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Prepared by: Ashlea R. Smith, PhD Argosy University-

Phoenix

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Copyright © 2010 by Pearson Education, Inc. All rights reserved.

Aging and Cognitive Disorders

Chapter 13


Chapter OutlineSymptoms and Disorders of Aging

Depression and Anxiety in Later Life

Substance Abuse and Psychosis in Later Life

Cognitive Disorders


Geropsychology as a unique field…Geropsychology is a subdiscipline of psychology that

addresses issues of aging, including normal development, individual differences, and psychological problems unique

to older persons.

Figure 13.1 The Aging Population of the

United States


What it takes to be successful at aging…

One-third of older adults age successfullyGood health and active lifestyleIndependence in functioningLack of disabilityAbsence of cognitive impairmentPositive social relationshipsSelective optimization and compensation


I OBJECT or ACCEPT! What are your thoughts?

1.The text defines successful aging as perceived good health, an active lifestyle, continued independence, lack of disability, absence of cognitive impairment, and positive social relationships.

Which do you feel would be the HARDEST to lose and why from the list below?

Can you think of anything else from maybe what you

see from older adults in your life that would

exhibit successful aging?


Psychological Symptoms and Disorders among Older People

20 to 30% of older adults have a psychological disorder

Higher among homebound and people who live in nursing homes with chronic illness

Stigma around seeking treatment (only 50% actually receive treatment)

Inadequate recognition and treatment

Ageism (attribute problems to advancing age)


Depression and anxiety in later life…

Things to consider:Types of loss (death of loved one, changes in job

or financial status, deterioration in physical abilities)

Most common psychological problemsNot a natural consequence of growing old


Unipolar and Bipolar DepressionExecutive dysfunction

(difficulty planning, thinking abstractly, initiating, and inhibiting actions)

Reversible dementia (also known as pseudodementia occurs when the full syndrome of dementia appears to be present but resolves after treatment)

-Vascular depression (a mood disorder that occurs in the context of cerebrovascular disease)

-Few older adults develop mania or bipolar after the age of 65

Older adults over the age of 65 commit suicide twice that of younger adults,

especially Anglo men are at a higher risk for completing suicide, however women attempt

suicide more frequently.


Suicide and Older Adults

What factors contribute to the high risk for suicide for older adults.

Figure 13.2 Suicide Rates Among Older Americans


Prevalence and Impact

Major depression impact 1 to 4% of older adults

Rates of depression increase to 14% for older adults who are homebound or have cognitive impairment

Affect daily functioning and survival-Depression affects outcome of medical disorder

-Recover less well, use more health care services, and greater cost

-Suicide riskCopyright © 2010 by Pearson Education, Inc. All rights reserved.

Sex, Race, and EthnicityAffect more womenMore common in African

American and Hispanic older adults, but less likely to receive treatment

Asian Americans and Anglo older adults both experience increased levels of suicidal ideation

Suicide rates are highest among Anglo men, followed by non-Anglo men

African American and Hispanic adults have lower rates of suicide than Anglos

Rates of suicide for Asian adults increase with age


Etiology of DepressionMost likely to have

existent cognitive impairment and more evidence of brain abnormalities

More common with vascular, neurological, or other physical diseases

Depression is diagnosed after a medical condition is diagnosed

Stressors (associated with retirement and the loss of a loved one)

Life-span developmental diathesis-stress model (reviews influence of biological, stressful life events, and personal protective factors associated with depression)

Loss of enjoyable activities


Factors that contribute to depression for older adults Figure 13.3 Life-span

Diathesis-stress Model


Treatment of Depression in Older Patients

Begin with a physical evaluation60% improve once on medicationElectroconvulsive therapy (ECT)

Lithium in one-half to two-thirds of dosage for younger patients

Cognitive-behavioral therapy Reminiscence Therapy


Research HOT Topic: Translating Research in Geropsychology to the

“Real World”Controlled clinical trials

-Participants are mostly Anglo

-Healthy

-Better educatedMany older adults never

seek treatment for mental health services, usually treated by primary care physician

What are some benefits of increasing evidence-based interventions in community practice settings?

How can we use this information to educate older

adults on the benefits of seeking treatment for mental

health issues?

Thoughts on home- based problem- solving

therapy?

Often barriers to treatment exist such as being too fragile

and unhealthy to get to a medical clinic.


Fact Or Fiction?

Anxiety disorders is one of the most common and significant mental health

problems affection older adults.

Fact or fiction?

Yes, approximately 3.5 to 10.2% of all older adults suffer from anxiety disorders.

Generalized anxiety disorder (GAD) is found to be more common in older adult women

than their male counterparts.

Fact or fiction?

Yes…especially African American women, however women have longer life expectancies which is not

considered to be a factor in determining prevalence rates.


