HLTHAGE 3N03 Midterm: Review
27 Oct 2018
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Midterm #2 Review
Diagnosing Elders
- Older adults have a lower prevalence of MI than younger age groups
- Elders who do have MI’s require age appropriate treatments and screening processes
- Clinicians must take into account the history of both the individual (daily schedule, coping
methods, medical history) and the illness (time course, symptoms)
- A depression diagnosis is validating but difficult to diagnose b/c there’s so many subtypes
- The most difficult diagnoses to disclose for both clinicians and patients are personality
disorders due to lack of information and risk of stigma
Unique Psychosocial Risk Factors for Elders
-Negative Life Events and Ongoing Difficulties → interpretation of past negative events
predicts ability to handle future negative events; survival hypothesis
-New Medical Illness → cancer, cardiovascular disease, etc. signal advancing age, which we
don’t like the idea of; can lead to MI, especially if it’s out of your control
-Death of a Loved One → must distinguish between normal grieving and depression and
examine circumstances before and after the death
-Disability and Functional Decline → bidirectional relationship; disability causes stress/MI
which furthers disability
Diagnostic Statistics Manual
- Purposes: satisfies the need for classification of illnesses, helps locate appropriate treatments,
informs prognosis, aids communication between healthcare providers
- Background: government wanted to know the prevalence of insanity in the population, so they
added questions to the census, many asylums had their own diagnostic system which differed
from institution to institution, by the 1950s there were 5 separate systems in various settings
(asylums, navy, army, veteran affairs, prison). APA says we need one common language
-DSM-I: contained short, broadly worded proses which had an-patient focus, based on people’s
reactions to stressors, categories of causality were separated into brain disease or not,
followed decision making process of clinicians
-DSM-II: more focus on outpatients, removal of the word ‘reaction’ (ex. Schizophrenic reactions
= schizophrenia), allowed for comorbidities in children, ensured compatibility with ICD
- Rosenhan study of pseudopatients challenged reliability and validity of DSM-II
-DSM-III/III-R: evidence-based shift, contained multiaxial diagnostic criteria aka no longer a
short and broad prose, grouped disorders into families
-DSM-IV: included an appendix of categories that require further study - prompts clinicians to
do further research and progress psychiatric knowledge
-Criticisms: overdiagnosis, subjective definitions of ‘disorder’, developed by a committee with
conflicts of interest, generates lots of money
Making the Diagnosis (Clinician Perspective)
- Diagnostic Assessment: must be comprehensive and time-intensive to ensure accuracy and
fit of diagnosis. Fluctuation of emotions/symptoms makes it difficult to give someone a label
they they identify with over a long period of time
- Disclosure: physicians struggle with giving diagnoses because sometimes they can do more
harm than good (stigma), so they may choose to talk about problems in a roundabout way
- Provision of Information: easier to give diagnosis if the clinician has resources to give
- Functional value in giving diagnosis: can offer a set clinical pathway in terms of treatment,
maintenance, and steps for recovery/remission
- Collaborative Relationship: family physician or psychiatrist may give the formal diagnosis,
but many people are involved in the conversation (including the patient)
- Involving Others: family, friends, and other support networks are made aware of the
diagnosis, and work with the patient
- Stigma: clinicians must avoid stigma in the conversation; often ensure the diagnosis is not the
whole person, it just happens to be a part of the person
Cognitive Impairment
- Cognitive impairment can be a normal part of aging, but there is variability in decline (i.e. some
things get better and some things get worse)
- Humans are adaptive, therefore deficits may go unnoticed (ex. making lists to assist memory)
- The greatest impact is on performance of complex tasks
- Memory declines with age, but the type of memory most impacted is secondary memory
(learning and retaining new information)
- Brain Games Debate: that brain games alter neural functioning in ways that improve cognitive
performance and/or prevent decline vs. no they do not
Neurocognitive Disorders and Aging
- Neurocognitive Disorders represent a substantial change from the ind’s previous level of
functioning, and are not
a normal part of adult development and aging
- We fail to recognize the extent of cognitive impairment because we expect a decline, so we
ignore it until it gets really bad and then it’s too late for intervention
-Delirium: a disturbance in awareness and other areas of cognition that develops quickly and
does not occur in the context of a reduced level of arousal (ex. coma)
- Increases with age, approx 14% of elders experience an episode
- Types: hyperactive (restless, rapid mood changes) and hypoactive (lethargic, in a
daze) and mix (combination of other types, shift happens quickly)
- Causes: acute illness, CNS damage, cardiovascular disorders, medication etc.
