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Prepared by: Ashlea R. Smith, PhD Argosy University-
Phoenix
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Aging and Cognitive Disorders
Chapter 13
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Chapter OutlineSymptoms and Disorders of Aging
Depression and Anxiety in Later Life
Substance Abuse and Psychosis in Later Life
Cognitive Disorders
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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
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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
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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?
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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)
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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
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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.
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Suicide and Older Adults
What factors contribute to the high risk for suicide for older adults.
Figure 13.2 Suicide Rates Among Older Americans
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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
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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
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Factors that contribute to depression for older adults Figure 13.3 Life-span
Diathesis-stress Model
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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
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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.
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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.
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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
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Prevalence and Impact
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
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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)
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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?
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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)
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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.
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Prevalence and Impact
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
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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
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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)
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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
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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
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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
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Treatment of Psychosis
Typical and atypical antipsychotic medications
Skills trainingFamily support
Cognitive-behavioral therapy
PsychoeducationCoping skills trainingBehavioral
management
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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.
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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
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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.
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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?
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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
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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
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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
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Living with Dementia
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Living with Dementia
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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?
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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.
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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)
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Ways to Protect or Increase Risks for Dementia
What would be some examples of mental activities
to engage as protective factors?
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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.
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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
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Quick Recap
1. Suicide rates for individuals over 65 are twice that of younger adults.
(a) True
(b) False
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Quick Recap
2. The Apolipoprotein (APOE) e4 allele is responsible for later in life depression and dementia.
(a) True
(b) False
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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.
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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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