• Aging: Issues and Methods
    • Social problems of aging are especially severe for women (wrinkles, sagging skin) *signs of aging not valued in women
    • Old defined as over 65 – set by social policies
    • Young old = 65-74, old-old = 75-84, oldest-old = 85+
    • Number of elderly population is growing

Myths About Late Life

  • Psychologists must examine stereotypes about late life  Common myths:

1) Aging involves inexorable cognitive decline o Severe cognitive problems do not occur for most

o Mild declines are common (processing speed & working memory)

2) Late life is a sad time and most elderly are depressed o Older individuals report less negative emotion than younger people, more skilled at regulating emotions o More brain activation in key areas when viewing positive images

 

3) Late life is a lonely time o Focus shifts away from seeking new social interactions, interested in a few close relationships = social selectivity

  • 4) Older people lose interest in sex o Sexual activity does not decrease from mid-to-late-life for most people
  • Underreport somatic symptoms, no more likely to meet criteria for somatic symptom disorders than young people
  • Negative self-views about aging can predict earlier death

The Problems Experienced in Late Life

  • 80% of elderly have at least one major medical condition
  • Quality and depth of sleep decline, sleep apnea rates increase, sleep deficits can worsen physical/psyc/cognitive problems
  • Polypharmacy = the prescribing of multiple drugs to a person
  • 1/3 are prescribed at least 5 medications *increased risk of side effects, prescribed more drugs to combat side-effects
  • Most psychoactive drugs are tested on younger people *difficult to estimate appropriate does for elderly

Research Methods in the Study of Aging

  • Age effects = consequences of being a certain chronological age
  • Cohort effects = the consequences of growing up during a particular time period with its unique challenges and opportunities
  • Time-of-measurement effects = confounds that arise because events at a particular point in time can have a specific effect on a variable that is being studied (e.g. post-earthquake)
  • Cross-sectional studies = the investigator compares different age groups at the same moment in time on the variable of interest o Do not examine the same people over time, they do not provide clear information about how people change as they age
  • Longitudinal studies = researcher periodically retests one group of people using the same measure over a number of years or decades (e.g. Baltimore longitudinal study of aging) o Results may be biased due to attrition = participants drop out of the study due to death = selective mortality, or other problems

 

  • Psychological Disorders in Late Life
    • Same criteria used for older and younger adults
    • No psyc diagnosis if symptoms are accounted for by medical condition/side-effects o Thyroid problems, Addison’s disease, Cushing’s disease, Parkinson’s, Alzheimer’s, hypoglycemia, anemia, testosterone deficiencies, vitamin deficiencies produce symptoms that mimic side effects of schizophrenia, depression, anxiety

Estimating the Prevalence of Psychological Disorders in Late Life

  • Those over 65 have lowest prevalence of psyc disorders of all age groups *National Comorbidity Survey-Replication (NCS-R)
  • No one 65+ met criteria for drug abuse/dependency disorder *NCS-R Study
  • Most who experience disorder in late life are experiencing a recurrence of a disorder that started in earlier life
  • Aging relates to more positive emotionality in close-knit social circles *could enhance mental health as we age

Methodological Issues in Estimating the Prevalence of Psychopathology

  • Discomfort discussing symptoms may minimize prevalence rates
  • Cohort effects – adults during drug-oriented era of 1960s, many continued using
  • People with psyc disorders are at risk for dying before age 65 o Heavy drinkers: die from cirrhosis between 55-64 years old o Anxiety/mood: cardiovascular disease o Worsened immune function overall

 

  • Neurocognitive Disorders in Late Life
    • Most elderly do not have cognitive disorders
    • Dementia = deterioration of cognitive abilities
    • Delirium = a state of mental confusion
  • Dementia
    • = Deterioration of cognitive abilities to the point that functioning becomes impaired o Impaired social and occupational functioning
    • Most common symptom: difficulty remembering things, especially recent events
    • Lose control of impulses, use coarse language, tell inappropriate jokes, shoplift, make sexually inappropriate remarks
    • Difficulty dealing with abstract ideas, emotional disturbances common (depression, flatness of affect, sporadic outbursts)
    • Delusions and hallucinations can occur
    • Language disturbances – vague patterns of speech
    • Become withdrawn and apathetic
    • Course may be progressive, static or remitting *mostly develops slowly, can detect subtle cognitive/behavioural defects before
    • Mild cognitive impairment = the early signs of decline noted before functional impairment is present
    • 1) DSM mild neurocognitive disorders are similar to mild cognitive impairment
    • 2) DSM major neurocognitive disorders are similar to dementia
    • Difference based on ability to live independently
    • Not all people with mild cognitive impairment develop dementia (10% will), 1% of adults develop dementia w/o MCI

Criteria for Mild Neurocognitive Disorder (Mild cognitive impairment)

1) Modest cognitive decline from previous levels in one or more domains based on the following:

Concerns of the patient, a close other or clinician

Modest neurocognitive decline (between the 3rd and 16th percentile) on formal testing or equivalent clinical evaluation

2) The cognitive deficits do not interfere with independence in everyday activities (e.g. paying bills or managing medications), even though greater effort, compensatory strategies, or accommodation may be required to maintain independence

