medical problems can also worsen the course of depression
§ Age-related deterioration in the vestibular system (e.g., balance) can account for panic symptoms
§ Depression is common after strokes or heart attacks
§ Antihypertensive medication, corticosteroids, and anti-parkinsonian medications may contribute to depression or anxiety
- Prevalence of psychological disorders
o Psychological disorders are less common in the elderly than in younger adults
§ More positive emotionally
§ More close-knit social circles
§ May grow out of some psychological symptoms
§ Methodological issues lead to underestimation of prevalence
o Most people with psychological disorders in late life are experiencing a continuation of symptoms that began earlier
- Methodological issues
o Response bias
§ Discomfort discussing symptoms may minimize prevalence estimates
o Cohort effects
§ E.g., many people who reached adulthood during the drug-oriented era of the 1960s continue to use drugs as they age
o Selective mortality
§ Psychological disorders are associated with premature mortality
- Treatment
o Similar to treatments that work in earlier life
§ However, many elderly may not be diagnosed properly by their primary care physicians
o Many medications can cause serious side effects in elderly
o Psychotherapy is the first line approach for anxiety
§ Adapt to adjust for vision and hearing loss
§ Telehealth for people with limited mobility
§ May include a caregiver in therapy sessions
§ Use of memory aids (e.g., worksheets on session content
- Dementia
o Deterioration of cognitive abilities causing impairment
§ Most common symptom is diminished memory, especially for recent events
§ Many different causes of dementia
§ Very high public health cost
o Psychiatric symptoms
§ 50% of people with dementia experience depression
§ Sleep disturbances are common
§ Delusions and hallucinations can occur
§ Difficulty with impulse control
o DSM-5 criteria: major neurocognitive disorder (dementia)
§ Cognitive or behavioral symptoms that:
· Reported by the patient or knowledgeable informant or are shown on an objective cognitive assessment
· Interfere with the ability to function at work or at usual activities
· Represent a decline from previous levels of functioning and performing
· The impairments are observed in at least 2 domains
o Memory, reasoning/judgment, visuospatial, language, personality/behavior
o Prevalence
§ Less than 2% before the age of 65
· Increases dramatically as people age
· More than 1/3 of people in their 90s
§ Age of onset is becoming later over time in United States and Europe
§ Number of cases expected to double by 2030 as the number of elderly grow
§ Appears lower in sub-Saharan Africa and high in Latin America
o Types
§ There are many types of dementia
§ We will discuss four:
· Alzheimer’s disease
o Irreversible brain tissue deterioration
§ Death usually occurs within 12 years
o Usually begins with:
§ Absentmindedness and gaps in memory for new material
§ Leaving tasks unfinished or forgotten
§ Difficulty finding words
o Other symptoms
§ Apathy, depression, disorientation
§ As brain deterioration progresses, the severity of symptoms increase
o At first, people are often unaware of their cognitive problems
§ Progresses to becoming oblivious of surroundings
o Brain changes in Alzheimer's disease
§ Plaques: β-amyloid protein deposits
· Primarily found in frontal cortex
§ Neurofibrillary tangles: protein filaments composed of tau
· Primarily found in hippocampus
§ Plaques and tangles measured using PET scans
§ Tangles can now also be detected in cerebrospinal fluid
§ Immune responses to plaques lead to inflammation
· Loss of synapses and neuronal death
o Etiology
§ Biological influences
· Late onset: heritability between 60-80%
· 19 specific genetic loci identified
o Most of the genes explain a very small amount of risk
· Most genes that increase risk are related to immune function and cholesterol metabolism
o Possibly related to increases in inflammation
· Polymorphism of a gene on chromosome 19
o Apolipoprotein or ApoE-4 allele
o Before the development of symptoms, people with two E4 alleles show
§ Overproduction of beta-amyloid plaques
§ Loss of neurons in the hippocampus
§ Low glucose metabolism in several regions of the cerebral cortex
§ Lifestyle factors
· Greater risk:
o Social isolation
o Insomnia
o Depression
· Lower risk:
o Fish consumption, Mediterranean diet, education
o Exercise
§ Predicts less decline in cognitive functioning and decreased risk of developing Alzheimer's
o Engagement in cognitive activities
§ “use it or lose it”
§ Frequent cognitive activity is related to a 46% decrease in risk
§ Intellectual activity protects against the expression of underlying neurobiological disease
§ Cognitive reserve: some people may be able to compensate for the disease by using alternative brain networks or cognitive strategies
· Frontotemporal dementia
o Loss of neurons in frontal and temporal lobes
o Typically begins in late 50s, progressing rapidly
§ Death usually occurs within 5 years
o Affects less than 1% of the population
§ Memory not severely impaired
o Similar lifestyle factors influence FTD as for Alzheimer’s disease
o There are multiple subtypes
o Most common subtype: behavioral variant
§ Deterioration in at least 3 areas
· Empathy, executive function, ability to inhibit behavior, compulsive or perseverative behavior, tendencies to put nonfood in mouth, apathy
§ Strikes emotional processes more profoundly than Alzheimer’s
o Often misdiagnosed
§ E.g., midlife crisis, bipolar disorder, depression
