Aging
Or: how everything falls apart.
References and Handouts
http://www.brown.edu/Courses/BI_278/
Everything Changes
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Psychological issues
Socioeconomic
Physical health
Mental Health
The stats on # elderly
• Increased 10-fold in last century
• Currently
– 35 million > 65
– 13% population
• By 2030
– 70 million
– 1/5 Americans > 65
– 1/11 > 85
More stats
• Gender (percentage women)
– > 65 58%
– > 85 70%
• Ethnicity
– Will be more diverse
• Currently 85% white
• By 2050, 64%
Everything Changes
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Psychological issues
Socioeconomic
Physical health
Mental Health
Psychological issues
– Aging has unique
• Challenges
• Life stresses
Ex. Erickson
Stage
Age
Basic Conflict
Oral-Sensory
Birth-12/18mo.
Trust v. Mistrust
Muscular-anal
18 mo – 3 yrs
Autonomy v.
shame/doubt
Locomotor
3-6 yrs
Initiative vs. guilt
Latency
6-12 yrs
Industry vs. inferiority
Adolescence
12-18yrs
Identity vs. role
confusion
Young Adulthood
19-40 yrs
Intimacy vs. isolation
Middle Adulthood
40-65 yrs
Generativity vs.
stagnation
Maturity
65-death
Ego Integrity vs.
despair
Stage 8: Maturity
• Age: Late Adulthood -- 65 years to death
• Conflict: Integrity vs. Despair
• Important Event: Reflection on and
acceptance of one's life
Stage 8: Maturity
• Elements for a positive outcome:
The adult feels a sense of fulfillment about
life and accepts death as an unavoidable
reality.
• Elements for a negative outcome:
Individuals who are unable to obtain a
feeling of fulfillment and completeness will
despair and fear death.
Other development
approaches
• Psychodynamic
– Formation versus elaboration of psychic
processes
• Levinson1
– Structure building and changing
– Periods of transition
1
Levinson, D. (1986). A conception of adult
development. American Psychologist, 41:3-13.
Unique challenges of the
elderly
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Losses
Disablement
Driving
Health concerns
What do the elderly worry
about?
45
40
35
30
25
20
15
10
5
0
Money
Health
Loneliness
Crime
National Council On Aging,
2000
Everything Changes
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Psychological issues
Socioeconomic
Physical health
Mental Health
Socioeconomic changes
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Retirement
Finances
Social security
Medicare
Living situations
Retirement
• Median age
– Men: 62.7
– Women: 62.6
Finances
• 65+:
– net worth = $92,399
• White = $181,000
• African American = $13,000
– annual household income = $22,812
Percent Living in Poverty
• Elderly: 12.1%
– 3 points below general
pop
White
Asian
AA
Hisp
Living situations
• Among 65+
– 80% own home
• 75% single unit/detached
– 45% live alone
– 17% elderly householder had no
transportation
Nursing Homes
• 65+
– 4% (1.46 million people)
• 85+
– About 192 out of every 1,000
Everything Changes
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Psychological issues
Socioeconomic
Physical health
Mental Health
Physical Health
• Self perception
• Survey of Americans age 65 (1996-96)
– vast majority considered themselves healthy.
• Whites: 74%
• AA’s: 59.3 %
• Hispanics 64.9%
The 3 big killers
• Heart disease
• Cancer
• Stroke
• Mortality rates
– Hrt Dx/Stroke: decr 1/3 since 1980
– Cancer: up slightly
Effects of Aging on the Body
• Bottom line
– Most of the news is bad.
• The question
– How much is inevitable?
Examples of things we can’t
change
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Ocular accommodation
Cardiac hypertrophy
GI: malabsorption/intolerances
Loss of immunity/allergies
Loss of brain volume
Examples of things we can
change somewhat
• Loss of skin elasticity
• Auditory acuity
• Cardiac loss of elasticity
Examples of things we can
change a lot
• Muscle Mass, Muscle/Fat Ratio
• Osteoporosis
• Functional Cognition
Everything Changes
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Psychological issues
Socioeconomic
Physical health
Mental Health
Prevalence of SMI over age 18 (2.8%)
60
50
51.3
42
40
18-24
30
20
21.6
25.9
20.6
15.7
10
6.5
0
SMI
Non-SMI
16.4
25-44
45-64
65+
Why Rates in Elderly are Low?
