Lecture 11- Mental Disorders
Overview
1. Defining Psychopathology
2. Cognitive Disorders
Dementia
Delirium
3. Other Mental Disorders
Depression
Anxiety (see text)
Lecture 11- Mental Disorders
Overview
4. Clinical Concerns
Elder Abuse
Suicide (see text)
5. Psychological Issues in
Long-Term Care
6. Myth Busting: Facts on Aging
Revisited
Psychological Disorders in Adulthood
Psychopathology=
Science of psychological disorders
Lie outside range of ordinary
human experience
•Subjective distress
•Impaired in everyday life
•Cause risk to self or others
•Engage in socially or culturally
unacceptable behavior
Psychological Disorders in Adulthood:
Diagnosis of Psychological Disorders
Diagnostic and Statistical Manual of
Mental Diseases (DSM-IV)
•Based on field studies of specific disorders
•Not developed specifically for older adults
Diagnostic process
•Match symptoms to those in manual
•Must meet specific criteria
•Develop treatment plan
Psychological Disorders in Adulthood:
Diagnosis of Psychological Disorders
DSM-IV Diagnostic Axes
Axis I
Clinical syndromes or disorders
Axis II
Personality disorders and mental
retardation
Axis III
Medical conditions
Axis IV
Psychosocial stressors
Axis V
General level of functioning
Terminology
Epidemiology
•Lifetime prevalence- percentage of people who
ever have had the disorder
•Incidence- new cases within given period
Cognitive Disorders (DSM-IV)
1.Dementia
2. Delirium
3. Amnestic Disorder
4.Cognitive Disorder Not Otherwise Specified
Cognitive Disorders: Dementia
Definition of Dementia
Dementia
Common
signs
•Clinical condition/syndrome
•Loss of cognitive function
•Interferes with normal activities
•Interferes with social relationships
1. Impairment of memory
2. Multiple disturbances of cognition
3. Impairment of executive function.
4. Disorientation.
5. Behavioral changes.
Dementia: Causes
1.Reversible
2. Irreversible
Reversible Dementia (some causes)
Dementia due to treatable condition:
•infections
•toxic effects of drugs (polypharmacy)
•normal pressure hydrocephalus
•head injury
•nutritional deficiencies
Korsakoff’s syndrome (vitamin B1)
Wernicke’s disease
•metabolic problems (e.g., hypothyroidism)
•mental and sensory deprivation
•Depression (pseudodementia)*
•Delirium*
Important to
treat early
Can become
irreversible
Irreversible: Neurological Diseases that
Can Cause Dementia
Disorder
Cause
Vascular
dementia
Transient ischemic
attacks
Frontal lobe
dementia
Damage to
frontal lobes
Major symptoms
More rapid decline than AD, decline
occurs in spurts
Parkinson’s
disease
Personality changes- apathy, lack of
inhibition, obsessiveness, loss of
judgment
Lack of dopamine in Tremors, shuffling gait, postural
basal ganglia
instability, speech problems
Lewy Body
dementia
Accumulation of
Lewy bodies
Confusion, hallucinations, motor
deficits
Pick’s
disease
Accumulation of
Pick bodies
Frontal and temporal lobe deterioration,
personality changes, loss of speech.
HIV dementia
Final stages of AIDS Apathy, confusion, concentration
problems, flattened emotions
Irreversible: Neurological Diseases that
Can Cause Dementia
Disorder
Cause
Major symptoms
Huntington’s
Hereditary
(chromosome 4)
Choreiform movements, loss of
detailed memories, decreased higher
order executive skills
CreutzfeldJakob
Slow virus
rapid dementia and decline
Down’s
Syndrome
Extra
chromosome 21
Alzheimer’s
Disease
Detailed notes
Mental retardation
Detailed notes
Canadian Study of Health and Aging
(1991-1992)
Prevalence
Normal
Dementia
8% of all Canadians aged 65+ meet
the criteria for dementia.
