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