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Disorders of Aging and Cognition
Chapter 18
Comer, Abnormal Psychology, 8eDSM-5 Update
Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System
Disorders of Aging and Cognition
Neurocognitive disorders are currently the most publicized and feared psychological problems among the elderly They are, however, hardly the only ones
A variety of psychological disorders are tied closely to later life
As with childhood disorders, some of the disorders of old age are caused primarily by pressures that are particularly likely to appear at that time of life, others by unique traumatic experiences, and still others – like neurocognitive disorders– by biological abnormalities
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Old Age and Stress
Old age is usually defined in our society as the years past age 65 Around 36 million people in the U.S. are
“old” – 12% of the population and growing
Older women outnumber older men by 3 to 2
Like childhood, old age brings special pressure, unique upsets, and profound biological changes
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Old Age and Stress
The stresses of elderly people need not result in psychological disorders; however, studies indicate that as many as 50% of elderly people would benefit from mental health services Fewer than 20% actually receive them
Geropsychology is the field of psychology dedicated to the mental health of elderly people
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Old Age and Stress
The psychological problems of elderly persons may be divided into two groups: Disorders that may be common in people of
all ages but are connected to the process of aging
Depressive, anxiety, and substance use disorders
Disorders of cognition that result from brain abnormalities
Delirium, mild neurocognitive disorders, and major neurocognitive disorders
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Depression in Later Life
Depression is one of the most common mental health problems of older adults
The features of depression are the same for elderly people as for younger people As many as 20% of people experience this
disorder at some point during old age The rate is highest in older women
Several studies suggest that depression among older people raises their chances of developing significant medical problems
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Depression in Later Life
Elderly persons are also more likely to die by suicide than younger ones, and often their suicides are related to depression
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Depression in Later Life
Like younger adults, older people who are depressed may be helped by cognitive-behavioral therapy, interpersonal therapy, antidepressant medications, or a combination of these approaches
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Depression in Later Life
More than half of older patients with depression improve with these treatments
It is sometimes difficult for elderly people to use antidepressant drugs effectively and safely because the body’s metabolism works differently in later life
Moreover, among elderly people, antidepressant drugs have a higher risk of causing some cognitive impairment
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Anxiety Disorders in Later Life
Anxiety is also common among the elderly
At any given time, around 6% of elderly men and 11% of elderly women in the U.S. experience at least one of the anxiety disorders GAD is particularly common, experienced
by up to 7% of all elderly persons The prevalence of anxiety increases
throughout old age
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Anxiety Disorders in Later Life
There are many things about aging that may heighten anxiety levels, including declining health Researchers have not, however, been able to
determine why certain individuals who experience such problems in old age become anxious while others who face similar circumstances remain relatively calm
Older adults with anxiety disorders are often treated with psychotherapy of various kinds, particularly cognitive-behavior therapy Many also receive antianxiety medications
Again, all such drugs must be used cautiously with older people
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Substance Misuse in Later Life
Although alcohol use disorder and other substance use disorders are significant problems for many older persons, the prevalence of such patterns actually appears to decline after age 60 Accurate data about the rate of substance
abuse among older adults is difficult to obtain because many elderly persons do not suspect or admit they have such a problem
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Substance Misuse in Later Life
Surveys find that 4% to 7% of older people, particularly men, have alcohol use disorder in a given year
Researchers often distinguish between older problem drinkers who have had alcohol use disorder for many years and those who do not start the pattern until their 50s and 60s The latter group typically begins abusive
drinking as a reaction to the negatives events and pressures of growing older
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Substance Misuse in Later Life
Alcohol use disorder in elderly people is treated much as in younger adults Approaches include detoxification,
Antabuse, Alcoholics Anonymous (AA), and cognitive-behavioral therapy
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Substance Misuse in Later Life
A leading kind of substance problem in the elderly is the misuse of prescription drugs Most often it is unintentional
Yet another drug-related problem is the misuse of powerful medications at nursing homes
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Psychotic Disorders in Later Life
Elderly people have a higher rate of psychotic symptoms than younger persons Among aged people, these symptoms are
usually due to underlying medical conditions such as delirium and Alzheimer’s disease
However, some elderly persons suffer from schizophrenia or delusional disorder
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Psychotic Disorders in Later Life
Schizophrenia is less common in older persons than in younger ones Many people with schizophrenia find
that their symptoms lessen in later life
It is uncommon for new cases of schizophrenia to emerge in later life
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Psychotic Disorders in Later Life
