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Abnormal_Chapter 16.docx

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Konstantine Zakzanis

Chapter 16: Aging and Psychological Disorders  Subjective age bias: the tendency by most people (including older adults) to report that they feel younger than they actually are  Indicates the presence of negative aging stereotypes  Younger subjective age usually linked with greater life satisfaction and positive outcomes  Ageism: discrimination against any person, young or old, based on chronological age  Especially severe for women due to devalued nature of aging for women in society  Popular misconceptions that intellectual deterioration is prevalent and inevitable, depression among old people is widespread, and loss of sexual function is a lost cause  Even family physicians feel less prepared to identify older patients with psychological problems than younger patients with them  Old defined as those over the age of 65 (set by social policies, not because it is a critical point at which aging begins)  Young-old → 65 to 74  Old-old → 75 to 84  Growing at a rate of 3.5% in Canada compared to general growth of 1%  Oldest-old → 85+  Projections that by 2050, 21% of the world will be 60+ Issues, Concepts, and Methods in the Study of Older Adults  Age Effects: the consequence of being a given chronological age  Ex: Jewish bar mitzvah for 13 year old boys  Cohort Effects: consequences of having been born in a given year and having grown up during a particular time period with its own unique pressures, problems , challenges, and opportunities  Time-of-measurement Effects: confounds that arise because events at an exact point in time cane have a specific effect on a variable being studied over time  Ex: People in the 90s probably respond to surveys about sexual behaviour more easily than people from 50s where public discuss of sex was more conservative  Two Major research designs  Cross-sectional Studies: investigation compares different age groups at the same moment in time on the variable of interest  Do not examine the same people over time  Allow us to make statements only about age effects in a particular study or experiment → not about age changes over time  Longitudinal Studies: selection of one cohort and periodically retest it using the same measure over a number of years  Allows researchers to trace individual paterns of consistency (cohort effects) Chapter 16: Aging and Psychological Disorders  Can analyze how behaviour in early life relates to behaviour in old age  Conclusions drawn will be restricted to the cohort chosen  Selective mortality → participants often drop out as studies proceed (bias) o Least-able people more likely to drop out and will leave a non- representative group of people who are usually healthier than general  Nature and manifestation of mental disorders usually assumed to be the same in adulthood and old age  Symptoms in older adults can either mean regular physical changes or the sign of a disorder  Ex: somatic symptoms are more prevalent in later life, but can also by symptoms of depression  Measure of cognitive functioning often included as standard practice to determine if elderly respondent has experienced declines in cognitive ability  Use of the Mini-Mental State Examination  Brief measure of an individual’s cognitive state  Clock Test suitable for elderly people who have diminished attention span  Put the numbers of a clock on a circle and drawing the hand placement for 11:10  Geriatric Depression Scale → tailored for the elderly  Regarded as the standard measure for assessing depression in the elderly  Geriatric Suicide Ideation Scale  Higher scores were associated with depression and health problems and lower scores in various domains of well-being, including positive relations with others and self- acceptance Old Age and Brain Disorders  Dementia :  Senility  General descriptive term for gradual deterioration of intellectual abilities to the point that social and occupational functions are impaired  Difficulty remembering things, especially recent events  Leave tasks unfinished because they forget to return to them after an interruption  Poor hygiene, appearance  Get lost even in familiar settings  Faulty judgement and have difficulty comprehending situations, making plans/decisions  Lose control of impulses → coarse language, inappropriate jokes, shoplift  Deterioration in dealing with abstract ideas, disturbances in emotions → depression, flatness of affect, sporadic emotional outburst  Likely to show language disturbances (vague pattern of speech)  Difficulty carrying out motor activities Chapter 16: Aging and Psychological Disorders  Trouble recognizing familiar surroundings or naming common objects  Episodes of delirium, state of mental confusion  Distinguished from paraphrenia → schizophrenia that has its onset during old age  Course of dementia may be progressive, static, or remitting  Eventually become withdrawn and apathetic  Person will eventually narrow in social involvement and become oblivious to surroundings  Dementia increases