- Treatment: determining and correcting whatever caused it
- Mild Neurocognitive Disorders: impairment in at least one domain of cognitive functioning
that doesn’t interfere with the capacity for independence in daily activities, but some deficits
require compensatory strategies or accommodation
- Types: amnestic (memory) and nonamnestic (thinking skills)
- Prevalence: 22% for inds over 70 y/o, rate of conversion to a major NCD is 12% (high)
-Major Neurocognitive Disorders: a noticeable decline from the person’s baseline which are
substantial enough to affect daily functioning, and that warrants intervention
- Types: Alzheimers
(slowly progressing brain disease that affects plaques and proteins
in the brain causing decline; affects more women and has no specific etiology) and
Major NCD with vascular involvement
(dementia with the presence of a stroke)
Depression and Cognitive Impairment
- Depression is also associated with memory deficits and cognitive performance
- Depressed people make negative self evaluations (critical of their cognitive abilities)
- 30-50% of those with dementia meet criteria for depression
- Emergence of late life depression associated w decline in cognitive functioning
- Many elders lack awareness of their problems and will focus on cognitive impairment,
completely ignoring depressive symptoms
- Vascular depression hypothesis: cardiovascular disease can predispose a depressive episode
Assessment for Cognitive Impairment
- Needs to be multidisciplinary/holistic and involve multiple professionals to be comprehensive
- Must do a physical medical evaluation and get a list of medications
- Must assess social history/baseline and psychological/emotional functioning along w memory
- Areas to assess: family stress, caregiver burden, depression in family members or caregivers,
decision-making abilities
- Tools: mini-mental state exams, if a high threshold is met a full screening is done. Full
assessment involves an in-depth assessment of all cognitive domains and results are
compared to individual norms and are interpreted in the context of the individual
Interventions for Cognitive Impairment
-Reversible: treatment should correct underlying condition
-Non-Reversible: manage the disease and prevent excessive disability or rapid decline
-Planning Interventions: ensure legal and financial affairs in good standing prior to significant
impairment (so they can make decisions about their future before they are unable to). This
includes selection of a decision-maker and a caregiving plan
-Environmental Interventions: provide sufficient challenge without generating frustration;
life-course pictures of the self can help orient the person and help with recognition; technology
-Behavioural Interventions: promoting self-care behaviours, navigation, and eating. Limits
wandering, disruptive vocalizations, and inappropriate sexual behaviours
-Cognitive Enhancement Interventions: using medications and memory aids that can assist
memory, but do nothing to slow the decline
Depression, Anxiety, Bipolar and Suicide
Major Depressive Disorder
Diagnostic Criteria/Symptoms
- Must have at least one of the two core features: depressed mood most of the day or
diminished interest/pleasure in activities
- 5+ symptoms present during at least a 2 week period, must represent change from normal
- Significant weight loss or weight gain, change in appetite; insomnia or hypersomnia;
psychomotor agitation; fatigue; feelings of worthlessness/guilt; diminished ability to
think/concentrate; recurrent thoughts of death/suicide
- Individual has never had a manic or hypomanic episode
- Consider sub-types of depression: seasonal affective disorder, bereavement, etc.
Document Summary
Older adults have a lower prevalence of mi than younger age groups. Elders who do have mi"s require age appropriate treatments and screening processes. Clinicians must take into account the history of both the individual (daily schedule, coping methods, medical history) and the illness (time course, symptoms) A depression diagnosis is validating but difficult to diagnose b/c there"s so many subtypes. The most difficult diagnoses to disclose for both clinicians and patients are personality disorders due to lack of information and risk of stigma. Interpretation of past negative events predicts ability to handle future negative events; survival hypothesis. Cancer, cardiovascular disease, etc. signal advancing age, which we. Must distinguish between normal grieving and depression and. Bidirectional relationship; disability causes stress/mi don"t like the idea of; can lead to mi, especially if it"s out of your control examine circumstances before and after the death which furthers disability.
