Chapter 16Aging and Psychological Disorders

• Issues, concepts, and methods in the study of older adults, old age, and brain disorders

•Old age and psychological disorders• Treatment and care of older adults • Issues specific to therapy with older adults

Chapter Outline

Facts About Aging Population

• 65 years old and older: • Young-old: 65-74• Old-old: 75-84• Oldest-old: 85 and over

•Changing demographics in Canada• In 1998, 3.7 million (12.3%) of population were 65 and

over• In 2011, over 5 million (14.8%) of Canadians • In 2041, expectation are 10 million Canadians• In 2015, more senior citizens than children

• In 2050, 1 in 5 people in the world will be 60 and older

Issues, Concepts and Methods in the Study of Older Adults

Dementia

•Dementia— term for gradual deterioration of intellectual abilities to the point that social and occupational functions are impaired

•Course may be progressive, static, or remitting

• Prevalence of dementia with advancing age• 13.9% in people aged 71 and older• 37.4% in people aged 90 and older

• Incidence of cognitive impairment without dementia occurs in 22.2% of people age 71 or older

Symptoms of Dementia

•Difficulty remembering things• Especially recent events

• Leaving tasks unfinished •Hygiene may be poor and appearance sloppy •Getting lost •Difficulty comprehending making plans or

decisions• Poor impulse control

• May use coarse language, tell inappropriate jokes, or shoplift

•Deterioration of abstract ideas, make faulty judgments

•Disturbances in emotions, including outbursts, depression

Classification of Dementias

•Alzheimer’s Disease•Frontal-temporal Dementias•Frontal-subcortical Dementias

Alzheimer’s Disease (AD)

•Described by German neurologist Alois Alzheimer (1906)

•Accounts for about 50% of dementia in older people• Prevalence in Canada: 1.5% of population (2010)• Estimated prevalence 2.8% of population (2038)• 1/13 Canadians over age 65 has AD or related dementia

•Death usually occurs 10 or 12 years after onset•Although women live longer, more die as a result

of AD than men • Promoting mental and physical exercise could

reduce risks by 10%

Alzheimer’s Disease (cont.)

Main neurological changes:•Atrophy of cerebral cortex

• Begins with entorhinal cortex and hippocampus, then frontal, temporal, and parietal lobes

• As neurons and synapses are lost, fissures widen and ridges become narrower and flatter

• Ventricles also become enlarged

• Plaques— small, round areas comprising remnants of lost neurons and b-amyloid are scattered throughout cortex

•Neurofibrillary tangles— tangled, abnormal protein filaments accumulate within cell bodies of neurons

• Plaques and tangles are present throughout cerebral cortex and hippocampus

Alzheimer’s Disease (cont.)

Causes of Alzheimer’s Disease

•Genetics – strong evidence

• Risk first-degree relatives of afflicted individuals

• Concordance for MZ twins is greater than for DZ twins

•Environmental role• ‘Use it or lose it’• Research shows:

• Engaging in cognitive activities helps to preserve intellectual functioning

• Cognitive activity preserves crystallized intelligence more than fluid intelligence (new learning)

• Cognitive reserve hypothesis that high education levels help to delay onset of dementia

Frontal-Temporal Dementias

•Accounts for 10 to 15% of cases• Typical age of onset is late fifties•Marked by extreme behavioural and

personality changes•Not closely linked to loss of cholinergic

neurons• Pick’s disease is one cause of frontal-temporal

dementia • Degenerative disorder where spherical inclusions

(known as Pick bodies) are present in neurons

Frontal-Subcortical Dementias

Types include:•Huntington’s chorea —caused by single

dominant gene located on chromosome 4 • Major behavioural feature presence of writhing

(choreiform) movements

• Parkinson’s disease — marked by muscle tremors, muscularrigidity, and akinesia • an inability to initiate movement

•Vascular dementia — diagnosed when patient with dementia has neurological signs or when brain scans show evidence of cerebrovascular disease

Other Causes of Dementia

• Infectious diseases• Encephalitis• Meningitis• Syphilis (Treponema

pallidum)

•Head traumas•Brain tumours•Nutritional

deficiencies• Especially of B-

complex vitamins

• Kidney or liver failure

• Endocrine-gland problems• Hyperthyroidism

• Exposure to toxins• Lead or mercury• Chronic drug and

alcohol use

Treatment of Dementias

•Biological Treatments of Alzheimer’s Disease• Involves death of brain cells that secrete

acetylcholine thus try to levels• Blocking creation of amyloid from its precursor

protein • Antioxidants (vitamin E) may be useful in

slowing progression

Treatment of Dementias (cont.)

