Module 8

brain death

(complete cessation of all activity in the brain and brain stem) is the prevailing definition, although world-wide, it is by no means universal Even so, declaring brain death is still rather complicated since some argue that cessation of just higher cortical functioning (and therefore, higher thought processes) is all that should be necessary to declare death. It is obvious that how we define death holds strong implications for the types of end-of-life decisions we make.

Alzheimer's disease

(named after the discoverer, Dr. Alzheimer) is the most common type of dementia (60 percent of cases). Like a few other disorders (for example, autism and schizophrenia), the variety of symptoms displayed by individuals with Alzheimer's disease supports the current belief among professionals that Alzheimer's is not just one disorder. That is, what we currently call "Alzheimer's disease" is actually a variety of dementias. Further research will hopefully help to uncover the causes and symptom patterns of each. For now, we will briefly discuss what is currently understood about Alzheimer's disease.

A traumatic brain injury

(which involves trauma to the brain from impact to the head paired with a number of symptoms such as loss of consciousness or amnesia) can result in cognitive impairment such as difficulty concentrating and slowed processing.

Diagnoses

-Psychiatrist/psychologist to screen for mental health -nurse to screen physical health -fMRI -social worker to give assessment of memory functioning

Dementia

-affects 8-10% of adults over 65 and 30-50% of adults over 85 Types of dementia: -parkinson's disease -vascular dementia--brought on by a stroke -multi infarct dimentia is associated with hypertension and a series of ministrokes -cruetzfeldt-jacob disease is an infection -AIDS (2/3 have dementia) -Alzheimer's disease (60% of dementia cases)

Biology of ADRD

-deficiency of acetylcholine -neurofibrillary tangles -amyloid plagues

Selective optimization with compensation and successful aging

-selection -optimization -compensation Successful aging: -how can an older adult be content

What happens to a brain with Alzheimer's disease is well-documented. The brain shrinks as the disease kills neurons (brain cells). A few abnormalities have been noted that seem to facilitate this process.

1. Amyloid plaques (beta-amyloid protein deposits) disrupt normal communication between neurons. AD is thought to be at least partly attributed to problems processing beta-amyloid. 2. Neurofibrillary tangles are formed when threads in the tau protein twist and tangle, which disrupts the brain's ability to transport necessary nutrients throughout the brain. While it may appear clear that these two abnormalities cause Alzheimer's disease, experts are more cautious. The reason for this is that brain imaging of the brains of older adults with no symptoms of AD may also have plaques and tangles! As stated before, our brains and bodies are incredibly resilient and can often function successfully even with damage. The issue, then, is not just whether these abnormalities are present. Better questions are: "Why, for some individuals, do these plaques and tangles form so extensively?" and "Why can some adults function normally despite structural brain changes while others cannot?"

Kubler-Ross's five stages of dying

1. Denial. When one hears the diagnosis of a terminal illness, denial may be common. 2. Anger. One may feel thwarted and robbed of life. 3. Bargaining. The individual may bargain with God, doctors, friends, and family to try to obtain extra time. 4. Depression. Depression is a natural result to feeling there is nothing one can do to change one's life circumstances. 5. Acceptance. May occur only at the end (if at all) for some people, and it is characterized by feelings of peace. Unfortunately, since this is such a well-known and greatly used stage theory, it is often misunderstood. Kubler-Ross always stated that these five stages are not "fixed." That is, one doesn't have to go through stages one through five in order. You can skip over stages, in fact. If an individual is confronting loss, it is important to not insist that he experience anger and depression, for example! Many professionals argue that the best way to view these stages is as coping strategies rather than a five-step stage theory. Also, there may be additional "stages" that grieving individuals go through, depending on their particular circumstances.

What is death?

A variety of answers can be given to this question! As this module discusses, brain death is a prevailing definition in current Western society. This refers to the cessation of both higher and lower cortical processes. However, other cultures (and other times in history) have used other definitions. Furthermore, all of these definitions focus on the physical, rather than spiritual aspect of death. An in-depth study of death and dying would necessitate exploration of religious explanations of death.

