• 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