with advancing age  Alzheimer`s Disease  Accounts for 50% of dementia in older people (1 in 13 Canadians 65+)  Modifying environmental factors by promoting mental and physical exercise would result in about a 10% reduction in prevalence  Irreversible deterioration of brain tissue, with death occurring 10-12 years after onset o Median survival time is 3.1 years for Canadians with AD (3.3% for those with vascular dementia)  Women with AD live longer than men, but more women die as a result of the disease o 10 leading cause of death for women, 15 for men in Canada  Have difficulty in concentration and memory for newly learned material  Appear absent-minded and irritable  As disease develops → blames others for personal failings and have delusions of being persecuted o Deterioration of memory, increasing disorientation and agitation  Atrophy of the cerebral cortex o First entorhinal cortex and hippocampus, later frontal, temporal, and parietal lobes o Fissures widen and ridges become narrower and flatter o Ventricular enlargement o Plaques: small, round areas making up the remnants of the lost neurons and b-amyloid scattered throughout cortex o Neurofibrillary tangle accumulate within the cell bodies of neurons  Present throughout the cerebral cortex and hippocampus  Most reliable predictor of progression from mild cognitive impairment to AD is atrophy in entorhinal area in the hippocampus and hypometabolism in inferior parietal lobules  Cerebellum, spinal cord, and motor and sensory areas of cortex less affected → reason why AD patients do not have any physical irregularities until late stages o Over-learned habits like walking and small talk are intact Chapter 16: Aging and Psychological Disorders  25% of AD have deterioration similar to that in Parkinson’s (lost of neuron in nigrostriatal pathway)  Strong evidence for genetic basis  Risk for AD is increased in first-degree relatives, concordance MZ twins greater than DZ  By the age of 80 o Children of parents who both developed = 54% risk o One only parent developed = 1.5 times less o Both parents did not = 5 times less  Early onset (60), inheritance pattern could be from single dominant gene (<5% prevalence) o Apolipoprotein E 4 allele on chromosome 19 (different gene = low risk)  Having one E4 allele increases risk for AD to almost 50%, 2 = 90%  Risk of dementia increased with age for those with low educational level o Presence of E4 allele increased by 400% o Related to the development of plaques and tangles  Nun Study o High levels of linguistic ability predict less cognitive impairment and fewer neuropathological indicators of AD o Those who expressed more positive emotions lived longer  Risk factors o Environment plays role in most cases of AD o History of head injury is risk factor o Depression  Preventions o Non-steroidal anti-inflammatory drugs (aspirin) reduce the risk o Nicotine o Remaining active at the cognitive level may buffer/protect individual in terms of the degree of cognitive decline experienced o Cognitive Reserve Hypothesis → notion that high education levels delay the clinical expression of dementia  Brain develops backup or reserve neural structures as form of neuroplasticity o Bilingualism → protects against the negative effects of agin on cognitive control (faster responses) Chapter 16: Aging and Psychological Disorders  Frontal-Temporal Dementias  Accounts for 10-15% of cases  Typically begins in late 50s  Cognitive impairment typical to dementia  Extreme behavioural and personality changes (frontal-temporal dementias)  Apathetic and unresponsive to environment  Show opposite pattern of euphoria, overactivity, and impulsivity  Affected serotonin neurons, widespread loss of neurons in frontal and temporal  Pick’s Disease o Degenerative disorder in which neurons are lost (caused by F-T dementia) o Characterized by presence of Pick bodies → spherical inclusions within neurons  Strong genetic component  Frontal-Subcortical Dementias  Affects both cognition and motor activity  Huntington’s Chorea o Caused by single dominant gene located on chromosome 4 o Presence of writhing (choreiform) movements  Parkinson’s Disease o Marked by muscle tremors, muscular rigidity, akinesia (inability initiate movement) o Can lead to dementia  Vascular ndmentia st o 2 most common type (AD = 1 ) o Diagnosed when patient with dementia has neurological signs like weakness in arm or abnormal reflexes o Cerebrovascular diseases o Series of strokes → cloth forms, impairs circulation and causes cell death o Risk factors associated with cardiovascular disease → bad cholesterol  Other o Encephalitis  Inflammation of brain tissue → caused by viruses entering brain from other parts of the body or mosquito bites o Meningitis  Inflammation of membranes covering outer brain (bacterial infection) o Organism that produces syphilis (Treponema pallidum) can invade brain and case dementia Chapter 16: Aging and Psychological Disorders o Head traumas, nutrional deficts (especially B-complex vitamins), kidney, live failure, endocrine-gland proteins o Exposure to toxin (lead or mercury), chronic