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Chapter Eighteen: Disorders of Aging and Cognition

  • Old Age and Stress

    • Old Age: Years past age 65

    • Overall population of the elderly is on the rise

    • Older women outnumber older men by almost 3 to 2

    • People become more prone to illness and injury as they age

      • About half of adults 65+ have two or three chronic illnesses

      • 15% have four+ chronic illnesses

      • At least half of elderly people have some measure of insomnia or other sleep problems

    • Geropsychology: The field of psychology concerned with the mental health of elderly people

Depression in Later Life

  • One of the most common mental health problems of older adults

  • Features are the same for elderly people as for younger people

  • Particularly common among those who’ve recently undergone a trauma

  • As many as 20% of people become depressed at some point during old age

  • Rate is highest in older women

  • Rate climbs much higher among aged people who live in nursing homes

  • Depression raises an elderly person’s chances of developing significant medical problems

    • Older depressed people with high blood pressure at almost three times more likely to suffer a stroke

    • Older depressed people recover more slowly and less completely

  • Elderly people are more likely to die from suicide than young people, and often their suicides are related to depression

  • CBT, interpersonal psychotherapy, antidepressants, ECT, or a combo

  • Body breaks down drugs differently later in life, making it difficult for older people to use antidepressants effectively

  • Among elderly people, antidepressants have a higher risk of causing some cognitive impairment

Anxiety Disorders in Later Life

  • Anxiety is common among elderly people

  • Prevalence of anxiety increases throughout old age

  • Anxiety in the elderly tends to be underreported

    • May misinterpret physical symptoms of anxiety as symptoms of a medical condition

  • Older people who have significant medical illnesses or injuries report more anxiety than those who are healthy or injury-free

  • Psychotherapy, CBT, anti-anxiety meds, serotonin-enhancing antidepressants

Substance Misuse in Later Life

  • Prevalence of substance use disorders declines after age 65

  • Majority of older adults don’t misuse alcohol or other substances

  • Older patients who are institutionalized display high rates of problem drinking

  • Late-onset Alcoholism: When alcohol use disorders begin in a person's 50s or 60s

    • Typically begins abusive drinking as a reaction to the negative events and pressures of growing older

  • Misuse of prescription drugs

    • Often intentional

    • At any given time, elderly people are taking 3-5 prescription drugs and 2 over-the-counter drug

    • Physicians and pharmacists often try to simplify medications, educate older patients about their prescriptions, and clarify directions

  • Misuse of powerful medications at nursing homes

    • Antipsychotic drugs are currently being given to almost 30% of the total nursing home population in the US

    • Used to sedate and manage patients

    • 17% of new nursing home patients who’ve never before taken an antipsychotic are administered such drugs within 100 days of admission

Psychotic Disorders in Later Life

  • Elderly people have a higher rate of psychotic symptoms than younger people

  • Usually caused by underlying medical conditions

  • Schizophrenia

    • Schizophrenia is less common in older people than in younger ones

    • Many people with schizophrenia find that their symptoms lesson in later life

    • It is uncommon for new cases of schizophrenia to emerge in late life

    • Some elderly people with schizophrenia have been untreated for years and continue to be untreated when they’re elderly

  • Delusional Disorder: A kind of psychotic disorder in which people develop beliefs that are false but not bizarre

    • Prevalence increases in the elderly population

    • Rise may be related to

      • Deficiencies in hearing

      • Social isolation

      • Greater stress

      • Heightened poverty

Disorders of Cognition

Delirium

  • Delirium: A major disturbance in attention and orientation to the environment

  • Makes it very difficult to concentrate and think in a clear and organized manner

  • Typically develops over a short period of time

  • May occur in any age group, but is most common in elderly people

  • When elderly people enter a hospital, 10% show the symptoms right away, and 10-20% develop delirium during their stay

  • Causes: fever, disease, infection, poor nutrition, head injury, stroke, stress, intoxication

  • Admission doctors detected only 1 of 15 cases of delirium - contributes to a high death rate for older people with delirium

Alzheimer’s Disease and Other Neurocognitive Disorders

  • Neurocognitive Disorder: A disorder marked by a significant decline in at least one area of cognitive functioning