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Greater difficulty remembering past symptoms
Less psychologically oriented
Greater mortality
Cohort effect
Sampling errors
Instrument errors
Diagnostic challenges
Elderly Specific Criteria?
Diagnostic Criteria
Major Depression
Prevalence
AGECAT
11.4
DSM-IV
4.5
Age 65+ Edmonton Canada
Newman et al. Psychological Medicine 28; 1998
Oupatient General Medical Utililization
by Age
80
70
60
50
40
30
20
10
0
N
ew
H
55-64
65-74
75-84
85+
a
n
e
v
B
al
m
ti
e
r
o
S
t.
Lo
s
i
u
D
h
r
u
am
,
N
C
Mental Health Utilization by Age
16
14
12
10
8
55-64
6
65-74
4
75-84
2
85+
C
N
is
u
,
m
a
rh
u
D
S
t.
L
im
B
a
lt
a
H
w
e
N
o
o
ve
re
n
0
Some specific diseases
Psychotic Disorders
Schizophrenia
Age
1-Month
1-Year
Lifetime
All
0.7
1.0
1.5
65+
0.1
0.1
0.3
Schizophrenia
1.5
1
All
0.7
65+
0.3
0.1
1-Month
0.1
1-Year
Lifetime
Psychosis in the Elderly
• Negative versus positive symptoms
• Look for alternative causes
– Esp. if NEW ONSET or no history
• Most common:
– MEDS
– ACUTE problems: infections, metabolic.
» Tumors, etc. less common
Mood Disorders in the Elderly
Manic Episode
0.8
0.6
0.5
All
65+
0.1
0.1
0
1-Month
1-Year
Lifetime
Depressive Episode
6.3
3.7
All
2.2
2
1.4
0.7
1-Month
1-Year
Lifetime
65+
Depression in the Elderly
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Why so low? (see earlier…)
Forme Frustres
“Pseudodementia”
Diagnosing depression in complex cases
– How to approach…
Anxiety Disorder in the Elderly
Panic Disorder
1.6
0.9
All
65+
0.5
0.4
0.1
1-Month
0.2
1-Year
Lifetime
Anxiety Disorders
• Primary Versus Secondary
– Common Secondary Causes
• Drugs
• Medical Illness (cardiac, respiratory)
• Disorders that confuse (dementia, delirium)
Substance Abuse in the Elderly
Alcohol Abuse/Dependence
13.8
7.5
All
6.3
65+
3
0.9
1-Month
1.8
1-Year
Lifetime
Substance Abuse
• Gender differences and drug choice
Dementia
Problems in Dementia
Prevalence Studies
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Size of sample
Sample composition
Age range
Proportion of very old
Education
Method for case identification
Content of Interview
Supplementary diagnostic information
Diagnostic criteria (NINCDS-ADRDA v DSM)
Prevalence Estimate
Age Specific Prevalence
45
40
35
30
25
20
15
10
5
0
60-64 65-69 70-74 75-79 80-84 85-89 90-95
Jorms (1987)
Stages of Dementia
• Depend on both
– Cognitive ability
• Testing
– Functional Ability
• Observe, ask.
Special Settings
One-Year Prevalence of Mental Disorders
in Nursing Homes Estimates from ECA
18
16
14
12
10
All
65+
NH
8
6
4
2
0
Schiz Mania
Dep
OCD
Panic
Differences in the Psych.
Interview in the elderly
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Use of multiple sources
Respect for confidentiality, but…
Relaxing of boundary issues
Focus of interview
– Symptoms versus stories
• Explanations and honesty
• The power of genuine interest
Epilogue: the question you are
all asking
• How can I age well?
To stay healthy
• Pick really healthy parents
Other things you can do
• Don’t smoke
• Low-fat, high-fiber diet
• Exercised vigorously for AT LEAST 30 min
ALMOST EVERY day
• Maintained a healthy weight
• Consume a moderate amount of alcohol (about
one drink per day).
• All 5 = 80% reduction in heart attack/stroke risk
– Which then also helps cognitionPrimary prevention of coronary heart disease in
women through diet and lifestyle. M. Stampfer, et
al., The New England Journal of Medicine, 2000,
vol. 343, pp. 16--22