Module 5: Mental Health in the Aging Individual and Neurocognitive Disorders
Perspectives on Aging and the Growing Older Population
Relativity of Aging: Supreme Court Justice Oliver Wendell Holmes, Jr. (retired at 91) famously stated, ‐Old is fifteen years older than I am,‐ highlighting that ‐old‐ is subjective to the individual.
Cultural Context: American culture has historically been youth-oriented, making the prospect of aging undesirable for many.
Demographic Shift: By the year 2030, an estimated 66 million baby boomers will have reached their 65th birthday, shifting societal focus to the needs of the elderly.
Emerging Disciplines:
Gerontology: The study of the aging process.
Geriatrics: The branch of clinical medicine specializing in problems of the older adult.
Geropsychiatry: The branch of clinical medicine focused on psychiatric disorders in older adults.
Historical Longevity:
Prehistoric life span was approximately 40 years, with an average living age of 18.
Mortality remained high due to famine and malnutrition until the mid-17th century.
Factors increasing longevity: Assured food supply, improved production, better housing, progressive medical facilities, and sanitation.
Current Statistics:
1900: Average life expectancy was 47 years; only 4% of the population was 65 or older.
2020: Average life expectancy is 77 years (a decrease of 1.8 years from 2019).
Classifying the Aging Individual
U.S. Census Bureau Classification:
Older: 55 through 64 years.
Elderly: 65 through 74 years.
Aged: 75 through 84 years.
Very old: 85 years and older.
Alternative (Simpler) Classification:
Young old: 60 through 74 years.
Middle old: 75 through 84 years.
Old old: 85 years and older.
Mental Health Keys (WHO 2017): Over 20% of adults over 60 have a mental or neurological disorder. Essential factors for mental health include security, freedom, adequate housing, social support, elder abuse prevention, and the availability of health/social programs.
Pandemic Impact: The WHO (2022) estimates common mental disorders like depression and anxiety increased by 25% since COVID-19 began.
Epidemiology and Socioeconomic Factors of the Elderly
Population Growth:
1980: 25.5 million adults aged 65+.
2017: 54.1 million.
2060 projection: 94.7 million.
Centenarians (100+): 100,322 in 2019 (tripled since 1980).
Marital Status: 70% of men vs. 48% of women aged 65+ were married in 2020. There are three times as many widows as widowers.
Living Arrangements:
27% of older adults live alone; 42% of women over 75 live alone.
In 2019, 1.1 million grandparents aged 60+ were responsible for grandchildren under 18.
Nursing home residency remains a small portion: 1% for ages 65–74, rising to 8% for ages 85+.
Economic Status:
8.9% live below the poverty level (adjusted to 12.8% when accounting for medical out-of-pocket expenses).
Highest poverty rates: Hispanic women living alone (32.1%) and African American women living alone (31.7%).
Employment: The Age Discrimination in Employment Act (1967) makes forced retirement or age discrimination illegal for those over 40. In 2020, 10.6 million Americans aged 65+ (19.4%) were in the labor force.
Health Status: Most adults 65+ have at least one chronic illness. Prevalence order: Hypertension, arthritis, heart disease, diabetes, cancer, stroke.
Theories of Aging
Biological Theories
Genetic Theory: Life span is predetermined. Supported by identical twin studies.
Epigenetics/DNA Methylation: DNA methylation drift in aging stem cells reduces plasticity and promotes chronic inflammation.
Wear-and-Tear Theory: The body wears out on a schedule. Free radicals (waste products of metabolism with unpaired electrons) cause DNA damage and accumulation of age pigments.
Environmental Theory: Secondary aging factors include carcinogens, sunlight, trauma, and infection.
Autoimmune Theory: Decline in immune function results in susceptibility to infection and the body attacking its own tissues (e.g., rheumatoid arthritis).
Neuroendocrine Theory: Hypothalamic ability to regulate hormones decreases. Hypotheses include reduced serotonin, pineal gland decline, and chronically elevated cortisol levels due to stress.
Psychosocial Theories
Successful Aging (Rowe and Kahn): (a) absence of disease/disability, (b) maintaining physical/mental function, (c) active engagement in life.
Personality Theory: Traits like conscientiousness are stable and protective against health issues and dementia.
Developmental Task Theory (Erikson):
Primary task: Ego Integrity vs. Despair.
Transcendence: A shift from a rational/materialistic view to a wider worldview, increasing meaning and well-being.