    • Major Neurocognitive Disorder: When the decline in cognitive functioning is substantial and interferes with a person’s ability to be independent

    • Mild Neurocognitive Disorder: When the decline in cognitive functioning is modest and doesn’t interfere with a person’s ability to be independent

  • Alzheimer’s disease: The most common type of neurocognitive disorder, usually occurring after the age of 65, marked most prominently by memory impairment

    • Early onset: When Alzheimer’s disease appears in middle age

    • Late onset: When Alzheimer’s disease appears after the age of 65

    • 11% of all people over 65 have Alzheimer’s

    • African Americans and Hispanic Americans are twice as likely to develop this disease

    • Gradually progressive disease in which memory impairment is the most prominent cognitive dysfunction

    • Time between onset and death is typically 3-8 yrs

    • Usually begins with mild memory problems, lapses of attention, and difficulties in language and communication

    • 17% develop major depressive disorder

    • Usually remain in fairly good health until the later stages of the disease

    • Responsible for almost 94,000 deaths each year in the US

    • 6th leading cause of death in the country

    • 3rd leading cause of death in the elderly

    • Can only be diagnosed with certainty after death, when structural changes in the person’s brain can be examined

      • Senile Plaques: Sphere-shaped deposits of beta-amyloid protein that form in the spaces between certain neurons and in certain blood vessels of the brain as people age

        • Exceptionally high in people with Alzheimer’s

      • Neurofibrillary Tangles: Twisted protein fibers found within the neurons of the hippocampus and certain other brain structures

        • Extraordinary among in people with Alzheimer’s

  • Genetic Causes

    • Many plaques formed by the beta-amyloid proteins also causes tau proteins within neurons to start breaking down, resulting in tangles and the death of many neurons

      • Abnormal activity by the beta-amyloid protein causes the repeated formation of plaques

      • Abnormal activity by the tau protein causes the excessive formation of tangles

    • Early-Onset Alzheimer’s

      • Caused by abnormalities in genes responsible for the production of the beta-amyloid precursor protein and the presenilin protein

      • Some families transmit mutations of one or both genes

        • Leads to abnormal amyloid-protein buildups

        • Leads to plaque formations

    • Late-Onset Alzheimer’s

      • Doesn’t typically run in families

      • Results from a combination of genetic, environmental, and lifestyle factors

      • ApoE gene

        • Located on chromosome 19

        • Normally responsible for the production of a protein that helps carry various fats into the bloodstream

      • ApoE-4 gene

        • 30% of the population

        • Promotes the excessive formation of beta-amyloid proteins

        • Makes people particularly vulnerable to the development of Alzheimer’s disease

        • Not everyone with this form of the gene develops the disease

    • Alternative Genetic Theory

      • Abnormal tau protein activity is not always the result of these abnormal beta-amyloid protein buildups

      • Multiple genetic causes for the formation of numerous tangle formations

        • Gene forms that promote beta-amyloid protein formations and plaques

        • Gene forms that more directly promote tau protein abnormalities and tangle formations

  • Brain Structure and Biochemical Changes

    • Prefrontal Cortex: Part of the brain that enables humans to hold info temporarily and continue working with the info as long as it’s needed

    • Temporal lobes and diencephalon help in transforming short-term memory into long-term memory

    • Deficient activity levels of certain brain chemicals can prevent the formation of memories

  • Other Explanations

    • High levels of zinc in the brains of some Alzheimer’s patients

    • Lead may contribute to the development of Alzheimer’s

    • Autoimmune Theory: Changes in aging brain cells may trigger an autoimmune response that helps lead to the disease

    • Viral Theory: A virus may cause Alzheimer’s, especially in cases of particularly fast-moving forms

  • Assessing and Predicting Alzheimer’s

    • Diagnosticians are usually able to build a very strong circumstantial case and arrive at an accurate diagnosis

    • Biomarkers: Biochemical, molecular, genetic, or structural characteristics that usually accompany a disease

      • Large number of beta-amyloid proteins

      • Large number of tau proteins

    • Many biomarkers appear in the brain long before the obvious onset of the disease

