Aging

Or: how everything falls apart.

References and Handouts

http://www.brown.edu/Courses/BI_278/

Everything Changes

• 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

• Psychological issues

• Socioeconomic

• Physical health

• Mental Health

Psychological issues

– Aging has unique• Challenges• Life stresses

Ex. EricksonStage Age Basic ConflictOral-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• Losses

• Disablement

• Driving

• Health concerns

What do the elderly worry about?

0

5

10

15

20

25

30

35

40

45

Money Health Loneliness Crime

National Council On Aging, 2000

Everything Changes

• Psychological issues

• Socioeconomic

• Physical health

• Mental Health

Socioeconomic changes

• 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

• 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

• 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

• Psychological issues

• Socioeconomic

• Physical health

• Mental Health

21.6

51.3

20.6

6.5

15.7

42

25.9

16.4

0

10

20

30

40

50

60

SMI Non-SMI

Prevalence of SMI over age 18 (2.8%)

18-24

25-44

45-64

65+

Why Rates in Elderly are Low?

• 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 CanadaNewman et al. Psychological Medicine 28; 1998

01020304050607080

Oupatient General Medical Utililization

by Age

55-64

65-74

75-84

85+

0

2

4

6

8

10

12

14

16

Mental Health Utilization by Age

55-64

65-74

75-84

85+

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

0.7

0.1

1

0.1

1.5

0.3

1-Month 1-Year Lifetime

Schizophrenia

All

65+

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

0.5

0

0.6

0.1

0.8

0.1

1-Month 1-Year Lifetime

Manic Episode

All

65+

2.2

0.7

3.7

1.4

6.3

2

1-Month 1-Year Lifetime

Depressive Episode

All

65+

Depression in the Elderly

• Why so low? (see earlier…)

• Forme Frustres

• “Pseudodementia”

• Diagnosing depression in complex cases– How to approach…

Anxiety Disorder in the Elderly

0.5

0.1

0.9

0.2

1.6

0.4

1-Month 1-Year Lifetime

Panic Disorder

All

65+

Anxiety Disorders

• Primary Versus Secondary– Common Secondary Causes

• Drugs• Medical Illness (cardiac, respiratory)• Disorders that confuse (dementia, delirium)

Substance Abuse in the Elderly

3

0.9

6.3

1.8

13.8

7.5

1-Month 1-Year Lifetime

Alcohol Abuse/Dependence

All

65+

Substance Abuse

• Gender differences and drug choice

Dementia

Problems in Dementia Prevalence Studies• 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

0

5

10

15

20

25

30

35

40

45

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

0

2

4

6

8

10

12

14

16

18

Schiz Mania Dep OCD Panic

All

65+

NH

Differences in the Psych. Interview in the elderly

• 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 cognition Primary 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