Disengagement Theory: Proposes a systematic, inevitable withdrawal from society. Often criticized as undesirable by healthy elders.
Activity Theory: Direct opposition to disengagement; success requires staying active.
Continuity Theory: Adjustment is predicted by previously established coping styles and character traits. Internal continuity preserves self-esteem.
Normal Biological Aging Process
Integumentary System: Loss of elastin and collagen (wrinkling/sagging); loss of subcutaneous fat cushions; sensitivity to temperature extremes; slower wound healing.
Cardiovascular System: Modest hypertrophy; loss of pacemaker cells; decreased maximal heart rate and cardiac output. Diminished blood flow to brain, kidneys, and muscles.
Respiratory System: Diminished thoracic expansion; increased fibrous tissue; loss of elastin; increased residual air. Reduced cough and laryngeal reflexes.
Musculoskeletal System: Loss of muscle mass (slower in men). Demineralization of bone at per year ( in menopausal women). Thinning muscle fibers and lost glycogen storage.
Gastrointestinal System: Loss of dentine and root pulp; gingival retraction. Decreased gastric acid and intrinsic factor ( malabsorption). Slower motility in the large intestine leads to constipation.
Endocrine System: Lowered basal metabolic rate due to decreased thyroid hormones. Impaired glucose tolerance and peripheral insulin resistance.
Genitourinary System: Nephron attrition and sclerosis in glomeruli. Enlargement of the prostate in men; loss of sphincter control in women.
Immune System: Thymus gland decreases to of original size by age 50. Susceptibility to cancer and autoimmune disorders like rheumatoid arthritis increases.
Nervous System: Loss of gray matter volume, cortical thinning, and reduced white matter integrity. Reduction in N-acetyl-aspartate () and increased myo-inositol ().
Sensory Changes in Aging
Vision:
Presbyopia: Blurred near vision due to loss of crystalline lens elasticity.
Cataracts: Lens becomes opaque as proteins lump together.
Faded iris, irregular pupils, constricted pupils (requiring more light), and decreased lacrimal secretions (dryness).
Hearing:
Presbycusis: Age-related hearing loss affecting sound discrimination, especially high-frequency sounds. Affects over half of adults by age 75.
Taste and Smell: Decline after age 70 due to taste bud atrophy. Bitter taste predominates; sweet/salty sensitivity diminishes. Olfactory nerve ending loss.
Touch and Pain: Sensitivity declines due to decreased blood flow to nerve endings or the spinal cord.
Psychological and Psychiatric Aspects of Aging
Memory Functioning: Short-term memory (recall of recent info) deteriorates; long-term memory (remote info) remains stable. Time required for memory scanning increases.
Intellectual Functioning:
Crystallized abilities: Wisdom/knowledge from education; stable or increased.
Fluid abilities: Solving novel problems; decline gradually.
Loss and Grief: Cumulative loss can lead to Bereavement Overload, a predisposition to depression.
Death Anxiety: Lower in those with meaning in life and high self-esteem. Interventions like Cognitive Behavior Therapy () are effective.
Depression: Prevalence is to generally, but up to in hospitalized elders.
Pseudodementia: Somatic symptoms of depression mimicking neurocognitive disorders ().
Medication risks: Tricyclic antidepressants (orthostatic hypotension) and SSRIs (hyponatremia).
Suicide: Men aged 65+ have the highest overall rate. Risk factors: isolation, loss, illness, and financial problems.
Psychotic Disorders: Late-onset Schizophrenia (after age 60) is rare, more common in women, and characterized by paranoid delusions.
Substance Use: Opioid misuse and alcohol are underdiagnosed. Alcohol withdrawal is a primary cause of sudden-onset delirium in hospitalized elders.
Wernicke’s encephalopathy and Korsakoff syndrome are associated with chronic alcohol dependence.
Elder Abuse and Neglect
Definitions:
Psychological: Yelling, threats, social isolation.
Physical: Shoving, beating, restraints.
Financial: Misuse of property or assets.
Neglect: Failure to fulfill physical needs (intentional or unintentional).
Sexual: Non-consensual sexual activity.
Prevalence: 1 in 10 older adults are victims; only 1 in 24 cases are reported. Abusers are most often relatives/caregivers living with the victim.
Victim Indicators:
Psychological: Depressed, withdrawn, agitated.
Physical: Unexplained bruises, fractures, burns.
Neglect: Weight loss, poor hygiene, listlessness.
