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Chapter 16

Chapter 16 - Aging and Psychological Disorders.doc

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Konstantine Zakzanis

Chapter 16 – Aging and Psychological Disorders - most segments of North American society tend to have certain assumptions about old age - in contrast to the esteem in which they are held in most Asian countries, older adults are generally not treated very well in North America, and numerous myths abound - the general public endorses many mistaken beliefs about the elderly; for instance, considerably mythology has surrounded sexuality and aging, the principal assumption being that at the age of 65 sex becomes improper, unsatisfying, and even impossible; however, older people, well into their 80s and beyond, are capable of deriving enjoyment from sexual intercourse and other kinds of lovemaking - the social problems of aging may be especially severe for women - although grey hair at the temples and even a bald head are often considered distinguished in a man, signs of aging in women are not valued in society ageism – discrimination against someone because of his/her age - the physical realities of aging are complicated by ageism, which can be defined as discrimination against any person, young or old, based on chronological age - like any prejudice, ageism ignores the diversity among people in favor of employing stereotypes - in any discussion of the differences between the old and the not yet old, the old are usually defined as those over the age of 65; the decision to use this age was set largely by social policies - to have some rough demarcation (separation) points, gerontologists usually divide people over 65 into 3 groups; the young-old, those aged 65-74; the old-old, those aged 75-84; and the oldest-old, those over age 85; the health of these groups differs in important ways Issues, Concepts, and Methods in the Study of Older Adults Diversity in Older Adults - the word “diversity” is well suited to the older population - not only are older people different from one another, but they’re more different from one another than are individuals in any other age group - people tend to become less alike as they grow older Age, Cohort, and Time-of-Measurement Effects - in the field of aging, as in studies of earlier development, a distinction is made among 3 kinds of effects:  age effects – are the consequences of being a given chronological age eg: Jewish boys are bar mitzvahed at age 13  cohort effects – are the 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 eg: people who invested money in the stock market in the late 1990’s view investments in equities as a reasonably safe and very lucrative place to put their money – unlike people who lost a lot of money in the bear markets of the 1930’s or late 1960’s  time-of-measurement effects – are confounds that arise because events at an exact point in time can have a specific effect on a variable being studied over time eg: time of measurement could affect the results of studies assessing PTSD in Holocaust survivors if one of the assessments occurs shortly after 9/11 - the 2 major research designs used to assess developmental change are the cross-sectional and the longitudinal - in cross-sectional studies, the investigator compares different age groups at the same moment in time on the variable of interest cross-sectional studies – studies in which different age groups are compared at the same time - cross-sectional studies do not examine the same people over time; consequently, they allow us to make statements only about age effects in a particular study or experiment, not about changes over time - in longitudinal studies, the researcher selects one cohort – say, the graduating class of 2002 – and periodically retests it using the same measure over a number of years longitudinal studies – investigation that collects information on the same individuals repeatedly over time, perhaps over many years, in an effort to determine how phenomena change - longitudinal studies allows researchers to trace individual patterns of consistency or change over time – cohort effects – and to analyze how behavior early in life relates to behavior in old age - however, because each cohort is unique, conclusions drawn from longitudinal studies are restricted to the cohort chosen - an additional problem with longitudinal studies is that participants often drop out as the studies proceed, creating a bias commonly called selective mortality selective mortality – a possible confound in longitudinal studies, whereby the less healthy people in a sample are more likely to drop out of the study over time - the least-able people are the most likely to drop out, leaving a nonrepresentative group of people who are usually healthier than the general population - thus, findings based on longitudinal studies may be overly optimistic about the rate of decline of a variable such as sexual activity over the lifespan Diagnosing and Assessing Psychopathology in Later Life - the DSM-IV-TR criteria for older adults are basically the same as those for younger adults - the nature and manifestations of mental disorders are usually assumed to be the same in adulthood and old age, even though little research supports this assumption - a measure of cognitive functioning is often included as standard