Chapter 16
Aging and Psychological
(Cognitive) Disorders
Ch 16
Issues in Aging
• Cultural view of the aged in the U.S.A. is typically
negative
• Aging may have a greater negative impact for
– Women
– Minorities
• Ageism refers to discrimination against any
person based on age
– Can be young or old person
Ch 16.1
Diversity in Aging
• Levels of “old”
– Young-old: ages 65-74
– Old-old:
ages 75-84
– Oldest-old: over age 85
• The one aspect that the elderly have in common
is age
– The elderly differ from one another as well as from
other age groups
Ch 16.2
Measurement Issues in Aging
Research
• Age effects are the consequences of being a
given chronological age
• Cohort effects are the consequences of having
been born in a particular year and having grown
up during a particular period of time
• Time-of-measurement effects are confounds that
arise because particular historic events have
specific effects
• Selective mortality refers to a bias due to the least
able people drop out as the studies proceed
Ch 16.3
Table 16.1 Age, Cohort, and
Time-of-Measurement Effects
Brain Disorders in Old Age
• Dementia refers to a gradual deterioration of intellectual
ability that Interferes with social and occupational function
• Dementia can involve problems in
– Memory
– Poor hygiene
– Language disorder
– Faulty judgment
– Delirium (state of mental confusion)
• Distinguishing cognitive symptoms of depression from
early dementia may be difficult
• Prevalence of dementia
– 1% (65-74yrs), 4% (75-84yrs), 10% (over 84yrs)
Ch 16.4
Dementia: An Overview
• Nature of Dementia (BD, 3rd. Edition)
– Gradual deterioration of brain functioning
– Affects judgment, memory, language, and advanced cognitive processes
– Dementia has many causes and may be reversible or irreversible
• Progression of Dementia: Initial Stages
– Memory impairment, visuospatial skills deficits
– Agnosia – Inability to recognize and name objects (most common
symptom)
– Facial agnosia – Inability to recognize familiar faces
– Other symptoms – Delusions, depression, agitation, aggression, and
apathy
• Progression of Dementia: Later Stages
– Cognitive functioning continues to deteriorate
– Person requires almost total support to carry out day-to-day activities
– Death results from inactivity combined with onset of other illnesses
Alzheimer’s Disease
• Alzheimer’s Disease involves a progressive
deterioration of the cerebral cortex and
hippocampus leading to difficulty in concentration
and memory loss (50% of old age dementia; more
common in women--why?)
• Alzheimer’s disease involves
– Loss of nerve cells within brain due to amyloid plaque formation
and neurofibrillary tangles
– Reduced activity of the neurotransmitter acetylcholine (ACh)
– The role of amyloid proteins (apoE-2, apoE-3, and
apoE-4)
– Brains of Alzheimer’s patients tend to atrophy
Ch 16.5
Dementia of the Alzheimer’s
Type: An Overview
• DSM-IV Criteria and Clinical Features
– Multiple cognitive deficits that develop gradually and steadily
– Predominant impairment in memory, orientation, judgment, and
reasoning
– Can include agitation, confusion, depression, anxiety, or
combativeness
– Symptoms are usually more pronounced at the end of the day
• Range of Cognitive Deficits
– Aphasia – Difficulty with language
– Apraxia – Impaired motor functioning
– Agnosia – Failure to recognize objects
– Difficulties with planning, organizing, sequencing, or abstracting
information
– Impairments have a marked negative impact on social and
occupational functioning
Alzheimer’s Disease: Some Facts
and Statistics
• Nature and Progression of the Disease
– Deterioration is slow during the early and later stages, but rapid
during middle stages
– Average survival time is about 8 years
– Onset usually occurs in the 60s or 70s, but may occur earlier
• Prevalence of Alzheimer’s Disease
– Affects about 4 million Americans and many more worldwide
– Prevalence is greater in poorly educated persons and women
– Prevalence rates are low in some ethnic groups (e.g., Japanese,
Nigerian, Amish)
Genetics of Alzheimer’s Disease
• Strong evidence for genetic basis of ALZ
• Chromosome 21 contains a gene that controls the formation of
amyloid which forms plaques
– The chromosome 21 gene accounts for 5% of early onset
Alzheimer’s cases and no person with this gene has made it past
the age of 67 without developing Alzheimer’s disease
• Chromosome 19 contains a gene allele that controls the likelihood of
developing Alzheimer’s (1=50%, 2=90%) (diathesis)
• E4 allele related to Alzheimer’s disease among Caribbean Hispanics
• E4 allele are likely cause of higher rates among degree relatives of
African Americans with the disease.