• Psychosocial Treatments for Patients• Supportive psychotherapy aiming at minimizing

the disruption caused by the person’s behavioural changes

•Many individuals with dementias are supported by family members• Ratio of individuals with dementia living with

family in the community versus in institutions 2:1

Treatment of Dementias (cont.)

•Caregiver burden – four kinds identified:• Emotional• Physical• Financial • Employment

•Caregivers more likely to experience chronic health problems

•Resources available to caregivers• On-line forum• Support groups• Respite from caregiving (health care workers take over

from family for periods)

Delirium

•Delirium— “a clouded state of consciousness” • Trouble concentrating and focusing attention• Cannot maintain coherent thought• Early stages— person frequently restless especially at

night• Perceptual disturbances • Memory impairment• Paranoid delusions in 40 to 70%

• severe delirium• Speech is rambling and incoherent• Person is bewildered and confused

•Difference between delirium and other conditions• People with delirium have lucid intervals, show

fluctuations in mental state over the course of the day

Dementia vs. Delirium

Causes and Treatment of Delirium

Causes• Drug intoxications • Drug-withdrawal

reactions• Metabolic and

nutritional imbalances • Uncontrolled

diabetes and thyroid dysfunction

• Infections or fevers• Neurological disorders• Stress

Treatment• If syndrome identified

correctly and underlying cause promptly treated• 1-4 weeks for

condition to clear

• If underlying cause not treated• Permanent brain

damage• Death

• Intervention addresses risk factors • Sleep deprivation,• Immobility• Dehydration• Visual and hearing

impairment• Cognitive

impairment

Old Age and Psychological Disorders

•Rates of mental disorders are lowest in age 65 and older, most are free from serious psychopathology

• Instead, cognitive impairments are more common • 5.5% of older men and 4.7% of older women

•About 10 – 20% of older adults have psychological problems serious enough to need professional help

Depression

•Depression is less prevalent in older adults than younger people

• In Canada (2005): • 2.6% with major depression • 4.9% with minor depression (2-4 symptoms)

• Late onset depression (first episode in old age)

•Causes of depression:• Less involvement in daily activity• Depression maintained by self-critical thoughts• Is related to medical illness • Bereavement

Treatment of Depression

•Depression is under-treated in the elderly•Cognitive, behavioural, interpersonal and

brief psychodynamic approaches have been used

•Quality of client-therapist alliance is a key predictor of therapeutic response

•Reminiscence therapy can be effective• ‘life review therapy’• reflect on past experiences• re-examine events• Example: perfectionists who are pre-occupied

with past mistakes work on less self-critical interpretations of their experiences

Anxiety Disorders

•Anxiety more prevalent than depression • Less prevalent in older people than younger

adults; about 7% of people 65 and older •Risk factors: e.g., being female, having several

chronic medical conditions, not being married, low levels of education

•Can complicate other conditions •Most prevalent: GAD and agoraphobia

Substance-Related Disorders

•Alcohol use and dependence • In Canada: 8.9% had definite alcohol abuse; 3.7% had

questionable alcohol abuse • In US: 10.8% of elderly men; 2.9% in elderly women • In England: 28.6% in elderly men; 10.3% in women • Heavy drinking is linked to depression, anxiety, health

problems

•Medication misuse • Much greater problem than drug and alcohol abuse • Elderly are 13% of population but they consume 33% of all

prescribed meds • Problem: Obtain prescriptions from several doctors

Sleep Disorders

• Insomnia: • Common problem: 1 in 5 older adults (65-79) • More frequent, less severe than in younger

populations with more complications• Less night-time sleep, more daytime naps, more

night-time interruptions, less time in REM sleep• More sleep disturbance in older men than in

older women

•Causes of sleep disorders: • Medication, anxiety, depression, lack of activity,

poor sleep habits, sleep apnea

• Treatment of sleep disorders• Pharmacotherapy, possible over-use in nursing

homes

Suicide

• Prevalence: 3x higher than in younger adults

• Peak ages for suicide: 80-84 in white US men

•Older adults are less likely to communicate their intention than younger adults

•Ratio between attempted and completed suicide are much higher in older adults (4:1) compared with 8:1 in overall population

•Causes of suicide: loneliness, poor cognitive functioning, general and interpersonal hopelessness

• Link between health problems, depression and suicide

•Alcohol use associated with more violent methods

Treatment & Care of Older Adults

•Nursing Homes•Alternative Living

Settings•Community-Based

Home Care

•Considerations in Therapy:• Social context• Loneliness• Physical frailty• Death and dying

Treatment and Care of Older Adults

APA Practice Guidelines

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