Chapter 17: Disorders of Aging and Cognition

medical consequences of depression in the elderly

- Rate is higher among ppl in nursing homes - older depressed people with high blood pressure are more likely to suffer a stroke as older nondepressed people with the same condition. - recover more slowly and less completely from heart attacks, hip fractures, pneumonia, and other infections and illnesses. - elderly people are also more likely to die from suicide than young people, and often their suicides are related to depression.

the most common neurocognitive disorder

Alzheimer's which remains incurable and almost untreatable

autoimmune theory

Changes in aging brain cells may trigger an autoimmune response, leading to alzheimer's

Diagnosis of Alzheimer's

Diagnosticians are usually able to build a very strong circumstantial case and arrive at an accurate diagnosis Battery of assessment tools, including neuropsychological tests, brain scans, blood tests, and other lab work, and careful history taking

Treatments for the cognitive features of Alzheimer's disease

Drug therapy, cognitive techniques, behavioral interventions, support for caregivers, and sociocultural approaches None of these interventions stops the progression of the disorder

Psychotic Disorders in Later life

Elderly ppl have a higher rate of psychotic symptoms than younger persons Their symptoms are usually due to underlying medical conditions such as neurocogntive disorders - some elderly ppl suffer from schizophrenia or delusional disorder

____ is particularly common in the elderly

GAD

treating delirium

If a clinician accurately identifies delirium, it can often be relatively easy to correct — by treating the underlying infection, for example, or changing the patient's drug prescription

DSM-5 Checklist: delirium

Over the course of hours or a few days, individual experiences fast-moving and fluctuating disturbances in attention and orientation to the environment. Individual also displays a significant cognitive disturbance.

retrieval

Remembering info stored in long-term memory

neurocognitive disorders

Significant cognitive deterioration; used to be called dementia

the __ and ___ contribute to neuron death

The plaques and tangles The plaques (which occur between neurons) accomplish this by interfering with neuron-to-neuron communications, while the tangles (which occur inside neurons) accomplish it by blocking the transportation of essential molecules within neurons

Brain structure and brain circuitry related to alzheimer's disease

There may be multiple genetic causes triggering the numerous tangle formations and the onset of alzheimer's disease: 1. Gene forms that start the ball rolling by first promoting beta-amyloid protein formations and plaques 2. Gene forms that more directly promote tau protein abnormalities and tangle formations

Lisa mosconi and colleagues biomarker research on alzheimers

Using brain scans and other biological tests, this research team measured a combination of biomarkers in dozens of elderly research participants and conducted follow-up studies. The researchers found that those who developed such disorders had displayed more biomarker abnormalities, including low hippocampus activity, on their initial brain tests than the participants who remained healthy. Overall, the biomarker tests, administered years before the onset of symptoms, predicted mild neurocognitive impairment and major neurocognitive impairment

One of the most frequent reasons for the institutionalization of ppl with Alzheimer's disease is

overwhelmed caregivers can no longer cope with the difficulties of keeping them at home

Delirium

(cognitive disorder) major disturbance in attention and orientation to environment - State of massive confusion typically occurs over a short period of time, usually hours or days With diminishing awareness, individual has great difficulty concentrating, focusing attention, and thinking sequentially --> misinterpretations, illusions, hallucinations Sufferers may believe that it is morning in the middle of the night/that they are home when actually they are in a hospital room. May occur in any age group; more common in elderly - Incorrect diagnoses (relatively common) can lead to significant medical and psychological difficulties, including a heightened death rate for older ppl with delirium

Early-onset alzheimer's disease

(familial) caused by abnormalities in genes responsible for the production of beta-amyloid precursor protein (beta-APP) and presenilin protein some families transmit mutations, or abnormal forms, of one or both of these genes — mutations that lead ultimately to abnormal beta-amyloid protein buildups and, in turn, to plaque formations

ApoE-4 gene

(form of apolipoprotein E gene) promotes the excessive formation of beta-amyloid proteins, helping to spur the formation of plaques and, in turn, the breakdown of the tau protein, the formation of numerous tangles, the death of many neurons, and, ultimately, the onset of Alzheimer's disease

Late-onset alzheimer's disease:

(sporadic) appears to result from a combination of genetic, environmental, and lifestyle factors - apolipoprotein E gene is generally responsible for the production of a protein that helps transport cholesterol in the bloodstream - (those who inherit ApoE-4 - particularly vulnerable to develop this disease)

Disorders of Cognition

1. Cognitive problems more often have organic roots, particularly when these appear in later life - The leading such disorders among the elderly are delirium, major neurocognitive disorder, and mild neurocognitive disorder 2. problems in memory and related cognitive processes can occur without biological causes, in the form of dissociative disorders.

Psychological problems of elderly persons may be divided into two groups

1. Disorders common in ppl of all ages but are connected to the process of aging Depressive, anxiety, and substance use disorders 2. Disorders of cognition that result from the brain abnormalities Delirium, mild neurocognitive disorders, and major neurocognitive disorders

DSM-5 Checklist for Mild Neurocognitive Disorder:

1. Individual displays modest decline in at least one of the following areas of cognitive function: Memory and learning Attention Perceptual-motor skills Planning and decision-making Language ability Social awareness. 2. Cognitive deficits do not interfere with the individual's everyday independence.