3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to another psychological disorder

Criteria for Major Neurocognitive Disorder (Dementia)

1) Significant cognitive decline from previous levels in one or more domains based on both of the following:

Concerns of the patient, a close other, or clinician

Substantial neurocognitive impairments (below the 3rd percentile on formal testing) or equivalent clinical evaluation

2) The cognitive deficits interfere with independence in the everyday activities

3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to another psychological disorder

0.4% prevalence of dementia in 2000

  • Prevalence increases with age, 1-2% ages 60-69, increases to 20% in ages 85+
  • Types:
    • Alzheimer’s – most researched o Frontotemporal dementia – affects frontal and temporal lobes o Vascular dementia – caused by cerebrovascular disease o Dementia with Lewy Bodies – presence of Lewy bodies

Alzheimer’s Disease

  • Brain tissue irreversibly deteriorates, death usually occurs within 12 years
  • 6th leading cause of death in US
  • Most common symptom is memory loss, may begin with absentmindedness and gaps in memory for new material
  • Interferes with daily living
  • Apathy is a common symptom before cognitive symptoms are noticeable, 1/3 develop depression, problems with language and word finding, visual-spatial abilities decline – disorientation = confusion with respect to time, place or identity
  • Unaware of own cognitive problems initially, become agitated
  • Personality loses its sparkle/integrity “not him/herself anymore”
  • Become oblivious to surroundings
  • Plaques = small, round beta-amyloid protein deposits outside the neurons o Mostly in frontal cortex, may be present 10-20 years before cognitive symptoms o Measured using special PET scan
  • Neurofibrillary tangles = twisted protein filaments composed largely of the protein tau in the axons of neurons o Measured in cerebrospinal fluid o Most densely present in hippocampus
  • Immune response to plaques leads to inflammation, triggers a series of brain changes
  • Loss of acetylcholinergic (ACh) and gluateminergic neurons, neurons begin to die
  • Entorhinal cortex and hippocampus shrink, followed by shrinking of frontal, temporal, and parietal lobes
  • Ventricles become enlarged
  • Cerebellum, spinal cord and motor/sensory areas less affected *do not appear to have anything physically wrong at first
  • 25% eventually experience motor deficits
  • Heritability estimate of 79%, 21% due to environmental factors
  • A set of 10 genes explains 20% of the risk for AD among white non-Hispanic samples
  • Polymorphism of gene on chromosome 19 called apolipoprotein (ApoE-4 allele) o Having 1 allele increases risk by 20%
    • Interferes with clearing excess beta-amyloid from brain
    • 2 alleles – overproduction of beta-amyloid plaques, loss of neurons in hippocampus and low glucose metabolism BEFORE AD
  • Immune process and high cholesterol can trigger inflammation, related to greater risk of AD (e.g.

type II diabetes)

  • Brain trauma from accident/injury increases risk
  • Lifestyle variables: smoking, being single, obesity, depression, low social support = higher risk o Lower risk: Mediterranean diet, exercise, education, engagement in cognitive activities
  • Exercise may predict fewer memory problems, less decline in cognitive function
    • Low levels of plaques in brain
  • Frequent cognitive activity related to 46% decrease in risk, protects against cognitive decline
  • Cognitive reserve = the idea that some people may be able to compensate for the disease by using alternative brain networks or cognitive strategies such that cognitive symptoms are less pronounced  Depression can be a consequence of dementia, opposite effect occurs as well

Frontotemporal Dementia

  • = Caused be a loss of neurons in the frontal and temporal regions of the brain (anterior temporal and prefrontal)
  • Begins in mid-to-late 50s, progresses rapidly, death occurs in 5-10 years, less than 1% prevalence  Memory is not severely impaired
  • There are multiple subtypes, most common = behavioural variant FTD o Deterioration in at least 3 areas at a level that leads to functional impairment:
    • Empathy, executive function, ability to inhibit behaviour, compulsive/perseverative behaviour, hyperorality (= tendencies to put nonfood objects in the mouth) and apathy
    • Changes in personality and judgment, emotional regulation
  • Often misdiagnosed as a midlife crisis (begin chain smoking, over eating, drinking alcohol) or depression/bipolar/schizophrenia
  • Affects emotion more than AD, damages social relationships, inability to properly express emotions
  • May violate social conventions
  • Affects marital satisfaction more than AD
  • Caused by different molecular processes: Pick’s disease = presence of Pick bodies within neurons  Some have high levels of tau = protein filaments that contribute to neurofibrillary tangles
  • Strong genetic component

Vascular Dementia

  • = Caused by cerebrovascular disease
  • Stroke causes blood clot, impairs circulation, results in death of neurons
  • 7% develop dementia in year after stroke, risk increases with recurrent strokes
  • Similar risks as for cardiovascular disease: high levels of bad cholesterol (LDL), smoking, elevated blood pressure
  • More common in African American than Caucasian
  • Symptoms vary depending on where stroke occurred
  • Onset usually more rapid, can co-occur with AD

Dementia with Lewy Bodies (DLB)