    • Certain combinations of biomarkers can predict cases of Alzheimer’s

  • Other Types of Neurocognitive Disorders

    • Vascular Neurocognitive Disorder: Blood flow to specific areas of the brain is cut off after a stroke, damaging the areas

      • Progressive

      • Symptoms begin suddenly rather than gradually

      • Cognitive functioning may continue to be normal in areas of the brain not affected by the stroke

    • Frontotemporal neurocognitive disorder: Rare disorder that affects the frontal and temporal lobes

    • Neurocognitive disorder due to prion disease

      • Caused by a slow-acting virus that may live in the body for years before the disease develops

      • Symptoms that include spasms of the body

      • Rapid course once launched

    • Neurocognitive disorder due to Huntington’s disease

      • Inherited progressive disease in which memory problems, personality changes, and mood difficulties worsen over time

      • Movement problems - severe twitching and spasms

      • Children of ppl with Huntington’s have a 50% chance of developing it

    • Parkinson’s disease: Slowly progressive neurological disorder marked by tremors, rigidity, and unsteadiness

      • Can result in neurocognitive disorder due to Parkinson’s disease

      • Similar to neurocognitive disorder due to Lewy body disease

        • Involves the buildup of clumps of protein deposits

        • Progressive cognitive problems

        • Significant movement difficulties, visual hallucinations, and sleep disturbances

        • Second most common neurocognitive disorder

    • Other neurocognitive disorder causes

      • HIV infections

      • Traumatic brain injuries

      • Substance abuse

      • Various medical conditions

        • Meningitis

        • Advanced syphilis

  • Treatments

    • Drug Treatment

      • Designed to affect acetylcholine and glutamate, the neurotransmitters that play important roles in memory

      • Short-term memory and reasoning ability improves slightly

      • Benefits of drugs are limited and their side effects can be problematic

      • Greatest use to ppl in the early, mild stage of Alzheimer’s

      • Vitamin E will may slow down some cognitive difficulties

      • Drugs for preventing or delaying the onset of Alzheimer’s

        • Estrogen after menopause

        • Nonsteroidal anti-inflammatory drugs (ex: ibuprofen, Advil)

    • Cognitive-Behavioral Techniques

      • Cognitive activities sometimes help prevent or delay the onset of Alzheimer’s disease

      • Cognitive-behavioral strategies that focus primarily on behaviors rather than on cognitions seem to be even more useful

        • Physical exercise helps improve cognitive functioning

        • Regular physical exercise may reduce the risk of developing Alzheimer’s and other neurocognitive disorders

      • Behavior-focused interventions

        • Changing everyday patient behaviors that are stressful for the family

        • Teaches family members how and when to use reinforcement in order to shape more positive behaviors

    • Support for Caregivers

      • 90% of all people with Alzheimer’s are cared for by their relatives

      • Caregivers are overwhelmed and burnt out

      • One of the most important aspects of treating Alzheimer’s is to focus on the emotional needs of the caregivers

    • Sociocultural Approaches

      • Day-care facilities

        • Provides treatment programs and activities for outpatients during the day

        • Returns patients to their homes and families at night

      • Assisted living facilities

        • Live in cheerful apartments

        • Receive needed supervision

      • Tracking beacons to help locate patients who may wander off

Issues Affecting the Mental Health of the Elderly

  • Discrimination based on race and ethnicity

    • To be old and a member of a minority group is a kind of double jeopardy

    • Older women in minority groups are a triple jeopardy

    • Clinicians must take into account their older patients’ race, ethnicity, and gender as they try to diagnose and treat their mental health problems

    • Language barriers

    • Cultural beliefs

  • Long-term care

    • Quality of care in these residences varies widely

    • Older adults live in fear of being “put away”

    • Worry about the cost of long-term care facilities

    • Most health insurance plans available today don’t cover the costs of long-term or permanent placement

  • Health-maintenance / Wellness Promotion Approach

    • Current generation of young people should do things that promote physical and mental health

    • Older adults will adapt more readily to changes and negative events if their physical and psychological health is good