Anxiety and the Older Adult Population

Worries center around health issues, stressful life transitions, care-giving responsibilities, economic and legal issues, reduced income, increased health care costs, and end of life planning

Wording is important (shame, guilt, fret, or concern to describe worry or anxiety)

Overlap with depression and other medical conditions



Anxiety most common and significant mental health problem (particularly specific phobias and Generalized Anxiety Disorder)

3.5 to 10.2% of older adults suffer from anxiety disorders

More common in those living in nursing homes and homebound older adults

Associated with less physical activity and poorer functioning


Sex, Race, and Ethnicity

More common among women

Anxiety disorders are more common among African American women

GAD occurs most frequently among older Puerto Rican medical patients

Higher level of suicidalityPoorer self-perceptions of

health Increased use of health

servicesCulture-bound syndromes

(may be more common in older adults due to lower levels of education, less assimilation to majority culture, and foreign born adults)


Etiology of Anxiety in Later Life

Experience of long-term or lifetime symptoms of anxiety

Stressful life events play a role in anxietyOverlap with other medical diseasesPsychological response to medical illness

With the current state of the economy do you think we will see a dramatic

increase in the amount of older adults reporting anxiety symptoms?


Treatment of Anxiety in Older Patients

Rule out physical illnesses

Benzodiazepines are the most frequently prescribed

-Can create serious side effects (memory problems and slowing of motor behaviors)

Antidepressants (such as serotonin reuptake inhibitors)

-Effective for older adults

-Fewer side effectsWhen given a choice older

adults prefer psychosocial treatments than medication

CBT (best suited for older adults because time-limited, directive, and collaborative)


Substance Abuse and Older adults

Most common problems-Overuse of alcohol

-Misuse of prescription medications

-Tobacco use

Alcohol abuse is associated with-Antisocial behavior

-Legal problems

-Unemployment

-Lower socioeconomic status

The National Institute on Alcohol

Abuse and Alcoholism

recommends that adults age 65 and over have no more than one drink per day or 7 drinks per

week.



Tobacco is the most commonly abused substance (over 17.1 million adults over age 50)

Alcohol abuse or dependence for men (1.9 to 4.6% and women 0.1 to 0.7%)

Older adults take 25% of the medications consumed in the United States

Late onset alcohol abuse occurs more often in women


Sex, Race, Ethnicity, and Etiology

Older adult males use alcohol twice that of the rate of women

Differences consist across ethnic and racial groups

Illicit drug use is more common in older men

Women are more likely to abuse prescription medication for nonmedical reasons

No differences in substance abuse based on ethnicity

Drinking is uncommon among older Chinese Americans

Personal history of habitual use or risky drinking


Treatment of Substance Abuse

Brief alcohol counseling (BAC)

Behavioral self-control proceduresMedications for alcohol abuse (naltrexone and

disulfiram)

Medications for benzodiazepines abuse (gradual discontinuation)

Smoking cessation (brief interventions in primary care, transdermal nicotine patch therapy)


Late-onset Schizophrenia (schizophrenia that first appears after age 40)

Very-late-onset Schizophrenia (a schizophrenic-like-disorder, but with symptoms that do not include deterioration in social and personal functioning)

80% of older adults with schizophrenia, the onset occurred in young adulthood

Psychosis and Older adults


Prevalence, Gender, and EthnicitySchizophrenia occurs in

0.6% of people age 45 to 64 and 0.1 to 0.5% age 65 and older

Psychotic symptoms are more common among patients in nursing homes

Poor functioning related to worse cognitive performance, less education, and severe negative symptoms

Late-onset schizophrenia is more common in women

Symptoms of psychosis and schizophrenia common across all racial and ethnic groups

African Americans most likely to be diagnosed

Use of spirituality, witchcraft, and herbal medications


Genetics (10 to 15% have a relative with the disorder)

Brain abnormalities (enlarged ventricles, increased density of dopamine receptors, and reduced size of the superior temporal gyrus)

Other causes (hormonal changes, psychosocial stressors, and deficits with hearing and vision)

Medical conditions (stroke, tumor, Alzheimer's disease)

Etiology of Schizophrenia and Psychosis


Treatment of Psychosis

Typical and atypical antipsychotic medications

Skills trainingFamily support

Cognitive-behavioral therapy

PsychoeducationCoping skills trainingBehavioral

management


Cognitive Disorder: Delirium

Alteration in consciousness that typically occurs in the context of a medical illness or after ingesting a substance

Altered states of consciousness (hypoactive type decreased wakefulness and stupor and hyperactive type hyperarousal)

Onset is sudden (hours or days) and symptoms can persist for months for older adults

Men are at a greater risk for delirium than women.