Prevalence of dementia in Canada: Canadian Study
of Health and Aging (1991-1992)
• Female to male ratio is 2:1
• 2.4 % for 65-74 years
• 34.5% for those aged 85+
• If prevalence estimates remain constant,
592,000 persons will have dementia by
2021
Prevalence of Alzheimer’s Disease and
Vascular Dementia in Canada
• Alzheimer’s 5.1% for 65+
– 1.0% for 65-74 years
– 26% for 85+ years
• Vascular dementia 1.5% for 65+
– 0.6 % for 65-74 years
– 4.8 % for 85+ years
Dementia: Vascular Dementia
Features
•Associated with damage to the cerebral blood vessels
through arteriosclerosis
•found in middle and later life (age of onset between 50-70)
•accumulated effect of multiple cortical and subcortical infarcts
lead to clinical presentation
•incidence higher in men
•first sign delirium or small stroke
Dementia: Vascular Dementia
Clinical Presentation
•Abrupt onset
•step-wise deterioration
•somatic complaints
•emotional incontinence
•history of hypertension
•history of cebrovascular accidents
•focal neurological symptoms
•focal neurological signs
Dementia:Alzheimer’s Disease History
Alois Alzheimer (1864-1915)
•Patient Auguste D. had dementia
symptoms
•Brain studies after her death revealed
microscopic changes
•Symptoms due to neuronal changes
Dementia and Related Neurological
Disorders: Alzheimer’s Disease
NINCDS/ADRDA Guidlines
Criteria for probable Alzheimer’s diagnosis=
•Dementia
•Significant cognitive deficiencies
•Progressive deterioration
•No loss of consciousness
•40-90 years of age
•No other diseases
Also includes
•Medical tests
•Family history
•Brain scans
•Other symptoms
Alzheimer’s Disease: “Stages” of Progression
Psychological Symptoms
Early
Memory loss for familiar
objects and events
Middle
Personality changes
Behavior changes
Late
Loss of ability to perform simple
everyday functions
People do not die of Alzheimer’s per se.
Regular
progression
of
loss
Clinical Presentation:
•Memory loss
•Aphasia
•Apraxia
•Agnosia
•Disturbance in executive functioning
Diagnosis
done by
exclusion
Autopsy is only
reliable method
Clinical Presentation
Alzheimer’s Disease
Amyloid Plaques
Amyloid plaque
•Collection of waste
products of dead neurons
around a core of amyloid.
•Formation occurs long
before symptoms are
evident
•Amyloid-42 most common form found in plaques
Alzheimer’s Disease
Formation of amyloid plaques
•Proteases snip the APP into fragments.
•If APP is snipped at wrong place,
beta amyloid 42 is formed.
•Beta amyloid fragments eventually
clump together.
Alzheimer’s Disease
Tangles
http://www.ahaf.org/alzdis/about/AmyloidPlaques.htm
Alzheimer’s Disease
Neurofibrillary Tangles
•Made up of tau protein
•Tau maintains microtubules
within axons
•Tangles form when tau
changes chemically and can
no longer support the
microtubules
•Leads to collapse of
transport system within
neuron
Neurofibrillary
tangle
Alzheimer’s Disease
Neurofibrillary Tangles
http://www.alzheimers.org/tangle.html
Alzheimer’s Disease
Causes of Alzheimer’s Disease
Familial
Alzheimer’s
Disease
•Early onset
•Late onset
supports
Gene
Genetic theory
Chromosome
ApoE gene
19
APP gene
21
Presenilin 1
14
Presenilin 2
1
Alzheimer’s Disease
Causes of Alzheimer’s Disease
Familial
Alzheimer’s
Disease
•Early onset
•Late onset
supports
Gene
Genetic theory
Chromosome
ApoE gene
19
APP gene
21
Presenilin 1
14
Presenilin 2
1
Majority of
early-onset
cases
Alzheimer’s Disease
Causes of Alzheimer’s Disease
Environmental
Life style
•Twin data
•Japanese men who moved
to Hawaii
•Nun Study on mental
activity
Head injury
•Severe injuries
involving loss of
consciousness
•Causes damage to
neurons
Treatment: Alzheimer’s Disease
Category
Action
Name
Anticholinesterase
Increases
available
acetylcholine
Glutamate
enhancers
Facilitate
Labazimide
glutamate
No trade
Stimulate
neuron growth name
Stop free
Seligiline
radicals
Nerve growth
factors
Antioxidants
Tacrine
Anti-inflammatory
Not known
Advil
HRT
Not known
Estrogen