  • = Protein deposits (Lewy bodies) form in the brain and cause cognitive decline
  • 2 subtypes depending on whether it occurs in context of Parkinson’s
  • 80% with PD develop DLB
  • Hard to distinguish symptoms from PD (shuffling gait) and AD (loss of memory)
  • More likely than AD to include visual hallucinations and fluctuating cognitive symptoms
  • Extremely sensitive to physical side effects of antipsychotic medications
  • Experience intense dreams with levels of movement/vocalizing (acting out dreams)

Dementias Caused by Disease and Injury

  • Encephalitis – inflammation of brain tissue caused by viruses that enter the brain
  • Meningitis – inflammation of membranes covering the outer brain, caused by bacterial infection
  • Organism that produces syphilis can invade brain and cause dementia
  • HIV, head trauma, brain tumor, nutritional deficiencies (B-complex vitamin), kidney/liver failure, endocrine problems (hyperthyroidism), exposure to toxins (mercury/lead) Treatments

No cure, some medications used to treat symptoms

Medications

  • No medications address cognitive symptoms of FTD
  • Most treatment research focused on AD and memory decline, medications can slow the decline but cannot restore memory
  • Cholinesterase inhibitors used – interfere with breakdown of ACh *donepezil and rivastigmine o Vitamin E, statins, nonsteroidal anti-inflammatory drugs o Slow memory decline compared to placebo
  • Memantine – drug that affects glutamate receptors involved in memory
  • Preventative work focuses on processes involved in the creation of amyloid from its precursor protein
  • Aversive side effects – nausea
  • Use medical treatments to address psyc symptoms: depression, agitation that co-occur
  • Depression produces more cognitive impairment in elderly than younger patients
  • Antipsychotics can relieve agitation, increase risk of death
  • Cognitive deficits continued/worsened after destroying the plaques  Focus mostly on prevention Psychological/Lifestyle Treatments
  • Supportive psychotherapy to help patients and family deal with effects of disease o Discuss illness, learn about it, learn how to care for family member, encourages realistic attitude in dealing with specific challenges
  • Increase exercise to improve cognitive function
  • Cognitive training programs – focus on improving memory, reasoning, cognitive processing speed o Try to teach meta-cognitive skills (thinking about thinking, strategies for enhancing memory) o Training in multi-tasking helps memory as well
  • Behavioural approaches to compensate for memory loss & reduce depression/disruptive behaviour of early AD o External memory aids (shopping lists, calendars, labels) o Pleasant/encouraging activities to decrease depression o Identify triggers for disruptive behaviour and decrease them o Music can help reduce agitation

 

  • Delirium
    • 1) Disturbances in attention and awareness
    • 2) A change in cognition, such as disturbance in orientation, language, memory, perception, or visuospatial ability, not better accounted for by a dementia
    • 3) Rapid onset (hours/days) and fluctuation during the course of a day
    • 4) Symptoms are caused by a medical condition, substance intoxication or withdrawal, or toxin
    • “Out of track”, deviating from usual state, clouded state of consciousness
    • Two most common symptoms: extreme trouble focusing attention, profound disturbances in sleep/wake cycle
    • Cannot maintain coherent stream of thought, trouble answering questions
    • Become drowsy during the day, awake/agitated at night
    • Vivid dreams and nightmares
    • Speech is rambling and incoherent
    • Lose track of what day it is, where they are, who they are
    • Memory impairment for recent events is common

 

Perceptual disturbances are frequent, mistake unfamiliar for familiar, visual hallucinations, delusions in 25% of older adults (poorly worked out, fleeting and changeable)

  • Mood/activity swings, disordered thoughts, erratic, shift between emotions
  • Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, incontinence of urine and feces
  • Become lethargic/unresponsive
  • Have lucid intervals – alter and coherent *daily fluctuations help distinguish from AD
  • Symptoms worsen during sleepless nights
  • More common among young children and older adults (nursing homes and hospitals)
  • 6-12% nursing home residents developed delirium in 1 year
  • Often misdiagnosed, especially if lethargy is present or if person has dementia
  • High mortality rate if left untreated, 1/3 die within a year
  • Increased risk for further cognitive decline Etiology
  • Caused by medical conditions: drug intoxications, withdrawal reactions, metabolic and nutritional imbalances (diabetes, thyroid dysfunction, kidney/liver failure, congestive heart failure, malnutrition), dehydration, infections, fevers, neurological disorders, stress of major injury
  • One of most common triggers is hip surgery
  • Usually has more than one cause
  • Physical declines of late life, increased susceptibility to chronic diseases, many medication prescribed, greater sensitivity to drugs = increased vulnerability for elderly

Treatment

  • Recovery if underlying cause is treated promptly
  • Atypical antipsychotic medication
  • Treatment takes 1-4 weeks for condition to clear, longer in older people  Preventative strategies: o Clocks of hospital patients in field of vision, helps stay oriented o Shades open during the day, lights turned off at night
    • Minimal sleep disruptions o Stress-free, hydration
  • Risk factors: sleep deprivation, immobility, dehydration, visual/hearing impairment
  • High risk of delirium among those with dementia