Prevalence and Impact of Delirium

Common in general hospitals (11 to 16%)

Common in patients with AIDS (30 to 40%)

Increased risk of institutional placement

20% of patients with Alzheimer’s disease

Causes longer hospital stays, complications after surgery, and poor post-hospitalization functioning


Stop and Think!

Does dementia have it’s greatest impact on the patient or the caregivers? Why or why not? Are the caregivers of the patient with dementia at risk for psychological issues as well?

Key Points: The text outlined that dementia affects caregivers and family members, specifically the wives, daughters, and daughter-in-laws have the greatest burden of care. Family members are responsible for assistance with nutrition, activities of daily living,

behavioral plans, and memory aids.


Etiology of DeliriumCaused by serious systemic medical

illness (AIDS, congestive heart failure, infection, or toxic effects of medication)

Metabolic disorders (hypothyroidism or hypoglycemia)

Neurological disorders (head trauma, stroke, seizure, or meningitis)

Other health issues (malnutrition, severe dehydration, substance use)

How does the diathesis-stress model

explain delirium?


Treatment of Delirium

Often missed or inadequately treated

First step is screening for known risks

Support for family and patient

Medication (antipsychotic and benzodiazepines)

Education and supportive care

Beneficial environmental manipulations


Cognitive Disorder: Dementia

Takes away ability to function independently (multiple cognitive difficulties) and causes significant emotional problems (for the patient and family)

Not accompanied by changes in consciousness or alertness

Requires extensive interviews, history taking to make a diagnosis, and testing


Types of Dementia

Dementia due to other general medical conditions

Alzheimer’s diseaseCerebral senile

plaquesNeurofibrillary

tangles

Dementia of the Alzheimer’s type

Vascular dementiaSubstance-induced

dementiaMulti-infarct

dementiaSubcortical dementia


Living with Dementia


Real People, Real Disorders… Ronald Regan

40th President of the United States (1981-1989)

Diagnosed in 1994, died in 2004

He knew something was wrong ( at a regular medical check-up)

Friends noticed signs in the early 1990s

Strain on his family

What may be some early warning signs to be aware

of if you think a family member has Alzheimer’s

Disease?

How does being diagnosed with Alzheimer’s Disease

change one’s life?


Prevalence and Impact: DementiaFigure 13.4 The Prevalence of Dementia Increases with Age

Progressive dementia occurs in 5 to 10% of

adults age 65 and older. Although many

patients remain undiagnosed.


Sex, Race, Ethnicity, and Etiology

More frequent in women than men

Higher rates are found in African Americans and Hispanic groups

Presence of the Genetic allele (APOE) for Anglos and Japanese patients

Asian populations have increased rates of Alzheimer’s and vascular dementia

Genetic factors Increasing age itselfMutation of (e4, APOE gene)Mild cognitive impairmentDiathesis-stress modelAmnestic MCI (mild

cognitive impairment in which cognitive complaints focus on memory difficulties)


Ways to Protect or Increase Risks for Dementia

What would be some examples of mental activities

to engage as protective factors?


Is MCI a precursor of dementia or a separate syndrome?

Let’s examine the evidence

1. 10 to 15% of MCI progress to AD

2. People with MCI and APOE4 allele gene are at an increased risk of dementia

3. Neuroimaging shows shared features

Fact: Some people with MCI never progress to significant cognitive impairment with conversion rates varying widely, and last MCI can result from numerous causes.

Evidence: Amnestic MCI is probably a risk factor for dementia but there are likely many forms of MCI like dementia.


Treatment of Dementia and Related Difficulties

Cannot be reversed or cured

Targets delaying disease progression

Providing support and assistance to caregivers

Changing the environment

Medication (cholinesterase inhibitors CEIs and Aricept, memantine or Namenda)

High doses of vitamin E

AntidepressantsAntipsychotics


Quick Recap

1. Suicide rates for individuals over 65 are twice that of younger adults.

(a) True

(b) False


Quick Recap

2. The Apolipoprotein (APOE) e4 allele is responsible for later in life depression and dementia.

(a) True

(b) False


Critical Issues to Remember1. Geropsychology is the subdiscipline of psychology that

focuses on problems unique to older adults.

2. Approximately 20 to 30% of older adults have a psychological disorder that often goes missed or misdiagnosed.

3. When evaluating older adults symptoms it is important to remember that psychological symptoms and cognitive impairment can overlap with medical conditions.

4. Dementia and delirium are two major cognitive disorders however delirium deals with changes in consciousness and dementia deals with difficulties in memory.


Critical Issues to Remember

5. The best approach to understanding the development of cognitive disorders is by using the diathesis-stress model emphasizing psychological, biological, and environmental stressors.

6. The treatment options that are most commonly used to treat younger adults with depression, anxiety, substance abuse, and psychosis are also used to treat older adults with modifications in dosage levels. While the medication for dementia slows the progression of the disease and improves quality of life.


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