PERSONALITY AND AGING:MORE GRUMPY? –NOT SO

Randy Summerville, PsyDARCC Neuropsychology

NEUROCOGNITIVE ASSESSMENT

The study of brain behaviors using normative standards and psychological/cognitive testing proceduresGoal: Measure Functional level It identifies what the patient needs.Adaptive accommodationsMaximize their quality of life and/ appropriate support

PERSONALITY & AGING

per·son·al·i·ty

pərsəˈnalədē/

Noun: the combination of characteristics or qualities that form an individual's distinctive character.

synonyms: character, nature, disposition, temperament, makeup, persona, psyche

ag·ing

ˈājiNG/

the process of growing old.

PERSONALITY TYPESDSM V criteria basedNarcissisticHistrionicDependentAntisocialSchizoid

Myers-Briggs introspective based 16 types 4 items per type

Extra version vs introversion Sensing vs intution Thinking vs feeling Judging vs perceiving

A COMPLEMENTING COMBINATIONNeurology and Neuroimaging

•Display space occupying lesionsNeurocognitive testing

Produces a taxonomy of the brain behaviors and can detect abnormalities that are not visible on neuroimaging•Compares them to age and education based norms.

•Gives information about cognitive abilities (not just memory)

CLINICAL EVALUATIONNeurocognitive TestingShort-term memory & verbal learningWorking memory Logical memory Delayed recall Logical memoryConfrontational namingFrontal lobes executive functioning Left frontal lobe skills of abstract categorization and verbal reasoning Right frontal lobe skills of complex sequencingProcedural memory

FRONTAL LOBE FUNCTIONS

Right Frontal lobe Judgment Planning Complex sequencing Non-verbal reasoning

Executive Functions

Sustained attention

Goal directed behavior

Left Frontal Lobe Abstract categorization Expressive language Verbal Reasoning

Working memory

Impulse control and response inhibition

Verbal fluency

FRONTAL LOBE EXECUTIVE PROCESS

RegulationActs as Ego and superego self controlWhen disinhibited very much impulsive like the ID

GENERAL FALSE STEREOTYPES OF AGINGAlzheimer’s disease is to be expected with old ageSickness and disability come with old ageOlder people cannot learnOld people are weak and helplessOld people are boring and forgetfulOld people are unproductiveOld people are grouchy and cantankerous

STEREOTYPES Grumpy old man

The old guy who loves to complain about how things were better in his day, and that kids these days show no respect.

“damn young’uns, no respect, don’t know how good they have it?. In my day we had to walk 15 miles through the snow to get to school, uphill both ways! And we didn't complain, no sir, we were happy, and we got a dime a year to work 17 hours a day in the mines, one cent an hour, but did we complain? NO!”

Little old Italian/Greek Mother/grandmother

The old lady who is boss, everyone in the family listens her and obeys out of a mix of fear and respect but she has absolutely no idea what’s going on in reality.

STEREOTYPES

Dirty Old Man Disinhibited and often inappropriate. (deacon with right frontal lobe infarction)

Crazy Old Cat Lady

This person is invariably not good with people, she usually only has an affinity with one specific type of animal. She lives alone except for the large number animals living with her. She is often feared by the community and seen as an eccentric recluse.

What is acceptable and what is not?

MOOD VS PERSONALITY VS COGNITIVE DECLINE

Case examples

Anxiously avoidant and helpless

(refusing support and care, lack of self care, deconditioning. )

Unresolved bereavement with memory loss

Sorrowful irritable stubbornly independent with estranged family and recovered alcoholic.

NORMAL AGINGSlowed processing speed The ability to process new information

Decreased working memory The ability to process and manipulate new information Critical for encoding information

Sustain recall previously learned information Wisdom Book smarts

Decreased cognitive flexibility and logical thinking Street smarts

ISSUES OF AGINGLosses Friends, retirement & financial

BereavementAnger, denial, anger/guilt, depression & acceptance

Physical declineMobility, vision, hearing, arthritis, pain, deconditioning,

& shortness of breath

WHEN DOES MEMORY LOSS BEGIN

Memory Loss affects nearly ¼ of those over age 65 At age 2 the brain is about 85% developedAround age 16 the brain is fully developedAround age 25 the brain begins to deteriorate.Around age 85 the brain has deteriorated about 15%.