drug use Treatment of Dementia  If the dementia has reversible cause, appropriate medical treatment can be beneficial  No clinically significant treatment has been found that can halt or reverse Alzheimer’s disease  Some drugs show promise in effecting modest improvement in cognitive functions for a short period  Biological Treatments of Alzheimer’s Disease  AD involves the death of brain cells that secret acetylcholine  Inhibits enzymes that break down ACH produces mild improvement or slows progression of cognitive decline (tacrine) o Cannot be used in high doses → toxic to liver (severe side effects) o Use of donezepril to produce similar method of action, less side effects  5 drugs approved thus far: o Tacrine, donepezil, rviastigmine, galantamine, memantine o Slow down progression of symptoms, but do not stop progression overall o Questionable cost effectiveness  Psychosocial Treatments for Individual and Family  Overall goal: minimize the disruption caused by person’s behavioural changes  Allow the person and the family the opportunity to discuss the illness and its consequences, provide accurate info about it, help family members care for the person in the home, encourage realistic attitude in dealing with the disease’s specific challenges  Psychotherapy provides limited long-term benefit due to cognitive deterioration o Some patients still enjoy being reassured by occasional conversations with professionals (with others not directly involved in their lives) o Butler’s life review can be useful for early-to-mid stage AD (has not deteriorated) o Contrast to other psychological problems, denial may be best coping mechanism rather than being force to acknowledge problem  2:1 ratio for those living in community vs. those institutionalized because of severity o Depression is twice as evident among caregivers as among non-caregivers of those with AD o Depression and feelings of being burdened are highly correlated among caregivers o Emotional burden, physical burden, financial burden, and employment burden due to need of changing one’s own employment status to take care of individual o Increasing stress when AD comes with other physical health problems (Ex: diabetes, heart disease, high blood pressure) Chapter 16: Aging and Psychological Disorders o Resilience and optimism can help promote well-being among caregivers experiencing significant burdens  Caregivers more likely to experience chronic health problems, more physical illness, and weaker immune functioning → attributable to the stresses of caregiving  Caregivers can benefit from participating in psychoeducation groups  Weekly sessions on stress appraisal and coping reported significant improvement in reactions to behaviour problems of care receivers o Skill training in behaviour management, depression management, and anger management  Respite programs available, but underused by care givers or used when they had already assumed role for 2-4.5 years  Intense feelings of guilt, worry when care receiver has to be institutionalized  Predictor of institutionalization → level of aggression, incontinence, and presence of psychiatric disturbances by elderly person  Delirium  Described as “clouded state of consciousness”  Sometimes, rather than suddenly,has great trouble concentrating and focusing attention and cannot maintain a coherent and directed stream of though  Early stages  Frequently restless (at night),  Sleep-waking cycle becomes disturbed,  Drowsiness during the day and awake/restless/agitated during the night  Common to have vivid dreams and nightmares  May be impossible to engage in conversations because of wandering attention and fragmented thinking  Rambling incoherent speech, lose their sense of time and place, memory impairment  May have lucid intervals of being alert in a 24-hour period  Daily fluctuations help distinguish delirium from AD  Frequent perceptual disturbances → mistake the unfamiliar for the familiar (Ex: thinking that they are at home instead of in hospital)  Common to have hallucinations (visual and mixed visual-auditory), not always present  Paranoid delusions found in 40-70% of delirious old adults  Poorly worked out, fleeting, changeable  Swings in activity and mood accompany disordered thoughts and perceptions  Can be erratic → ripping clothes at one moment, sitting lethargically in the next  Great emotional turmoil and shift rapidly from one emotion to another Chapter 16: Aging and Psychological Disorders  Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, and incontinence are common  Person will completely lose touch with reality and seem like they are in a trance  Often misdiagnosed and neglected in research  Older adults frequently misdiagnosed as having irreversible dementia and considered beyond hope  Long-term institutional care seen as the only option  <0.5% prevalence for those with delirium still living in their usual place of residence  Low survival rate however  Delirium is significant risk factor for development of dementia and dying early o Live less than half as long as those without delirium Cause of Delirium  Drug