Chapter Eighteen: Disorders of Aging and Cognition

  • Old Age and Stress

    • Old Age: Years past age 65

    • Overall population of the elderly is on the rise

    • Older women outnumber older men by almost 3 to 2

    • People become more prone to illness and injury as they age

      • About half of adults 65+ have two or three chronic illnesses

      • 15% have four+ chronic illnesses

      • At least half of elderly people have some measure of insomnia or other sleep problems

    • Geropsychology: The field of psychology concerned with the mental health of elderly people

Depression in Later Life

  • One of the most common mental health problems of older adults

  • Features are the same for elderly people as for younger people

  • Particularly common among those who’ve recently undergone a trauma

  • As many as 20% of people become depressed at some point during old age

  • Rate is highest in older women

  • Rate climbs much higher among aged people who live in nursing homes

  • Depression raises an elderly person’s chances of developing significant medical problems

    • Older depressed people with high blood pressure at almost three times more likely to suffer a stroke

    • Older depressed people recover more slowly and less completely

  • Elderly people are more likely to die from suicide than young people, and often their suicides are related to depression

  • CBT, interpersonal psychotherapy, antidepressants, ECT, or a combo

  • Body breaks down drugs differently later in life, making it difficult for older people to use antidepressants effectively

  • Among elderly people, antidepressants have a higher risk of causing some cognitive impairment

Anxiety Disorders in Later Life

  • Anxiety is common among elderly people

  • Prevalence of anxiety increases throughout old age

  • Anxiety in the elderly tends to be underreported

    • May misinterpret physical symptoms of anxiety as symptoms of a medical condition

  • Older people who have significant medical illnesses or injuries report more anxiety than those who are healthy or injury-free

  • Psychotherapy, CBT, anti-anxiety meds, serotonin-enhancing antidepressants

Substance Misuse in Later Life

  • Prevalence of substance use disorders declines after age 65

  • Majority of older adults don’t misuse alcohol or other substances

  • Older patients who are institutionalized display high rates of problem drinking

  • Late-onset Alcoholism: When alcohol use disorders begin in a person's 50s or 60s

    • Typically begins abusive drinking as a reaction to the negative events and pressures of growing older

  • Misuse of prescription drugs

    • Often intentional

    • At any given time, elderly people are taking 3-5 prescription drugs and 2 over-the-counter drug

    • Physicians and pharmacists often try to simplify medications, educate older patients about their prescriptions, and clarify directions

  • Misuse of powerful medications at nursing homes

    • Antipsychotic drugs are currently being given to almost 30% of the total nursing home population in the US

    • Used to sedate and manage patients

    • 17% of new nursing home patients who’ve never before taken an antipsychotic are administered such drugs within 100 days of admission

Psychotic Disorders in Later Life

  • Elderly people have a higher rate of psychotic symptoms than younger people

  • Usually caused by underlying medical conditions

  • Schizophrenia

    • Schizophrenia is less common in older people than in younger ones

    • Many people with schizophrenia find that their symptoms lesson in later life

    • It is uncommon for new cases of schizophrenia to emerge in late life

    • Some elderly people with schizophrenia have been untreated for years and continue to be untreated when they’re elderly

  • Delusional Disorder: A kind of psychotic disorder in which people develop beliefs that are false but not bizarre

    • Prevalence increases in the elderly population

    • Rise may be related to

      • Deficiencies in hearing

      • Social isolation

      • Greater stress

      • Heightened poverty

Disorders of Cognition

Delirium

  • Delirium: A major disturbance in attention and orientation to the environment

  • Makes it very difficult to concentrate and think in a clear and organized manner

  • Typically develops over a short period of time

  • May occur in any age group, but is most common in elderly people

  • When elderly people enter a hospital, 10% show the symptoms right away, and 10-20% develop delirium during their stay

  • Causes: fever, disease, infection, poor nutrition, head injury, stroke, stress, intoxication

  • Admission doctors detected only 1 of 15 cases of delirium - contributes to a high death rate for older people with delirium

Alzheimer’s Disease and Other Neurocognitive Disorders

  • Neurocognitive Disorder: A disorder marked by a significant decline in at least one area of cognitive functioning