Financial: Disparity between assets and living conditions.
Mandatory Reporting: Health-care workers are legally responsible for reporting suspected abuse. Competent elders have the right to return to abusive situations if they choose.
Core Concepts of Delirium
Definition: An acute disturbance of cognition involving short-term confusion, excitement, disorientation, and clouded consciousness.
Symptoms: Distractibility, rambling/pressured speech, impaired reasoning, illusions (misperceptions), and hallucinations (false perceptions).
Awareness states: Ranges from hypervigilance to stupor/semi-coma.
Course: Usually abrupt (head injury/seizure) or preceded by prodromal symptoms (restlessness, clear thinking difficulty). Duration is typically brief (1 week to 1 month).
Predisposing Factors:
Serious medical conditions: Febrile illness, hypoxia, hepatic/renal failure.
Metabolic: Electrolyte imbalances (, ), hypercarbia.
Medications: Anticholinergics, antihypertensives, anticonvulsants, cardiac glycosides, -receptor antagonists.
Neurocognitive Disorders (NCDs)
Classification: Mild NCD (formerly Mild Cognitive Impairment) vs. Major NCD (formerly Dementia).
Epidemiology: 6.5 million in the U.S. have Alzheimer’s Disease (). Affects of those aged 85+.
Alzheimer’s Disease Stages:
Stage 1: Preclinical . No apparent symptoms; brain changes detectable via scan/ analysis.
Stage 2: due to . Subtle memory loss noticeable by family; does not yet interfere with daily life.
Stage 3: Mild dementia due to . Assistance required for challenging tasks; confabulation used to hide gaps.
Stage 4: Moderate dementia. Longest stage; agitation, suspicion, difficulty with multistep tasks, sundowning.
Stage 5: Severe dementia. Assistance with nutrition/safety 24 hours/day; loss of communication; bed-bound.
Etiology/Predisposing Factors for AD:
Acetylcholine deficiency: Enzyme required to produce it is reduced.
Plaques and Tangles: Amyloid-beta () plaques and Tau protein tangles destroy neurons.
Genetics: Mutations on chromosomes 1, 14, and 21; gene presence.
Inflammation: Dysregulated Interleukin-6 signaling.
Specific Subtypes of NCDs
Vascular NCD: Caused by cerebrovascular disease (strokes/infarcts). Has an abrupt onset and ‐step‐ downward progression.
Frontotemporal NCD: Shrinking of frontal/temporal lobes (Pick’s disease). Behavioral/personality changes or speech/language problems.
NCD due to Lewy Body Disease: Rapidly progressive; early visual hallucinations and parkinsonian features. Highly sensitive to antipsychotic side effects.
NCD due to Parkinson’s: Involuntary movements, rigidity, and tremors with cognitive decline in of cases.
NCD due to HIV: Cognitive/motor complex. HAART therapy has reduced incidence.
NCD due to Huntington’s: Caused by DNA error in the huntingtin gene affecting the striatum. Characterized by ataxia (incoordination) and profound cognitive decline. Usually occurs between ages 30–50.
NCD due to Prion Disease: Caused by infectious prions (e.g., Creutzfeldt-Jakob’s). Rapid course (death < 2 years).
Medical Treatment and Nursing Interventions
AD Medications:
Cholinesterase Inhibitors: Donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Razadyne). (Inhibit degradation).
NMDA Receptor Antagonists: Memantine (Namenda). (Blocks excess glutamate, preventing calcium influx).
Monoclonal Antibody: Aducanumab (Aduhelm). (Targets amyloid plaques; risk of amyloid-related imaging abnormalities []).
Agitation Management:
Antipsychotics: Risperidone, Quetiapine. Boxed Warnings: Increased mortality risk in elderly with -related psychosis.
Non-pharmacological: WHELD Program (person-centered care, exercise, social interaction).
Validation Therapy: Acknowledge feelings rather than strictly reorienting (Box 22–4).
Specific Interventions:
Reminiscence Therapy: Reflection on the past to promote self-esteem.
Wandering: Keep individuals on a structured schedule; provide enclosed pacing areas; use electronic exits.
Delirium Treatment: Determine/treat underlying cause; use low-dose antipsychotics or Benzodiazepines (for withdrawal only); Melatonin/Ramelteon.
Nursing Primary Diagnoses: Risk for Trauma, Disturbed Thought Processes, Self-Care Deficit, Impaired Verbal Communication.