practice in research to determine whether the elderly respondent has experienced declines in cognitive ability - researchers often assess cognitive functioning with the Mini-Mental State Examination (MMSE) in its original or modified form (i.e., the Modified Mini-Mental State Exam) - the MMSE is a brief measure of an individual’s cognitive state, assessing “orientation, memory, and attention,.. ability to name, follow verbal and written commands, write a sentence spontaneously, and copy a complex polygon” - because some elderly people will have diminished attention spans, one goal is to develop short but reliable measures suitable for screening purposes - one relatively simple measure used to detect dementia and Alzheimer’s disease is the clock drawing subtest of the Clock Test - in this test, respondents are presented with a previously drawn circle (7cm in diameter) and are asked to imagine that the circle is the face of a clock and to put the numbers on the clock and then draw the hand placement for the time of 11:10; up to 25 different types of errors can occur ; this test has been found to be reliable and valid - another assessment goal is to create measures whose item content is tailored directly to the concerns and symptoms reported by elderly people, not to those of younger respondents - one well-known measure crafted for the elderly is the Geriatric Depression Scale (GDS), a true-false self-report measure - the GDS has acceptable psychometric characteristics and is regarded as the standard measure for assessing depression in the elderly - the Geriatric Suicide Ideation Scale (GSIS) is a new 31 item measure that is the 1 measure of suicide ideation created specifically for the elderly; the GSIS has a 10-item suicide ideation scale, as well as 3 other subscales tapping death ideation, loss of personal and social work, and the perceived meaning in life Range of Problems - as a group, no other people have more of these problems than the aged - they have them all: physical decline and disabilities, sensory and neurological deficits, loss of loved one, the cumulative effects of a lifetime of many unfortunate experiences, and social stresses such as ageism - one concern from the WHO is that elderly people with a mental disorder may suffer from “double jeopardy”; that is, they suffer the stigmas associated with being older and being mentally ill Old Age and Brain Disorders Dementia dementia – deterioration of mental faculties – memory, judgments, abstract thought, control of impulses, intellectual ability – that impairs social and occupational functioning and eventually changes the personality - dementia – what laypeople called senility – is a 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, is the most prominent symptom, and reported memory problems in people who objectively have normal cognition predict subsequent dementia - people with dementia may leave tasks unfinished because they forget to return to them after an interruption; judgments may become faulty, and the person may have difficulty comprehending situations and making plans or decisions; the ability to deal with abstract ideas deteriorates, and disturbances in emotions are common, including symptoms of depression, flatness of effect, and sporadic emotional outbursts; they could also show language disturbances; also, they may have trouble recognizing familiar surroundings or naming common objects - many people with progressive dementia eventually become withdrawn and apathetic - in the terminal phase of the illness, the personality loses its sparkle and integrity; relatives and friends say that the person is just not himself/herself anymore; social involvement with others keeps narrowing; finally, the person is oblivious to his/her surroundings - prevalence of dementia increase with advancing age - the Alzheimer’s Society of Canada estimates that more than 750,000 Canadians will develop Alzheimer’s and other dementias in the next 30 years Causes of Dementia - dementias are typically classified into 3 types - Alzheimer’s disease is the most common; then there are the frontal-temporal and frontal-subcortical dementias, which are defined by the areas of the brain that are most affected Alzheimer’s Disease Alzheimer’s disease – a dementia involving a progressive atrophy of cortical tissue and marked by memory impairment, involuntary movements of limbs, occasional convulsions, intellectual deterioration, and psychotic behavior - Alzheimer’s disease accounts for about 50% of the dementia in older people; about 1/13 Canadians over the age of 65 has Alzheimer’s disease or a related dementia - in Alzheimer’s disease, the brain tissue deteriorates irreversibly, and death usually occurs 10 or 12 years after the onset of symptoms - gender is a factor; women with Alzheimer’s disease live longer than men with Alzheimer’s disease, but more women than men die as a result of this disease st - the person may at 1 have difficulties only in concentration and in memory for newly learned material, and may appear absent-minded and irritable - as the disease develops memory continues to deteriorate, and the person becomes increasingly disoriented and agitated - the main physiological change in the brain is an atrophy (wasting away) of the cerebral cortex, st 1 the entorhinal cortex and the hippocampus and later the frontal, temporal, and