• Environmental stress may play a role(e.g., head injury, depression)
and educational level (cognitive ability) may be a protective factor.
Ch 16.6
Factors that may prevent
Alzheimer's
•
•
•
•
•
Anti-inflammatory drugs such as ibuprofen
Nicotine
Cholesterol reducing statins
High levels of cognitive ability
Maintaining high levels of cognitive activity
Frontal-Lobe Dementias
• Frontal-Temporal dementia (10-15% of
cases)(e.g., Pick’s disease) involves
– Cognitive impairments of memory
– Extreme behavioral & personality changes (apathy,
impulsivity)
– Loss of serotonin neurons in brain (rather than Ach)
• Frontal-Subcortical dementias include:
– Parkinson’s disease (muscle tremors)
– Huntington’s chorea (muscle writhing)
– Vascular dementia (muscle weakness-stroke) is the
second leading cause of brain disorders in old age, and
the prevalence is higher in men
Ch 16.7
Vascular Dementia
• 2nd only to Alzheimer’s disease as a cause
of dementia (stroke is the 3rd leading
cause of death in US, 500,000 die each
year)
• Lifetime risk of vascular dementia is 4.7%
for men, 3.8% for women;
• Usually sudden onset (from a stroke)
Dementias Due to Other General
Medical Conditions (DSM-IV)
• Dementia due to HIV disease
•
“
“ traumatic brain injury
•
“
“ Parkinson’s disease
•
“
“ Huntington’s disease
•
“
“ Pick’s disease
•
“
“ Creutzfeldt-Jakob disease
•
“
“ Other infectious diseases (e.g.
encephalitis, meningitis)
•
“
“ normal-pressure hydrocephalus
•
“
“ endocrine gland dysfunction (e.g., hyperthyroidism)
•
“
“ brain tumor
•
“
“ B-complex vitamin deficiency
•
“
“ toxin exposures damaging liver or kidneys
Treatment of Dementia
• Alzheimer’s Disease has no treatment to halt or reverse
the disease
– Drug studies seek to boost remaining acetylcholine
(Ach) function in brain using
• Drugs that block the breakdown of Ach (e.g., Aricept)
• Drugs that block the formation of B-amyloid
– Drugs are used to treat the specific symptoms of
Alzheimer’s disease (depression, anxiety, sleep
disorder)
• Psychological therapy is to be supportive
• Dementia due to known infectious diseases, nutrition
deficiencies, and depression can be treated if it is caught
early (BD, 3rd. Edition).
Ch 16.8
Amnestic Disorder: An
Overview
• Nature of Amnestic Disorder
– Circumscribed loss of memory
– Inability to transfer information into long-term memory
– Often results from medical conditions, head trauma, or
long-term drug use
• DSM-IV Criteria for Amnestic Disorder
– Cover the inability to learn new information
– Inability to recall previously learned information
– Memory disturbance causes significant impairment in
functioning
Amnestic Disorder: An
Overview (cont.)
• The Example of Wernicke-Korsakoff
Syndrome
– Caused by thalamic damage resulting from
stroke or chronic heavy alcohol use
– Attempt to restore thiamine deficiency in the
case of chronic alcohol abuse
• Research on Amnestic Disorders Is Scant
Delirium
• Delirium is a clouded (disturbed) state of consciousness
involving
– Acute onset, fluctuating, reversible disturbance
– Difficulty in concentration
– Disruption of the sleep-waking cycle
– Incoherent speech
– Memory impairment for recent events
– Perceptual disturbances (delusions and hallucinations)
– Mood/activity swings
• May occur at any age, but particularly common in hospitalized older
adults (10-45% in acute care units)
• Mortality rate for delirium is about 40%
• May be misdiagnosed as irreversible dementia (differential diagnosis
is important---see D&N text, pp. 532-534)
Ch 16.9
Causes and Treatment of
Delirium
• Causes of delirium include
–
–
–
–
–
–
Drug intoxications and drug-withdrawal reactions
Metabolic/nutritional imbalances (e.g., diabetes)
Infections (fevers)
Stress (environmental change)
Major surgery
Brain damage
• Treatment of delirium
– Recovery to “status quo ante” is possible if properly
diagnosed and underlying cause is promptly and
effectively treated
Ch 16.10
Table 16.2 Comparison of
Dementia and Delirium
Depression in the Elderly
• The prevalence of mood disorders is less in the
elderly (< 3 %) than in young people (20 %).