Another kind of psychotic disorder found among the elderly is delusional disorder, in which individuals develop beliefs that are false but not bizarre This disorder is rare in most age groups,
but its prevalence appears to increase in the elderly population
Some clinicians suggest that the rise is related to the deficiencies in hearing, social isolation, greater stress, or heightened poverty experienced by many elderly persons
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Disorders of Cognition
Cognitive “mishaps” (e.g., leaving without keys, forgetting someone’s name) are a common and quite normal feature of stress or aging As people move through middle age, these
memory difficulties and lapses of attention increase, and they may occur regularly by age 60 or 70
Sometimes, however, people experience memory and other cognitive changes that are far more extensive and problematic
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Disorders of Cognition
While problems in memory and related cognitive processes can occur without biological causes (in the form of dissociative disorders), more often, cognitive problems have organic roots, particularly when they appear in later life The leading cognitive disorders among
elderly persons are delirium and neurocognitive disorders
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Delirium
Delirium is a major disturbance in attention and orientation to the environment As a person’s focus becomes less clear,
he or she has great difficulty concentrating and thinking in an organized way
This leads to misinterpretations, illusions, and, on occasion, hallucinations
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Delirium
This state of massive confusion typically develops over a short period of time, usually hours or days It may occur in any age group, including children,
but it is most common in elderly persons Delirium affects fewer than 0.5% of the
nonelderly population, 1% of people over 55, and 14% of those over 85 years of age
Fever, certain diseases and infections, poor nutrition, head injuries, strokes, stress (including the trauma of surgery), and intoxication by certain substances may all cause delirium
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Alzheimer’s Disease and Other Neurocognitive
Disorders People with a neurocognitive disorder
experience a significant decline in at least one (often more than one) area of cognitive functioning, such as memory and learning, attention, visual perception, planning and decision making, language ability, or social awareness In certain types of neurocognitive disorder,
individuals may also experience changes in personality and behavior
At any given time, around 3% to 9% of the world’s adult population are suffering from a neurocognitive disorder
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Alzheimer’s Disease and Other Neurocognitive Disorders
If a person’s cognitive decline is substantial and interferes significantly with his or her ability to be independent, a diagnosis of major neurocognitive disorder is in order If, however, the decline is modest and
does not interfere with independent functioning, the appropriate diagnosis is mild neurocognitive disorder
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Alzheimer’s Disease and Other Neurocognitive Disorders
At any given time, around 3 to 9 percent of the world’s adult population are suffering from such disorders Their experience is closely related to age
Among people 65 years of age, the prevalence is around 1 to 2%, increasing to as much as 50% among those over the age of 85
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Alzheimer’s Disease
This disease is the most common type of neurocognitive disorder, accounting for as many as two-thirds of all cases Around 5 million people in the U.S.
currently have this disease This disease sometimes appears in
middle age (early onset), but most often occurs after the age of 65 (late onset) Its prevalence increases markedly among
people in their late 70s and early 80s
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Alzheimer’s Disease
This is a gradually progressive disease in which memory impairment is the most prominent cognitive dysfunction Technically, suffers receive a DSM-5
diagnosis of mild neurocognitive disorder due to Alzheimer’s disease during the early stages and major neurocognitive disorder due to Alzheimer’s disease during the later stages
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Alzheimer’s Disease
The time between onset and death is typically 8 to 10 years, although some people may survive for as many as 20 years
It usually begins with mild memory problems, lapses of attention, and difficulties in language and communication
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Alzheimer’s Disease
As symptoms worsen, the person has trouble completing complicated tasks and remembering important appointments
Eventually sufferers also have difficulty with simple tasks, distant memories are forgotten, and changes in personality often become very noticeable
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Alzheimer’s Disease
As the the neurocognitive symptoms intensify, people show less and less awareness of their limitations Eventually they become fully dependent on
other people, they lose almost all knowledge of the past and fail to recognize the faces of even close relatives
Alzheimer’s victims usually remain in fairly good health until the later stages of the disease
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Alzheimer’s Disease
In most cases, Alzheimer’s can be diagnosed with certainty only after death, when structural changes in the brain can be fully examined Senile plaques are sphere-shaped deposits of
a small molecule known as the beta-amyloid protein that form in the spaces between cells in the hippocampus, cerebral cortex, and certain other brain regions and blood vessels
Neurofibrillary tangles are twisted protein fibers found within the cells of the hippocampus
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Alzheimer’s Disease
Scientists do not fully understand what role excessive numbers of plaques and tangles play in Alzheimer’s disease, but they suspect they are very important
Today’s leading explanations for this disease center on these plaques and tangles and on factors that may contribute to their formation
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What Are the Genetic Causes of Alzheimer’s
Disease? It appears that Alzheimer’s disease
often has a genetic basis Clinicians now distinguish between
early-onset (familial) Alzheimer’s disease and late-onset (sporadic) Alzheimer’s disease