    • Major Neurocognitive Disorder: When the decline in cognitive functioning is substantial and interferes with a person’s ability to be independent

    • Mild Neurocognitive Disorder: When the decline in cognitive functioning is modest and doesn’t interfere with a person’s ability to be independent

  • Alzheimer’s disease: The most common type of neurocognitive disorder, usually occurring after the age of 65, marked most prominently by memory impairment

    • Early onset: When Alzheimer’s disease appears in middle age

    • Late onset: When Alzheimer’s disease appears after the age of 65

    • 11% of all people over 65 have Alzheimer’s

    • African Americans and Hispanic Americans are twice as likely to develop this disease

    • Gradually progressive disease in which memory impairment is the most prominent cognitive dysfunction

    • Time between onset and death is typically 3-8 yrs

    • Usually begins with mild memory problems, lapses of attention, and difficulties in language and communication

    • 17% develop major depressive disorder

    • Usually remain in fairly good health until the later stages of the disease

    • Responsible for almost 94,000 deaths each year in the US

    • 6th leading cause of death in the country

    • 3rd leading cause of death in the elderly

    • Can only be diagnosed with certainty after death, when structural changes in the person’s brain can be examined

      • Senile Plaques: Sphere-shaped deposits of beta-amyloid protein that form in the spaces between certain neurons and in certain blood vessels of the brain as people age

        • Exceptionally high in people with Alzheimer’s

      • Neurofibrillary Tangles: Twisted protein fibers found within the neurons of the hippocampus and certain other brain structures

        • Extraordinary among in people with Alzheimer’s

  • Genetic Causes

    • Many plaques formed by the beta-amyloid proteins also causes tau proteins within neurons to start breaking down, resulting in tangles and the death of many neurons

      • Abnormal activity by the beta-amyloid protein causes the repeated formation of plaques

      • Abnormal activity by the tau protein causes the excessive formation of tangles

    • Early-Onset Alzheimer’s

      • Caused by abnormalities in genes responsible for the production of the beta-amyloid precursor protein and the presenilin protein

      • Some families transmit mutations of one or both genes

        • Leads to abnormal amyloid-protein buildups

        • Leads to plaque formations

    • Late-Onset Alzheimer’s

      • Doesn’t typically run in families

      • Results from a combination of genetic, environmental, and lifestyle factors

      • ApoE gene

        • Located on chromosome 19

        • Normally responsible for the production of a protein that helps carry various fats into the bloodstream

      • ApoE-4 gene

        • 30% of the population

        • Promotes the excessive formation of beta-amyloid proteins

        • Makes people particularly vulnerable to the development of Alzheimer’s disease

        • Not everyone with this form of the gene develops the disease

    • Alternative Genetic Theory

      • Abnormal tau protein activity is not always the result of these abnormal beta-amyloid protein buildups

      • Multiple genetic causes for the formation of numerous tangle formations

        • Gene forms that promote beta-amyloid protein formations and plaques

        • Gene forms that more directly promote tau protein abnormalities and tangle formations

  • Brain Structure and Biochemical Changes

    • Prefrontal Cortex: Part of the brain that enables humans to hold info temporarily and continue working with the info as long as it’s needed

    • Temporal lobes and diencephalon help in transforming short-term memory into long-term memory

    • Deficient activity levels of certain brain chemicals can prevent the formation of memories

  • Other Explanations

    • High levels of zinc in the brains of some Alzheimer’s patients

    • Lead may contribute to the development of Alzheimer’s

    • Autoimmune Theory: Changes in aging brain cells may trigger an autoimmune response that helps lead to the disease

    • Viral Theory: A virus may cause Alzheimer’s, especially in cases of particularly fast-moving forms

  • Assessing and Predicting Alzheimer’s

    • Diagnosticians are usually able to build a very strong circumstantial case and arrive at an accurate diagnosis

    • Biomarkers: Biochemical, molecular, genetic, or structural characteristics that usually accompany a disease

      • Large number of beta-amyloid proteins

      • Large number of tau proteins

    • Many biomarkers appear in the brain long before the obvious onset of the disease

