Disorders of Aging and
Cognition
Chapter 18
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology, 8e
DSM-5 Update
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
2
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
7
Depression in Later Life

Like younger adults, older people who are
depressed may be helped by cognitivebehavioral therapy, interpersonal therapy,
antidepressant medications, or a
combination of these approaches
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
11
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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 cognitivebehavioral therapy
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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…
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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


The temporal lobes and the diencephalon


Appear to hold information temporarily and to continue
working with the information as long as it is needed
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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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 CreutzfeldtJakob 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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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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
Comer, Abnormal Psychology, 8e
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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
Comer, Abnormal Psychology, 8e
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