o Can be caused by many different molecular processes:
§ Pick’s disease
§ High levels of Tau
§ Strong genetic component
· Vascular dementia
o Caused by cerebrovascular disease
§ Most commonly stroke
o Same risk factors as cardiovascular disease
§ Older age, high “bad” cholesterol, smoking, high BP
o Racial disparities:
§ Strokes and vascular dementias are more common in African Americans than Caucasians
o Symptoms vary greatly depending upon location of stroke
· Lewy body dementia
o Protein deposits (Lewy bodies) form in the brain and cause cognitive decline
o Affects 1% or less of elderly individuals
o Symptoms hard to distinguish from Parkinson’s and Alzheimer’s diseases
o Symptoms more likely to include
§ Prominent visual hallucinations
§ Fluctuating cognitive symptoms
§ Sensitivity to physical side effects of antipsychotic medications
§ Intense dreams involving movement and vocalizing
§ Alzheimer’s is the most common form, accounting for more than half of dementias
o Treatment
§ Medications
· Some medications help to slow decline, but cannot restore functioning
o Cholinesterase inhibitors – increase acetylcholine to reduce motor symptoms
o Many people discontinue due to side effects
· Medications to improve cardiovascular health and to treat depression or agitation
§ Ongoing prevention research
· Prevent development of plaques and tangles
· Reduce chances of milt cognitive impairment
· Study people with early biological markers
§ Psychological treatments
· Supportive psychotherapy
o Education about disease and care for patient and family
· Behavioral approaches
o External memory aids
o Music to reduce agitation and disruptive behavior
o Psychotherapy to reduce depression
o Increasing pleasant and engaging activities
· Exercise and cognitive training to prevent cognitive decline before it begins
o Small benefit of training in individuals with mild cognitive impairments
- Mild cognitive impairment
o Most dementias develop slowly over a period of years
§ Behavioral deficits often emerge before noticeable impairment
o Early signs of decline before functional impairment
o DSM criteria: mild neurocognitive disorder (MCI)
§ Modest cognitive decline from previous levels in one or more domains based on concerns of the patient, a close other, or a clinician
§ Impairment in one or more cognitive domains compared to expectations for the patient’s age and educational level or compared to baseline testing
§ Preservation of ability to function independently
§ Cognitive deficits not due to vascular, trauma, or other medical conditions
o Problems with DSM-5 criteria requiring a low score on only one cognitive test
§ Some cognitive tests are more reliable and relevant than others
§ Current MCI criteria may not be very reliable
· Could lead to over-diagnosis
· Using more than one test improves reliability
§ 10% of the time, cognitive declines are tied to other problems
· Infection, sleep loss, thyroid disease, vitamin deficiencies
o Not all people with MCI develop dementia
- Huntington’s disease
o Neurocognitive disorder with memory problems and cognitive symptoms similar to Alzheimer's disease
o Nerve cells in the brain (particularly basal ganglia) gradually break down and die (neurodegeneration)
o Involves distinctive symptoms of chorea
§ Involuntary jerky movements
§ Problems with voluntary movements due to muscle rigidity or contractions; may affect gait or speech
o Autosomal dominant disorder caused by a defect in a single gene
§ Offspring of a parent with Huntington’s have a 50% chance of developing the disorder
- Signs of delirium
o Worsening or change in a person’s mental state that happens suddenly
o Confusion, sleepiness, disorientation
o Can be distressing especially when don’t know cause
o Clouded state of consciousness
§ Extreme trouble focusing attention
§ Cannot maintain a coherent stream of thought
§ Difficult to engage in a conversation
· Speech may become rambling and incoherent
§ Trouble answering questions
§ Disorientation of time, place, and name
§ Memory impairment of recent events
§ Perceptual disturbances
§ Disturbances in the sleep/wake cycle
· Drowsy during the day, yet awake and agitated at night
§ Vivid dreams and nightmares are common
- Delirium
o Rapid onset and can fluctuate during the course of a day
§ Lucid intervals where person becomes alert and coherent
§ Daily fluctuations help distinguish delirium from other syndromes, especially Alzheimer's disease
o Can occur at any age
§ Common in children and older adults
o Often misdiagnosed
§ Untreated, the mortality rate for delirium is high
§ Predictor of death within the next 6 months
§ Increased risk of further cognitive decline
o DSM criteria
§ Disturbance in attention and awareness
§ A change in cognition not better accounted for by a dementia
· E.g., disturbance in orientation, language, memory, perception, or visuospatial ability
§ Rapid onset (usually within hours or days) and fluctuation during the course of a day
§ Symptoms are caused by a medical condition, substance intoxication or withdrawal, or a toxin
o Treatment
§ Complete recovery if underlying cause is treated
§ Atypical antipsychotic medications are also used
§ Usually takes 1 to 4 weeks to clear
· Takes longer in older people than younger people
§ Reduce risk factors for delirium within the hospital setting:
· Sleep deprivation, immobility, dehydration, visual and hearing impairment
§ Family should learn about delirium symptoms and its reversible nature to avoid interpreting the onset of delirium as a new stage of progressive dementia