parietal lobes - as neurons and synapses are lost, the fissures widen and the ridges become narrower and flatter; the ventricles also become enlarged plaques – small, round areas composed of remnants of lost neurons and beta-amyloid, a waxy protein deposit; present in the brains of patients with Alzheimer’s disease neurofibrillary tangles – tangled abnormal protein filaments present in the cell bodies of brain cells in patients with Alzheimer’s disease - these plaques and tangles are present throughout the cerebral cortex and the hippocampus - researchers concluded that, in terms of structural imaging, volume loss within the hippocampus (and episodic memory impairment) best discriminated people in the early stages of Alzheimer’s disease from control participants - however, volume loss within the medial temporal lobes (and associated naming deficits) was the most sensitive measure when identifying patients with Alzheimer’s disease for 4 or more years - the cerebellum, spinal cord, and motor and sensory areas of the cortex are less affected, which is why Alzheimer’s patients don’t appear to have anything physically wrong with them until late in the disease process - although neural pathways using other transmitters deteriorate in Alzheimer’s, those using ACh are of particular importance; evidence suggests that anticholinergic drugs (those that reduce ACh) can produce memory impairments in normal people similar to those found in Alzheimer’s patients - there are fewer ACh terminals in the brains of patients with Alzheimer’s disease, and levels of the major metabolite of ACh are also low and are associated with greater mental deterioration - there is very strong evidence for a genetic basis for Alzheimer’s; the risk for Alzheimer’s is st increased in 1 degree relatives of afflicted individuals, and concordance for MZ twins is greater than for DZ twins - a gene controlling the protein responsible for the formation of b-amyloid was found on the long arm of chromosome 21, and studies have demonstrated that this gene causes the development of about 5% of cases of early onset Alzheimer’s; dominant genes causing the disease have also been found on chromosomes 1 and 13 - the majority of late-onset cases of Alzheimer’s disease exhibit a particular form of a gene (called the apolipoprotein E 4 allele) on chromosome 19 - the E 4 allele appears to be related to the development of both plaques and tangles, and it seems to increase the likelihood that the brain will incur damage from free radicals (unstable molecules derives from oxygen that attack proteins and DNA) - finally, the environment is likely to play a role in most cases of Alzheimer’s, as demonstrated by reports of long-lived MZ twins whoa re discordant for the disorder - life events may play a role; a history of head injury is a risk factor for developing Alzheimer’s disease; analyses of longitudinal data also show that depression increases the risk for Alzheimer’s disease - non-steroidal anti-imflammatory drugs such as aspirin appear to reduce the risk of Alzheimer’s disease, as does nicotine - general research on cognitive decline in the elderly supports the phase “use it or lose it!”; remaining active at the cognitive level may buffer or protect an individual in terms of the degree of cognitive decline experienced - there’s some support for the use it or lose it principle; there were 3 conclusions: 1. cognitive activity helps preserve cognitive functioning 2. cognitive activity helps crystallized intelligence more than fluid intelligence 3. there is support for the cognitive reserve hypothesis - the act of cognitive compensation creates a cognitive reserve - the cognitive reserve hypothesis is the notion that high education levels delay the clinical expression of dementia because the brain develops backup or reserve neural structures as a form of neuroplasticity - research indicates that being bilingual protects against the negative affects of aging on cognitive control Frontal-Temporal Dementias - this type accounts for 10-15% of cases - typically begins in a person’s late 50s - these dementias are marked by extreme behavioral and personality changes - sometimes patients are very apathetic and unresponsive to their environment; at other times, they show an opposite pattern of euphoria, over-activity, and impulsivity - serotonin neurons are most affected, and there is widespread loss of neurons in the frontal and temporal lobes - Pick’s disease is one cause of frontal-temporal dementia; like Alzheimer’s disease, Pick’s disease is a degenerative disorder in which neurons are lost; it is also characterized by the presence of Pick bodies, spherical inclusions within neurons - frontal-temporal dementias have a strong genetic component Frontal-Subcortical Dementia - because these dementias affect subcortical brain areas, which are involved in the control of motor movements, both cognition and motor activity are affected - types of frontal-subcortical dementias include:  Huntington’s chorea (jerky movements) – is caused by a single dominant gene located on chromosome 4 and is diagnosed principally by neurologists on the basis of genetic testing; its major behavioral feature is the presence of writhing (twisting movements) (choreiform) movements  Parkinson’s disease – is marked by muscle tremors, muscular rigidity, and akinesia (an inability to