Alzheimer’s Disease: Care for Person and
Caregiver
Psychosocial Treatments
•Person
•Prompts, cues, and guidance
•Modeling
•Positive reinforcement
•Structure daily activities
•modifications to environment
•caregiver
•Respite care
•Provide education
•info on the disease progression
•communication strategies
•support groups
Caregiver
burden
Lecture 11- Mental Disorders
Overview
1. Defining Psychopathology
2. Cognitive Disorders
Dementia
Delirium
3. Other Mental Disorders
Depression
Anxiety (see text)
Delirium (confusional state)
Definition
•Fluctuating clinical state characterized by
disturbances of attention, cognition, arousal,
mood and self-awareness
•common in the elderly
•often undiagnosed
Delirium (confusional state)
Symptoms
•Impairment in attention and disorientation
-distracted, slowed, disorganized thinking
•Hallucinations may be present
-usually more visual than auditory
•Fluctuating level of awareness
-mild confusion to stupor or active delirium
•Speech may be incoherent
•Confusion regarding day-to-day procedures or roles
•Remote and recent memory impaired
Delirium (confusional state)
Symptoms
•Restlessness, aggressiveness, frightened
•Delusions of persecution possible
•Disturbance of sleep-wake cycle
•Anxiety and lack of cooperativeness
•Fluctuations throughout day
•worse in the evening
•can be lucid intervals
Delirium (confusional state)
Causes
•Infections or fever
•strokes/cardiovascular disorders
•drug intoxication (polypharmacy or abuse) or withdrawl
•exacerbation of underlying medical illness
•metabolic and nutritional disorders
•postoperative stress*
•or other factors related to hospitalization such as
sleep loss, excessive sensory input
Delirium (confusional state)
Course and Treatment
•Brief duration (usually less than a week)
•some forms resolve on own
•other forms, treatment depends on cause
•while delirious
•carefully-controlled environment (not too stimulating)
•brief and continued reassurance
•monitor nutritional and fluid status of person
•help the caregivers understand what is going
Differential Diagnosis
Delirium
Dementia
• Rapid onset
• marked attentional
disturbance
• confusion
prominent/clouding of
consciousness
• fluctuating clinical
course
• agitation and behavioral
symptoms
• potentially reversible
• Usually insidious onset
• memory systems
impaired
• consciousness intact
• slower, progressive
course
• subtle behavioral
symptoms
• can be irreversible
Lecture 11- Mental Disorders
Overview
1. Defining Psychopathology
2. Cognitive Disorders
Dementia
Delirium
3. Other Mental Disorders
Depression
Anxiety (see text)
Depression
Mood Disorders and features
•Depressive disorders- sad mood
•Bipolar disorders- involve manic episode
•Dysthymic Disorder-chronic but less severe
•Mood disorders due to a general medical
condition
Diagnostic Features of Major Depressive Episode (DSM-IV)
Essential Features
Associated Symptoms
(5 of 9 required)
(1 of 2 required)
• Depressed mood
• Loss of interest or pleasure
•
•
•
•
•
•
•
•
•
Depressed mood for most of the day
marked reduction in interest in daily
activities
5% weight loss or significant change
in appetite (increase or decrease)
almost daily insomnia or
hypersomnia
almost daily physical agitation or
retardation
almost daily decreased energy or
fatigue
almost daily feelings of worthlessness
or feelings of guilt
almost daily decreased concentration
or decreased decisiveness
frequent thoughts of death or suicide
Depression
Prevalence of Depressive DIsorders
Lifetime prevalence:
NCS= 13% men
21% women
Persons over 65:
1% major depressive disorder
2% dysthymia (chronic but less severe depression)
However, 8-20% of older adults report symptoms
Depression
Higher Prevalence of Mood Disorders in
Medical Settings:
•12-20% in clinics and hospitals
•30% in long-term care settings
Can lead to greater risk of more
serious disorder and even fatal
impairment
Depression
Prevalence of Depressive DIsorders