    • Certain combinations of biomarkers can predict cases of Alzheimer’s

  • Other Types of Neurocognitive Disorders

    • Vascular Neurocognitive Disorder: Blood flow to specific areas of the brain is cut off after a stroke, damaging the areas

      • Progressive

      • Symptoms begin suddenly rather than gradually

      • Cognitive functioning may continue to be normal in areas of the brain not affected by the stroke

    • Frontotemporal neurocognitive disorder: Rare disorder that affects the frontal and temporal lobes

    • Neurocognitive disorder due to prion disease

      • Caused by a slow-acting virus that may live in the body for years before the disease develops

      • Symptoms that include spasms of the body

      • Rapid course once launched

    • Neurocognitive disorder due to Huntington’s disease

      • Inherited progressive disease in which memory problems, personality changes, and mood difficulties worsen over time

      • Movement problems - severe twitching and spasms

      • Children of ppl with Huntington’s have a 50% chance of developing it

    • Parkinson’s disease: Slowly progressive neurological disorder marked by tremors, rigidity, and unsteadiness

      • Can result in neurocognitive disorder due to Parkinson’s disease

      • Similar to neurocognitive disorder due to Lewy body disease

        • Involves the buildup of clumps of protein deposits

        • Progressive cognitive problems

        • Significant movement difficulties, visual hallucinations, and sleep disturbances

        • Second most common neurocognitive disorder

    • Other neurocognitive disorder causes

      • HIV infections

      • Traumatic brain injuries

      • Substance abuse

      • Various medical conditions

        • Meningitis

        • Advanced syphilis

  • Treatments

    • Drug Treatment

      • Designed to affect acetylcholine and glutamate, the neurotransmitters that play important roles in memory

      • Short-term memory and reasoning ability improves slightly

      • Benefits of drugs are limited and their side effects can be problematic

      • Greatest use to ppl in the early, mild stage of Alzheimer’s

      • Vitamin E will may slow down some cognitive difficulties

      • Drugs for preventing or delaying the onset of Alzheimer’s

        • Estrogen after menopause

        • Nonsteroidal anti-inflammatory drugs (ex: ibuprofen, Advil)

    • Cognitive-Behavioral Techniques

      • Cognitive activities sometimes help prevent or delay the onset of Alzheimer’s disease

      • Cognitive-behavioral strategies that focus primarily on behaviors rather than on cognitions seem to be even more useful

        • Physical exercise helps improve cognitive functioning

        • Regular physical exercise may reduce the risk of developing Alzheimer’s and other neurocognitive disorders

      • Behavior-focused interventions

        • Changing everyday patient behaviors that are stressful for the family

        • Teaches family members how and when to use reinforcement in order to shape more positive behaviors

    • Support for Caregivers

      • 90% of all people with Alzheimer’s are cared for by their relatives

      • Caregivers are overwhelmed and burnt out

      • One of the most important aspects of treating Alzheimer’s is to focus on the emotional needs of the caregivers

    • Sociocultural Approaches

      • Day-care facilities

        • Provides treatment programs and activities for outpatients during the day

        • Returns patients to their homes and families at night

      • Assisted living facilities

        • Live in cheerful apartments

        • Receive needed supervision

      • Tracking beacons to help locate patients who may wander off

Issues Affecting the Mental Health of the Elderly

  • Discrimination based on race and ethnicity

    • To be old and a member of a minority group is a kind of double jeopardy

    • Older women in minority groups are a triple jeopardy

    • Clinicians must take into account their older patients’ race, ethnicity, and gender as they try to diagnose and treat their mental health problems

    • Language barriers

    • Cultural beliefs

  • Long-term care

    • Quality of care in these residences varies widely

    • Older adults live in fear of being “put away”

    • Worry about the cost of long-term care facilities

    • Most health insurance plans available today don’t cover the costs of long-term or permanent placement

  • Health-maintenance / Wellness Promotion Approach

    • Current generation of young people should do things that promote physical and mental health

    • Older adults will adapt more readily to changes and negative events if their physical and psychological health is good

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