initiate movement) and can lead to dementia  Vascular dementia – is the 2 most common type, next to Alzheimer’s disease; it’s diagnosed when a patient with dementia has neurological signs, such as weakness in an arm or abnormal reflexes, or when brain scans show evidence of cerebrovascular disease; genetic factors appear to be of no importance Other Causes of Dementia - encephalitis, a genetic term for any inflammation of brain tissue, is caused by viruses that enter the brain either from other parts of the body (such as the sinuses or ears) or from the bites of mosquitoes or ticks - meningitis, an inflammation of the membranes covering the outer brain, is usually caused by a bacterial infection - the organism that produces the venereal disease sylphilis (Treponema pallidum) can invade the brain and cause dementia - finally, head traumas, brain tumors, nutritional deficiencies (especially of B-complex vitamins), kidney or liver failure, and endocrine gland problems such as hyperthyroidism can result in dementia - exposure to toxins, such as lead or mercury, as well as chronic use of drugs including alcohol, are additional causes Canadian Perspective 16.1 – The Canadian Study of Health and Aging - the Canadian Study of Health and Aging have a huge project with elderly people and they have 4 main goals: 1. to use a common research protocol to estimate the prevalence of dementia in Canadians aged 65 or older 2. to identify risk factors associated with Alzheimer’s disease 3. to examine patterns of caring for Canadians with dementia 4. to develop a uniform database for subsequent longitudinal investigations - they found that the onset of dementia is usually gradual - about half of Canadians with dementia are institutionalized and the other half are community residents - there are more than 60,000 new cases of dementia per year in Canada - frailty (having multiple, interacting illnesses) is associated with greater levels of psychiatric illness, while older age, in and of itself, is not associated with greater odds of psychiatric illness Focus on Discovery 16.1 – The Nun Study: Unlocking the Secrets of Alzheimer’s? - low linguistic ability was found in 90% of those who developed Alzheimer’s disease and in only 13% of those who didn’t - supplementary analyses continue to show that high levels of linguistic ability predict less cognitive impairment and fewer neuropathological indicators of Alzheimer’s disease - nuns who expressed more positive emotions lived longer, and nuns who eventually succumbed to Alzheimer’s disease gradually expressed fewer positive emotions prior to the disease’s onset Treatment of Dementia - no clinically significant treatment has been found that can halt or reverse Alzheimer’s disease, although some drugs show promise in effecting modest improvement in certain cognitive functions for a short period of time Biological Treatments of Alzheimer’s disease - because Alzheimer’s disease involves the death of brain cells that secrete ACh, various studies have attempted to increase the levels of ACh - Donepezil (Aricept), which inhibits the enzyme that breaks down ACh, is similar to tacrine in its method of action and results but produces fewer side effects - findings also indicate that antioxidants, such as vitamin E, may be useful in slowing the progression of the disease Psychological Treatments for Patients and their Families - the general psychological approach is supportive - the overall goal is to minimize the disruption caused by the patient’s behavioral changes - in contrast to approaches taken with other psychological problems, it may be desirable not to make an effort to get patients to admit to their problems, for denial may be the best coping mechanism available - caring for a person with Alzheimer’s disease has been shown to be extremely stressful and distressing; analyses indicate that depression is twice as evident among caregivers as among non-caregivers; depression n’ feelings of being burdened are highly correlated among caregivers - caregivers are also more likely than non-caregivers to experience chronic health problems - caregivers of patients with dementia can also benefit from participating in psychoeducation groups - a study found that there was substantial effectiveness for skill training programs with 3 elements: behavior management, depression management, and anger management - another study showed that levels of functioning were much higher in caregivers of relatives with dementia if the caregivers were relatively high in optimism - perhaps the most wrenching decision for caregivers is whether to institutionalize the person with dementia; a qualitative study of caregivers suggested that feelings of guilt among caregivers are intense when a person much be institutionalized, but their most prominent emotion is worry - a review concluded that the 3 best predictors of institutionalization are the elderly person’s level of aggression, incontinence, and the presence of psychiatric disturbances Delirium delirium – a state of great mental confusion in which consciousness is clouded, attention cannot be sustained, and the stream of thought and speech is incoherent; the person is probably disoriented, emotionally erratic, restless, or lethargic, and often has illusions, delusions, and hallucinations - the term delirium is derived from the Latin words “de” meaning “from” or “out of” and “lira” meaning “furrow” or “track”; the term implies being off track or deviating from the usual state - delirium is typically described as a clouded state of consciousness; the patient, sometimes rather suddenly, has great trouble concentrating and focusing attention and cannot maintain a coherent and directed stream of thought - in the early stages, the person with delirium is frequently restless, particularly at night; the sleep-waking cycle becomes disturbed, so that the person is drowsy during the day and awake, restless, and agitate during the night - delirious patients may be impossible to engage in conversation because of their wandering attention and fragmented thinking; also, perceptual disturbances are frequent - memory impairment, especially for recent events, is common; in the course of 24h hours, however, delirious people have lucid intervals and become alert and coherent; these daily fluctuations help distinguish delirium from other syndromes, especially Alzheimer’s disease - swings in activity and mood accompany disordered thoughts and perceptions; they are in great emotional turmoil and may shift rapidly from one emotion to another - although delirium is one of the most frequent biological mental disorders in older adults, it has been neglected in research, and like dementia, is often misdiagnosed - data suggests that delirium is very uncommon among people living in their usual place of residence with prevalence of less than 0.5% - people of any age are subject to delirium, but it is more common in children and older adults, especially hospitalized older adults, with perhaps up to one quarter of older adults inpatients experiencing delirium at some point during their hospitalization Causes of Delirium - the causes of delirium in older adults can be grouped into several general classes: drug intoxications an drug-withdrawal reactions, metabolic and nutritional imbalances (as in uncontrolled diabetes and thyroid dysfunctions), infections or fevers, neurological disorders, and the stress of a change in the person’s surroundings - also, delirium may also occur following major surgery, most commonly hip surgery - probably the most frequent cause of delirium in this age group is intoxication with prescription drugs - however, delirium usually has more than one cause - research concluded that the top 5 correlates of delirium among elderly hospitalized patients are dementia, being on medication, medical illness, age, and male gender Treatment of Delirium - complete recovery from delirium is possible if the syndrome is identified correctly and the underlying cause is promptly treated - it generally takes 1-4 weeks for the condition to clear; it takes longer in older patients than in younger patients - if the underlying cause is not treated, however, permanent brain damage and death can result Old Age and Psychological Disorders Overall Prevalence of Mental Disorders in Late Life - current prevalence data indicate that persons over age 65 have the lowest overall rates of mental disorder of all age groups when the various disorders are grouped together - for severe cognitive impairment, rates were 5.5% for older men and 4.7% for older women - the majority of persons 65 years of age and older are free from serious psychopathology, but 10-20% do have psychological problems severe enough to warrant professional attention Depression - greater prevalence of depression was associated with female gender, the presence of dementia, and the presence of health problems st - most depressed older adults are not experiencing depression for the 1 time, their depression is a continuation of a condition present earlier in life - the depression of those older adults who do have true late-onset depression can often be traced to a specific biological cause - unipolar depression is much more common than bipolar depression among older patients; the emergence of bipolar disorder after the age of 65 is rare - women have more periods of depression than men for most of their lives Characteristics of Depression in Older vs. Younger Adults - worry, feelings of uselessness, sadness, pessimism, fatigue, inability to sleep, and difficulties getting things done are common symptoms of depression in both older and younger adults - but, there are also some age-related differences - feelings of guilt are less common and somatic complaints are more common in depressed older adults - older adults are less likely to demonstrate impaired social and occupational functioning as a result of their depression because they are less likely than younger people to be working - some researchers have described a subtype of depression more commonly seen in older adults, called depletion syndrome; this syndrome is characterized chiefly by loss of pleasure, vitality, and appetite, as well as hopelessness and somatic symptoms; self-blame, guilt, and dysphoric mood are either absent or less prominent Causes of Depression in Older Adults - many aged patients in poor physical health are depressed - bereavement after the loss of a loved one has been hypothesized to be the most important risk factor for depression in the elderly - significant risk factors for depression across 20 prospective studies were bereavement, sleep disturbance, disability, prior dep
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