Regarding why we age, many people may believe in the "wear and tear" theory

According to this theory, time and exertion is the enemy. As we get older, we simply wear out. However, there are numerous holes to this theory, and it doesn't take into account that the body does an amazing job of repairing itself under normal circumstances. What is it about getting older that results in the body not being able to keep up with these repairs? Thus, this theory does not explain what actually causes this issue. That is, this theory focuses primarily on secondary aging but sidesteps the root of the problem, that is, primary aging. Also, individuals who engage in moderate to vigorous exercise and activity are typically healthier and longer-lived compared to more sedentary individuals. It is not simply that slowing down and taking it easy will minimize the effects of aging. Healthy levels of activity, at least for humans, are necessary for good health throughout the lifespan.

Primary and secondary aging

Aging seems to be such a natural part of life that few people (besides scientists!) may stop to consider why we age. There are actually two types of aging: primary and secondary aging.

successful aging

Aging simply happens, but not all adults age well. While celebrities and the media may make this statement clear to us in terms of physical changes, these theories are more concerned with maturity and social interaction. How should an older adult ensure that she will be happy with life, content with day-to-day activities, and connected with others? Selective optimization with compensation, in addition to other qualities such as spirituality and humor, are currently considered to be excellent strategies.

Alzheimer's Disease (AD) Continued

Alzheimer's disease (AD) is progressive, so as long as the person is alive, cognitive functioning will continue to deteriorate. While individuals differ in what this looks like, the course of the disease can be basically divided into three time points.

Cognitive Problems

As we've already learned, developing dementia (also known as a neurocognitive disorder) is not a normal part of aging. However, the older one gets, the more likely it is that one will develop a neurocognitive disorder. The likelihood increases with age.

C. Selective Optimization with Compensation Theory

Baltes and colleagues (for example, Baltes & Baltes, 1990; Freund & Blates, 2002) proposed the selective optimization with compensation theory. This theory links successful aging with three things: selection, optimization, and compensation.

Alzheimer's disease and related disorders

Beginning stages: -progressive memory decline: names, words -trouble with activities -altered mood Middle Stages: -independence is compromised -forgets family members' names -gait problems End Stages: -unable to walk, speak, eat or engage in life's basic activities

Mourning

Behaviors undertaken while grieving. Mourning behaviors are strongly culturally determined.

Palliative care

Comfort care. The emphasis is on comfort rather than cure, on enhancing the quality of life rather than prolonging it. Hospice emphasizes palliative care.

Scientists currently look at DNA for answers to the aging riddle.

For example, specific genes seem to be at least partly responsible for longevity as well as the age at which noticeable physical changes occur in aging. Other genetic theories consider cumulative effects that damage DNA, resulting in aging. For example, free radicals triggered by certain environmental contaminants might be linked to various diseases and maladies that coincide with aging. Accumulating free radicals over time might be associated with problems such as cataracts and arthritis (this is the free radical theory). However, much more work needs to be done to understand the process and causes of aging. As you watch the video in this module, be sure to note the following biological theories of aging: rate of living theory, cellular theories, and programmed cell death theories. Here are some additional notes to help guide you as you watch the video:

Final stages of AD

If the elder survives to these stages, he might not be able to speak, eat, walk, or use a toilet. All of these deficits have to do with forgetting how to do these things rather than any impairment of the limbs. However, people in the final stages of Alzheimer's typically have health problems resulting from the sedentary and bed-ridden lifestyle. The length of time it takes to reach the final stages varies. For some, it is a more rapid decline of a few years. For others, it takes 15 years. Women typically live longer with the disease.

Sub-types of Neurocognitive Disorders

Individuals can have either mild or major versions of neurocognitive disorders, and there are a number of potential causes. For example, the following are examples of causes of neurocognitive disorders. These are various subtypes of neurocognitive disorders/dementias. Again, individuals may have mild or major versions of each subtype.

Elisabeth Kubler-Ross's theory.

Kubler-Ross interviewed over 200 terminally ill individuals and came up with a stage theory to describe their responses to their own approaching deaths. It is important to understand Kubler-Ross's research method since this theory is usually applied to an individual coping with another person's impending death. While these stages may be applicable to coping with a variety of losses, they were originally conceived as applying to dealing with one's own approaching death.