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What Are the Genetic Causes of Alzheimer’s
Disease? Early-Onset
Researchers have found that this form of Alzheimer’s disease can be caused by abnormalities in the genes responsible for the production of two proteins
Apparently some families transmit these mutations and the onset of the disease is set into motion
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What Are the Genetic Causes of Alzheimer’s
Disease? Late-Onset
This form of the disease appears to result from a combination of genetic, environmental, and lifestyle factors
The genetic factor at play in sporadic Alzheimer’s Disease is different from the ones involved in familial Alzheimer’s disease
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How Does Brain Structure Relate to Alzheimer’s Disease?
Researchers have identified a number of biological factors related to the brain abnormalities seen in Alzheimer’s disease
To understand the role of these factors, an understanding of the operation and biology of memory is necessary…
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How Does Brain Structure Relate to Alzheimer’s Disease?
The human brain has two memory systems that work together to help us learn and recall Short-term memory, or working memory,
gathers new information Information held in short-term memory must be
transformed, or consolidated, into long-term memory if we are to hold on to it
Long-term memory is the accumulation of information that we have stored over the years
Remembering information stored in long-term memory is called retrieval
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How Does Brain Structure Relate to Alzheimer’s Disease?
Certain brain structures seem to be especially important in memory, including: The prefrontal lobes
Appear to hold information temporarily and to continue working with the information as long as it is needed
The temporal lobes and the diencephalon Seem to help transform short-term memory into
long-term memory Research indicates that cases of Alzheimer’s
disease involve damage to or improper functioning of one or more of these areas
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What Biochemical Changes in the Brain Relate to
Alzheimer’s Disease? Memory researchers have also identified
biochemical changes that occur in cells as memories form For example, several chemicals are responsible
for the production of proteins in key cells when new information is acquired and stored
If the activity of these chemicals is disturbed, the proper production of proteins may be prevented and the formation of memories interrupted
Some research suggests that abnormal activity by these chemicals may contribute to the symptoms of Alzheimer’s Disease
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Other Explanations of Alzheimer’s Disease
In addition to these two explanations, researchers offer additional possibilities: Several lines of research suggest that
certain substances found in nature, including zinc, may produce brain toxicity, which may contribute to the development of the disease
Another line of research suggests that the environmental toxin lead may contribute to the development of Alzheimer’s disease
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Other Explanations of Alzheimer’s Disease
Another explanation is the autoimmune theory: Changes in aging brain cells may trigger an
autoimmune response, leading to the disease
A final explanation is a viral theory Because Alzheimer’s disease resembles
Creutzfeldt-Jakob disease (a form of neurocognitive disorder caused by a virus), some researchers propose that a similar virus may cause Alzheimer’s disease
To date, no such virus has been detected in the brains of Alzheimer’s victims
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Assessing and Predicting Alzheimer’s Disease
Most cases of Alzheimer’s disease can be diagnosed with certainty only after death, when autopsy is performed
However, brain scans, which reveal structural abnormalities in the brain, now are commonly viewed as assessment tools
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Assessing and Predicting Alzheimer’s Disease
Several research teams are currently trying to create tools that can identify persons likely to develop Alzheimer’s disease One research team is using PET scans
The most effective interventions for Alzheimer’s disease and other neurocognitive are those that help prevent problems or, at the very least, are applied early, so it is essential to have tools that identify the disorders as early as possible
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Other Types of Neurocognitive Disorders
There are a number of other neurocognitive disorders, including: Vascular neurocognitive disorder
Follows a cerebrovascular accident, or stroke, during which blood flow to specific areas of the brain was cut off, with resultant damage
This disorder is progressive but its symptoms begin suddenly, rather than gradually
Cognitive functioning may continue to be normal in the areas of the brain not affected by the stroke
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Other Types of Neurocognitive Disorders
There are a number of other neurocognitive disorders, including: Frontotemproal neurocognitive disorder –
also known as Pick’s disease – a rare disorder that affects the frontal and temporal lobes and is clinically similar to Alzheimer’s disease
Neurocognitive disorder due to prion disease – also called Creutzfeldt-Jakob disease – has symptoms that include spasms of the body
This disorder is caused by a slow-acting virus
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Other Types of Neurocognitive Disorders
There are a number of other neurocognitive disorders, including: Neurocognitive disorder due to Huntington’s
disease – an inherited progressive disease in which memory problems worsen over time, along with personality changes, mood difficulties, and movement problems
Parkinson’s disease – a slowly progressive neurological disorder marked by tremors, rigidity, and unsteadiness that can cause neurocognitive disorder due to Parkinson’s disease
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Other Types of Neurocognitive Disorders
Finally, yet other neurocognitive disorders may be caused by: HIV infections
Traumatic brain injury
Substance abuse
Various medical conditions such as meningitis or advanced syphilis
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What Treatments Are Currently Available?
