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
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 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
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
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
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
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
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
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
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 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
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
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
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
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
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