– Bipolar depression is rare in the elderly
– Symptoms of depression are similar in the elderly
expect that feelings of guilt are less common and
somatic/memory complaints are more common
– Suicide attempts and completions increase for men as
they age
• Differential diagnosis with dementia is important
– Cognitive impairment found in both, but reversible in
case of depression
Ch 16.11
Causes of Depression in the
Elderly
• Depression in the elderly is associated with
– Poor physical health
– Medications that aggravate existing depression
•
•
•
•
Antihypertensive medications
Hormones
Corticosteroids
Antiparkinsonism medications
– Stressors
Ch 16.12
Anxiety Disorders in the Elderly
• Anxiety disorders are more common than
depression in the elderly
– Anxiety per se is quite common in the elderly
• Anxiety is associated with
– Medical illness or anticipation of illness
– Medication reactions
– Delirium accompanying illness
– Cardiovascular conditions (angina)
– Caffeine consumption
Ch 16.13
Delusional (Paranoid)
Disorders in Old Age
• May be a continuation of a disorder that began
earlier in life, or may accompany brain diseases
such as delirium or dementia
• Paranoid ideation may be related to sensory
losses, especially loss of hearing (see Zimbardo
analogue study, D&N, pp 542-543)
• Paranoid delusions may be related to social
maladjustment following isolation
• Be careful to rule out actual abuse of the elder as
a factor in the paranoid delusion
Schizophrenia in the Elderly
• Prevalence of schizophrenia is lower in the elderly
than in the young
– Schizophrenics die young
– Some schizophrenics show remission of their
symptoms as they enter old age
– Schizophrenia rarely has an onset after age 60
• Paraphrenia is the term used to characterize the
onset of schizophrenic symptoms in an older
person (more hallucinations and delusions)
• Paraphrenia may be a misdiagnosed mood
disorder or brain disorder (dementia, delirium)
Ch 16.14
Substance-Related Disorders
• Substance abuse is less prevalent among
the elderly than the young
– Alcohol abuse can have onset in the elderly
• Tolerance for alcohol is reduced in old age
• Older people metabolize alcohol more slowly
– Illegal drug abuse is expected to increase
among the elderly
– Medication misuse occurs in the elderly
• The elderly are 13% of the population but receive
33% of the legal prescriptions
Ch 16.15
Sleep Disorders
• Insomnia is a common (25%) sleep problem
in the elderly
• Other common sleep problems include
– Frequent awakenings at night
– Early morning awakenings
– Difficulty following asleep
– Daytime fatigue
• Elderly show reduced sleep time and less
time spent in REM sleep
Ch 16.16
Treatment of Sleep Disorders
• Older adults use a variety of medications to
treat sleep disorder and each have
associated problems:
– Sleeping pills lose their effectiveness and
cause sleep disorder (REM rebound sleep)
– Tranquilizers have adverse side effects such as
disruption of learning and reduced thought
clarity during the following day
– Alcohol reduces REM sleep
Ch 16.17
Suicide
• Older people are more likely to experience suicide
risk factors such as illness, social isolation, loss of
loved ones and financial pressure
• Suicide rates increase for men as they age and
decrease slightly for women
• Older people are less likely to communicate
suicidal intent and are more successful in their
suicide attempts
Ch 16.18
Sexuality
• Older people can maintain an active sex life
• Changes in sexuality in the elderly include
– Older men require longer to acquire an erection
• Erections fade more quickly after ejaculation
• Refractory period lengthens in elderly men
– Older women require more time to become
sexually aroused
• Vaginal lubrication is less in older women
• Older women return more quickly to a non-aroused
state
Ch 16.19
Treatment and Care of Older
Adults
• Nursing Homes
– Loss of control and mindlessness in nursing homes
• Alternative Living Settings (Assisted Living)
• Community-Based Care
• Interdisciplinary Teamwork in Geriatric Health
Care
• Issues specific to therapy with older adults
– Erikson’s “integrity vs. despair” crisis
– Importance of “Life Review” approach
Figure 16.1 Geriatric
Interdisciplinary-Team Role Map