Treatments for the cognitive features of Alzheimer's disease and most other types of neurocognitive disorder have been at best modestly helpful
A number of approaches have been applied, including drug therapy, cognitive techniques, behavioral interventions, support for caregivers, and sociocultural approaches
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What Treatments Are Currently Available?
The drugs currently prescribed affect acetylcholine and glutamate, the neurotransmitters known to play an important role in memory Although the benefits of the drugs are limited
and the risk of harmful side effects is sometimes high, the drugs have been approved by the FDA
Another approach, taking Vitamin E, seems to help prevent or slow down further cognitive decline
These drugs are administered after a person has developed Alzheimer’s disease
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What Treatments Are Currently Available?
Some studies suggest that certain substances now on the market for other problems (e.g., estrogen) may prevent or delay the onset of Alzheimer’s disease
A number of studies also seem to suggest that certain substances (e.g., estrogen, ibuprofen) may reduce the risk of Alzheimer’s disease
Cognitive treatments have been tried with some temporary success
Behavioral interventions have been tried with modest success
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What Treatments Are Currently Available?
Caregiving can take a heavy toll on the close relatives of people with Alzheimer’s disease and other types of neurocognitive disorders Almost 90% of all people with Alzheimer’s
disease are cared for by their relatives One of the most frequent reasons for the
institutionalization of people suffering from Alzheimer’s is that overwhelmed caregivers can no longer cope with the difficulties of keeping them at home
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What Treatments Are Currently Available?
Sociocultural approaches have begun to play an important role in treatment A number of day-care and assisted-living
facilities have been opened to provide care for those with Alzheimer’s disease
Studies suggest that such facilities often help slow the cognitive decline of residents and enhance their enjoyment of life
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Issues Affecting the Mental Health of the Elderly
As the study and treatment of elderly people have progressed, three issues have raised concern among clinicians: The problems faced by elderly members
of racial and ethnic minority groups
The inadequacies of long-term care
The need for a health-maintenance approach to medical care in an aging world
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Issues Affecting the Mental Health of the Elderly
Discrimination because of race and ethnicity has long been a problem in the U.S., particularly for those who are old To be both old and a member of a minority
group is considered to be in “double jeopardy” by many observers
Older women in minority groups are considered to be in “triple jeopardy”
Because of language barriers and cultural issues, it is common for elderly members of ethnic minority groups to rely solely on family members or friends for remedies and health care
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Issues Affecting the Mental Health of the Elderly
Many older people require long-term care outside the family “Long-term care” may refer variously to the
services offered in a partially supervised apartment, in a senior housing complex, or in a nursing home
The quality of care at such residences varies widely
Many worry about being “put away” and about the costs of long-term care
Worry over these issues can greatly harm the mental health of older adults, perhaps leading to depression and anxiety, as well as family conflict
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Issues Affecting the Mental Health of the Elderly
Medical scientists suggest that the current generation of young adults should take a health-maintenance, or wellness promotion, approach to their own aging process There is a growing belief that older
adults will adapt more readily to changes and negative events if their physical and psychological health is good
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