Myth: aging leads to depression- old age
is depressing
Reality: rates for major depression are
lower in the elderly compared to younger
adults
Depression
Features of Mood Disorders in Older Adults
•Less likely to report traditional symptoms
involving negative feelings
•More likely to seek treatment for bodily
complaints
•Seek treatment for disorders other than mood
(anxiety, cognitive, bodily delusions)
Depression
Features of Mood Disorders in Older
Adults/causes
Depletion syndrome
Late-onset depression
•Lack of energy
•Hopelessness
•Loss of appetite
•Mild or moderate
•First appears after age
65
Depression
Causes of Age Differences in Mood Disorders
•Personality and emotional changes associated
with aging
•Cohort differences in experience of depression
Depression
Problems in Diagnosis of Mood Disorders:
•Older adults do not report symptoms accurately
•Professionals not attuned to diagnosis of older adults
•Not enough time spent with older adults
•Wish to avoid stigmatization
•Therapists unaware of benefits
•cognitive difficulty can accompany depression
•dementia and depression can both be present
“pseudodementia”
Depression
Differentiating Dementia and Pseudodementia
•Dementia has insidious onset (years)
•history of psychiatric problems more common in
pseudodementia
•dementia (mild) complains little about memory/concealmen
•depressive pseudodementia complains
•dementia- behavior in line with clinical severity
•depression- incongruities between behavior and
severity of cognitive deficit
Depression
Treatment
•Drug therapies
•Psychotherapy
Lecture 11- Mental Disorders
Overview
4. Clinical Concerns
Elder Abuse
Suicide (see text)
5. Psychological Issues in
Long-Term Care
6. Myth Busting: Facts on Aging
Revisited
Elder Abuse
Actions taken against older adults
through inflicting psychological or
physical harm
Types of
Abuse
•Physical
•Sexual
•Emotional or psychological
•Neglect
•Abandonment
•Financial or material
Elder Abuse
Prevalence Estimates in Canada
•Podnieks et al. (1989) interviewed (by phone)
community dwelling seniors
•Rate for abuse and neglect among seniors
is 4% overall
•material abuse (2.5%)
•chronic verbal agression (1.4%)
•physical violence (.5%)
•neglect (.4%)
Elder Abuse
Prevalence Estimates in Canada (region)
•B.C. 5.3%
•Prairies 3.0%
•Ontario 4.0%
•Quebec 4.0%
•Atlantic 3.8%
Elder Abuse (see this table in the text)
Highest risk for oldest old
Children most frequent abusers
Lecture 11- Mental Disorders
Overview
4. Clinical Concerns
Elder Abuse
Suicide (see text)
5. Psychological Issues in
Long-Term Care
6. Myth Busting: Facts on Aging
Revisited
Psychological Issues in Long-Term Care
Biopsychosocial Factors
Differences among residents in physical
functioning
PSYCHO- Variations in psychological resources
and needs
BIO-
SOCIAL
Cultural factors further influence
relationships
Psychological Issues in Long-Term Care
Competence-Press Model of Environmental Adaptation
Positive affect
Adaptive behavior
Competence
Negative
affect
Maladaptive
behavior
Negative
affect
Maladaptive
behavior
Press
Lecture 11- Mental Disorders
Overview
4. Clinical Concerns
Elder Abuse
Suicide (see text)
5. Psychological Issues in
Long-Term Care
6. Myth Busting: Facts on Aging
Revisited
Myth Busting: Facts on Aging
Revisited
#1 The majority of old people (age 65+) are
senile (have defective memory, are
disoriented, or demented)
False
Myth Busting: Facts on Aging
Revisited
#5 The majority of old people feel miserable
most of the time.
False
Myth Busting: Facts on Aging
Revisited
#7 At least one tenth of the aged are living in
long-stay institutions (such as nursing
homes, mental hospitals, homes for the
aged, etc.)
False (see text)
Myth Busting: Facts on Aging
Revisited
#10 Over three fourths of the aged are healthy
enough to do their normal activities without
help.
True
Myth Busting: Facts on Aging
Revisited
#13 Depression is more frequent among the
elderly than among younger people.
False