Disorders of Aging and Cognition Chapter 18 Comer, Abnormal Psychology, 8e DSM-5 Update Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University

Disorders of Aging and Cognition

Chapter 18

Comer, Abnormal Psychology, 8eDSM-5 Update

Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System

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

2Comer, Abnormal Psychology, 8e

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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


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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


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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


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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


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Elderly persons are also more likely to die by suicide than younger ones, and often their suicides are related to depression


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Like younger adults, older people who are depressed may be helped by cognitive-behavioral therapy, interpersonal therapy, antidepressant medications, or a combination of these approaches


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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


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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


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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


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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


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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


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Alcohol use disorder in elderly people is treated much as in younger adults Approaches include detoxification,

Antabuse, Alcoholics Anonymous (AA), and cognitive-behavioral therapy


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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…


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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


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Certain brain structures seem to be especially important in memory, including: The prefrontal lobes

Appear to hold information temporarily and to continue working with the information as long as it is needed

The temporal lobes and the diencephalon 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


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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


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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


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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

Creutzfeldt-Jakob 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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Documents

Disorders of Aging and Cognition Chapter 18 Comer, Abnormal Psychology, 8e DSM-5 Update Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University