Biological aging

Late adulthood, which begins in one's 60s, can be the longest age grouping in one's life if an individual lives to old age. However, there are many misconceptions and misunderstandings about late adulthood. For example, consider the following questions.

loss of loved one situation

Many current grief researchers would emphasize that there is no "normal" way of grieving. Everyone grieves in his or her own way. However, there may be adaptive (helpful) and maladaptive (unhelpful) ways to grieve. Kubler-Ross's stage theory, while not originally applicable to your friend's situation, shows some common aspects of grief, some of which your friend is experiencing. Anger as a grief reaction is much more common than people think. It is not at all a problem that your friend did not experience denial. Hopefully your friend can come to some peace regarding the situation, since prolonged anger may not be the best way of holding onto a loving memory of the deceased individual (not to mention the psychological and physical distress, long-term, that may correspond to being very angry).

End of Life A. Definition of Death and Stages of Dying

Modern technology has somewhat complicated our definitions of death which, in the past, may have focused on the following: -cessation of all bodily processes -stopped heartbeat -stopped breath

Do most older adults need to live in a nursing home?

No. Most elders are able to care for themselves and are able to carry on their normal activities. However, elders who are physically unwell are more likely to have cognitive impairments or mobility issues that may necessitate long-term care.

Do most older adults develop dementia?

No. Some adults describe memory lapses as "senior moments" or "senility." Professionals now use the terms "dementia" or "neurocognitive disorder" to describe the loss of cognitive abilities due to a physical reason such as Alzheimer's disease or stroke. It is not typical for an older adult, or anyone, to have a neurocognitive disorder. This is not a normal part of aging. Neurocognitive disorders can be caused by various diseases, severe drug/alcohol abuse, stroke, or progressive deterioration caused by a variety of factors (as is likely the case with Alzheimer's disease, to be discussed later). Neurocognitive disorders are extremely rare prior to age 60. Only a small percentage of 65-to-75-year-old people have a neurocognitive disorder. However, this number increases with age so that approximately 50 percent of individuals 85 and older have a neurocognitive disorder.

B. Active Theory

Numerous researchers, beginning in the 1960s, asserted that not only was disengagement theory incorrect, the opposite is true. That is, the more active an older adult is, the more satisfied in life he will be. Again, recent research seems to support activity theory, showing that early retirement and low levels of physical activity can be detrimental unless the adult finds another avenue for involvement. While there may be many barriers for older adults to maintain social interaction, this theory says that older adults need to be creative in considering ways to maintain an active social life. However, more recent research and theory (see the next theory below) indicates some important considerations regarding elders' level of activity.

While many older adults (and middle-aged ones) may become nervous at the slightest change in memory performance, cognitive changes are common in later life.

Older adults simply do not perform at the same level as their younger counterparts on certain memory tasks. However, other types of cognitive ability (for example, vocabulary) tend to improve across the lifespan. An older adult does not have to be concerned about having Alzheimer's disease (AD) unless the cognitive deficits are disruptive to everyday life. Research on the causes of AD is still ongoing. Genetics play a role, particularly for those with early-onset Alzheimer's disease.

Summarize current findings regarding what causes AD.

Research has ruled out many environmental substances (for example, aluminum and aspartame) as primary causes of AD. However, the precise causes are still unknown. While amlyoid plaques and neurofibrillay tangles characterize the brains of patients with AD (and contribute to neural death and brain shrinkage), these abnormalities can also be observed in the brains of asymptomatic individuals. This leads researchers to investigate still further for insight into why individuals may function so differently with and without the presence of these abnormal brain structures.

Cellular theories of aging:

These theories include the phenomenon known as the Hayflick Limit (named after the discoverer of the phenomenon), which states that human adult cells have a limited number of times that they can divide (approximately 20). After this limit is reached, the cells will begin to die. The free radicals theory would also be a cellular theory.

A. Disengagement Theory

The first theory (that is, the earliest) is Cumming and Henry's (1961) disengagement theory, which states that older adults should withdraw from society in order to prepare for death. Late adulthood, according to this view, is a time for decreasing social interaction. Cummings and Henry felt that older adults would be most satisfied in life if they didn't overly concern themselves with society in their declining years. This theory has been soundly criticized and largely debunked. As stated earlier, taking it "too easy" can have dire physical consequences. It can also have dire social and cognitive consequences. The "use it or lose it" view is currently the more dominant philosophy among experts, rather than disengagement theory. However, many older adults (and others) today, may more or less subscribe to disengagement theory.

Programmed cell death theories:

These theories focus on how cells appear to be designed to self-destruct. A variety of processes contribute to this programmed cell death, and many of the diseases associated with aging, such as osteoporosis and Alzheimer's, have evidence of being at least partly caused by these processes.