intoxication and drug-withdrawal reactions (most frequent reason)  Metabolic and nutritional imbalance (Ex: uncontrolled diabetes and thyroid dysfunction)  Infections or fever  Neurological disorders  Stress of a change in person’s surroundings  May also occur following major surgery (hip surgery most common)  Withdrawal from psychoactive substances  Following head trauma or seizures  Physical illnesses  Congestive heart failure, pneumonia, urinary tract infection, cancer, kidney or liver failure, malnutrition, cerebrovascular accidents  Delirium usually has more than one cause  Top 5 correlates of delirium among elderly hospitalized patients 1. Dementia 2. Being on medication 3. Medical illness 4. Age 5. Male gender  Usually develops swiftly (within hours, days)  Exact mode of onset depends on underlying cause  Toxic reaction or concussion = abrupt onset  Infection or metabolic disturbances = more gradual Chapter 16: Aging and Psychological Disorders  Reasons why older adults more vulnerable to delirium  Physical declines of aging, increased general susceptibility to chronic disease, many medications prescribed for older people, greater sensitivity to drugs, vulnerability to stress  Brain damage Treatment of Delirium  Complete recovery is possible if syndrome is identified correctly and underlying cause is promptly treated  Generally takes 1-4 weeks for condition to clear  Takes longer in older vs. younger people  Can cause permanent brain damage, death if underlying cause is not treated  Primary prevention strategies appear to reduce high rate of delirium and duration of delirium episodes in hospitalized older adults  Intervention addresses risk factors like sleep deprivation, immobility, dehydration, visual and hearing impairment, cognitive impairment Comparative features of Dementia and Delirium Dementia Delirium  Gradual deterioration of intellectual  Trouble concentrating and staying with a abilities (Ex: memory of events) train of thought  Difficulties in everyday problem-solving Restlessness at night, nightmares  Periods of depression  Frequent lucid intervals  Problems naming common objects  Hallucinations, may lose contact with  Faulty orientation to time, place, and reality person  Large swings mood and activity  Usually progressive and irreversible  Usually reversible but potentially fatal if  Increased prevalence with age cause not treated  Prevalence high in both young and old Old Age and Psychological Disorders  Maladaptive personality traits and inadequate coping skills bringing person into old age play a role in psychological disturbances more than physiological changes of aging  Persons 65+ actually have lowest overall rates of mental disorder of all age groups when various disorders grouped together  Primary problem detected was cognitive impairment → seen in more than one disorder  14% prevalence for mild cognitive impairment, 5.5% (men) and 4.7% (women) for severe cases in elderly Chapter 16: Aging and Psychological Disorders  Majority are free from serious psychopathology → only 10-20% have psychological problems severe enough to warrant professional attention  Depression  Major depression tends to be less prevalent among adults 65+ relative to younger people  Greater prevalence of depression in elderly associated with female gender, presence of dementia, and presence of physical health problems  At least half of the depressed older adults are experiencing depression for the first time (late onset depression)  Likely to have family history of depression and personality dysfunction rendering them vulnerable  Women have more periods of depression than men for most of their lives Characteristics of Depression in Older vs. Younger Adults  Common symptoms  Worry, feelings of uselessness, sadness, pessimism, fatigue, inability to sleep, and difficulties getting things done  Negative correlates of depression → negative automatic thought, dysfunctional attitudes  Age-related differences  Feelings of guilt less common  Somatic complaints more common  Less likely to emonstrate impaired social and occupational functioning → less likely to be working in general compared to younger people  Depletion syndrome → depression without sadness o Loss of pleasure, vitality, and appetite o Hopelessness o Somatic symptoms  Absence or less prominence of self-blame, guilt, dysphoric mood Causes of Depression in Older Adults  Perhaps due to decreased involvement in daily activities and maintained by self-critical thoughts  Poor physical health  Many physicians are insensitive to the likelihood of depression coexisting with physical illnesses  Do not diagnose or treat psychological condition  Sleep disturbances, disability, prior depression, female gender  Bereavement after the loss of a loved one (may be most important)  Contributes to poorer prognosis in elderly people already suffering from depression  But may depend on the nature of the loss and the timing of the assessment Chapter 16: Aging and Psychological Disorders  Women with ill husbands anticipate the loss and may become dep
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