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