Grief

The psychological reaction to a loss. Typical aspects of grief include sadness, anxiety, and anger.

Are memory problems inevitable as we get older?

There are certainly cognitive changes that occur as adults age. One typical change is that elders have trouble remembering the precise source of information. For example, after telling a story for many years, an elder might forget that the story was based on an event that happened to someone else rather than himself. However, as mentioned earlier, neurocognitive disorders and dementia are not a typical part of aging.

Why do women typically outlive men?

This is a multi-faceted issue, but experts today indicate that the answer to this question is partly genetics, but it is particularly environmental. Men are more likely to engage in risky behaviors, abuse drugs and alcohol, and be less vigilant about their overall health.

Socioemotional Development: Theories of Aging

Various theories exist regarding socioemotional changes in late adulthood. We will explore some of the major theories.

Hospice

Very comprehensive program of services for the terminally ill, as well as their families. There may be a physical location for the hospice, but often most of the services are sent to the client's home. Services include treating physical needs, such as nausea and pain, and addressing social and spiritual needs.

Cognitive declines due to vascular disease

are due to a cerebrovascular event such as a stroke. Risk factors include hypertension, smoking, obesity, and any factors that contribute to cerebrovascular disease.

selection

due to some inevitable declines, older adults should be selective in what they choose to do. They shouldn't fully disengage but they may not be able to do all the same activities that they used to or in the same manner as their younger years.

A number of individuals with an HIV infection

have a neurocognitive disorder that is tied to this disease. Approximately 25 percent of individuals with HIV have symptoms for at least a mild neurocognitive disorder. The module video discusses the percentage of individuals with AIDs who have neurocognitive disorders. Great gains have been made with treatment for HIV/AIDS. Individuals receiving HAART (highly active antiretroviral therapy), which suppresses HIV replication, often experience lower rates of neurocognitive issues.

Optimization

involves maintaining what you can through practice, even if there are declines in other areas

secondary aging

is aging that is not inevitable. It is a result of choices that we make and environmental exposure. For example, smoking cigarettes and frequent sun exposure cause wrinkles.

A prion disease

is caused by transmissible agents called prions. For example, a form of Creutzfeldt-Jakob disease is known as "mad cow disease." In humans, Creutzfeldt-Jakob disease is very rare. While the precise process for developing a prion disease is not well understood, research indicates that transmission can occur by corneal transplantation, injection, and physical contact with contaminated matter.

primary aging

is genetically influenced and thought to be unavoidable at this point. What triggers this process, however, is up for debate.

Substance/medication induced neurocognitive disorder

is usually due to a lifetime of heavy drug use such as alcohol abuse. This may result in the individual having severe problems with concentration as well as some motor problems.

Parkinson's disease

may cause a neurocognitive disorder. Symptoms include anxiety, depression, hallucinations, and personality changes.

Beginning stages of AD

memory begins to decline. Typically, deficits in declarative memory are most common, such as routinely forgetting basic words and substituting them with odd words ("I put on my cat"). The individual may begin having trouble with some activities. This may or may not be evident to others. What may be noticeable to others is the social withdrawal and other social changes that result as the individual tries to cope with increasing memory difficulties. Because the individual is likely very aware of the memory problems, depression is common at this point.

compensation

occurs when an older adult cannot function as they used to and have to learn to compensate accordingly (ex: resting after physical activity, driving slower, or watching peoples' lips while they talk). Humans do these things all the time but they may become more necessary in later adulthood.

Euthanasia

painlessly killing or permitting the death of someone who is severely injured or sick. Euthanasia can be active (an agent—a doctor, for example-- actively administers something to hasten death) or passive (an agent does not permit life-sustaining measures to be used).

Middle stages of AD

the individual's problems with basic activities of daily living increase to the point that the elder loses some independence and cannot (or should not) cook or drive. Cognitive problems might result in the elder leaving uncooked food out on a table for days or forgetting to turn off the stove. The elder may forget names of spouses and children, be unaware of current events (including the year) and may have personality changes. Gait problems are common since Alzheimer's disease impacts more than memory. The brain begins to have problems interpreting visual stimuli, so that cluttered hallways filled with confusing patterns on the floor might make it impossible for the elder to navigate. Even in a room without clutter or chaotic colors, the elder may begin to walk with a shuffling step due to visuospatial reasoning problems.