RESEARCH SAYS…

Stereotypical “grumpy older people” are clearly less widespread than we like to assume.

EXISTENTIAL CRISIS

Meaning of relationships

Sense of giving back rather than takingWhat will I be remembered for?

Erickson 8th stage of maturity Ego Integrity vs. Despair Reflection on and acceptance of one's life and sense of oneself feeling fulfilled with an established identity of one’s self. Anguish or depression if the sense of wisdom has not bee achieved.

DEPRESSION IMITATES NEUROLOGICAL SYMPTOMS

Flattened AffectDisconnection of neurons from the limbic system

Common among individuals who suffer Parkinson’s Disease Sub-cortical ischemic changes

IrritabilityConfusion A good defense to intimidate the

other person

Anxiety

Disinhibition syndrome

DEPRESSION IMITATES NEUROLOGICAL SYMPTOMS

Vegetative symptomsLethargy and Apathy

A decline in executive functioning Impaired sustained attention Impaired goal-directed behavior Concentration Impaired working memory

Planning Complex sequencing Initiation and switching of activities Multi-tasking Impaired task initiation

WorthlessnessAccurate appraisal of some cognitive decline and feeling inadequate to function and fear of confusion.

This is a combination of both organic changes and a mood disorder.

HOW TO HELP TELL NORMAL AGING AND CHANGES IN PERSONALITY FROM DEPRESSION AND NEUROLOGICAL SYMPTOMS???

Diagnostic process

Medical history

Physical examination and laboratory tests

Personal interviews with patient and family members (social history)

Memory screening

Neuroimaging

Based on progression of symptoms over time, a diagnosis is made and care planning and treatment begin

NEUROPSYCHOLOGICAL EVALUATION

Diagnostic interview with the patient and loved onesReview history to assist in making the differential diagnosisDetermine appropriate testing battery to measure brain function

FEEDBACK FOR PATIENT AND FAMILY CARE PLANNING

Doctor and health care team provide recommendations, prescriptions and planCare planning Home modification and adaptation

Future planning Legal Financial Family intervention and care

Safety Driving Medication management Nutrition Assisted living care

THE BENEFITS OF BASELINE OR SCREENING

Neuropsychological screenings are recommended by the American Academy of Neurology

Abnormal screenings may help lead to early detection and intervention

Normal screen may provide reassurance for the “Worried Well”

The Mini Mental Status Examination can both under- or over-identify frontal lobe and memory problems

Annual screening for symptomatic individuals over the age of 65

EARLY DETECTIONDifferential diagnosisVascular Dementia vs. Alzheimer’s Disease and Pseudo-Dementia

Early interventionMedications

PlanningAddress safety issues Home living vs. long-term care Seek out resources Take legal action

PreventionHazardous situations and needless distress

EXERCISE YOUR BODY

Bad memory is linked to heart disease and diabetes

Clogged arteries slow blood flow in the brain

Heart healthy foods are important for the brain as well as the heart Low fat glycemic index foods Low sodium

TREATMENT DEVELOPMENT AND TRAINING

Educate caregivers about an individual’s strengths

Provide feedback about effective and ineffective strategies

Identify cognitive weakness which create an increased frustration for the individual and increased resistance for caregivers

Help caregivers with acceptance of the changes the loved one has undergone

COGNITIVE SKILLS AND CASE EXAMPLES

TRAILS B FRONTAL LOBE DISINHIBITION SYNDROME

CLOCK DRAWINGS83YR OLD ALZHEIMER’S DEMENTIA WITH AGITATION AND FRONTAL LOBE DISINHIBITION

95YO MILDRED, NURSING HOME RESIDENT, DX 331.0 ALZHEIMER’S DEMENTIA REFERRED FOR MARKED BEHAVIORAL CHANGES, ER, WAS WILDLY COMBATIVE

THANK YOUFOR ADDITIONAL QUESTIONS

AND CONSULTATION PLEASE CONTACT

(630) 424-8900.ARCC NEUROPSYCHOLOGY

Randy Summerville, Psy.D. Shani Bensman, Psy.D.

Greg Malo, Psy.D.Alexis Silas, Psy.D.

Kristin Clifford, Psy.D.

Sue Robinson, LCSWMadison Hurd, Psy.D., Post

Doctorate FellowKristen Wright. PsyD, Post

Doctoral Fellow