DSM-5 Checklist for Major Neurocognitive Disorder:

1. Individual displays substantial decline in at least one of the following areas of cognitive function: Memory and learning Attention Perceptual-motor skills Planning and decision-making Language ability Social awareness. 2. Cognitive deficits interfere with the individual's everyday independence.

Cognitive-behavioral Techniques for alzheimers

1. cognitive activities, including computer-based cognitive stimulation programs, sometimes help prevent or delay the onset of Alzheimer's disease 2. Cognitive-behavioral strategies that focus primarily on behaviors seem to be more useful in preventing and managing this disease (physical excercise - helps improve cognitive functioning and reduce risk of Alzheimer's) - focus on changing everyday patient behaviors that are stressful for the family, such as wandering at night, loss of bladder control, demands for attention, and inadequate personal care The therapists use a combination of role-playing exercises, modeling, and practice to teach family members how and when to use reinforcement in order to shape more positive behaviors.

human brain has two memory systems that work together to aid learning and recall

1. short term memory, or working memory, gathers new info - Info held in short-term memory must be transformed, or consolidated into long-term memory 2. Long-term memory is the accumulation of info that we have stored over the years

Neuropsychological tests:

: tests that measure a person's cognitive, perceptual, and motor performances on certain tasks

Genetic Causes of Alzheimer's:

Abnormal activity by the beta-amyloid protein is key to the repeated formation of plaques Abnormal activity of tau (protein) is key to the excessive formation of tangles Many plaques formed by beta-amyloid protein cause tau proteins within neurons to start breaking down, resulting in tangles and the death of many neurons

Viral/Prion theory

Because alzheimer's disease resembles Creutzfeldt-Jakob disease (a form of dementia caused by a virus/mishapen proteins called prions), some researchers propose that a similar virus may cause Alzheimer's disease

biomarkers

Biochemical, molecular, genetic, or structural characteristics that usually accompany a disease.

The aging Brain

Cerebral cortex: large neurons shrink. Amygdala deposits develop in spaces btw neurons Basal forebrain: ACh-secreting neurons shrink or die Amygdala: amyloid deposits develop in spaces btw neurons. Neurofibrillary tangles develop within neurons Hippocampus: large neurons shrink or die. Amyloid deposits develop in spaces btw neurons. Neurofibrillary tangles develop within neurons Locus coeruleus: neurons die Thalamus: selected neurons die/shrink Hypothalamus: selected neurons die

____ is one of the most common mental health problems of older adults

Depression - Same features of depression for elderly ppl and younger ppl feelings of profound sadness and emptiness; low self-esteem, guilt, and pessimism; and loss of appetite and sleep disturbances.

causes of delirium

Fever, certain diseases and infections, poor nutrition, head injuries, strokes, stress (including trauma of surgery) and intoxication by certain substances When elderly people enter a hospital (major change in their environment and routine) to be treated for a general medical condition, some show the symptoms of delirium.

Other potential neurocognitive disorder causes

HIV infections Traumatic brain injury Substance abuse Various medical conditions such as meningitis or advanced syphilis

Most Effective interventions for Alzheimer's disease

Help prevent problems Are applied early Essential to have tools that identify the disorder as early as possible

Biochemical changes in the brain related to alzheimer's disease

In order for new information to be acquired and remembered, certain proteins must be produced in key brain cells. Several chemicals (ACh, glutamate, RNA) and calcium are reponsible for the production of memory-linked proteins If the activity of these chemicals is disturbed, the proper production of proteins may be prevented and the formation of memories interrupted deficient activity levels of acetylcholine and glutamate in the brains of Alzheimer's victims, as well as irregularities in the breakdown of calcium

DSM-5 Checklist for Neurocognitive disorder due to alzheimer's disease

Individual displays the features of major or mild neurocognitive disorder. Memory impairment is a prominent feature. Genetic indications or family history of Alzheimer's disease underscore diagnosis, but are not essential to diagnosis. Symptoms are not due to other types of disorders or medical problems.

Neurocognitive disorder due to Huntington's disease

Inherited progressive disease in which memory problems, along with personality changes and mood difficulties, worsen over time Movement problems - severe twitching and spasms Children of ppl w this disease have a 50% chance of developing it

Treatment for bipolar disorder in older ppl

Like younger adults, older people who are depressed may be helped by cognitive-behavioral therapy, interpersonal psychotherapy, antidepressant medications, or a combination of these approaches, individual group therapy among elderly people, antidepressant drugs have a higher risk of causing some cognitive impairment. Electroconvulsive therapy, applied with certain modifications, has been used for elderly people who are severely depressed and have not been helped by other approaches

Vascular neurocognitive disorders

May follow a cerebrovascular accident, or stroke, during which blood flow to specific areas of the brain was cut off, with resultant damage In many cases, patient may not be aware of the stroke Progressive, but symptoms begin suddenly, rather than gradually - person's cognitive functioning may continue to be normal in areas of the brain unaffected by stroke

Ppl w neurocognitive disorder experience

Ppl w neurocognitive disorder experience a significant decline in at least one (often more than one) area of cognitive functioning Memory, attention, visual perception, planning and decision making, language ability, or social awareness Changes in personality and behavior The experience of neurocognitive disorder is closely related to age; early and late onset 65-74 years of age, prevalence is around 3% 75-84 years old, prevalence is 17% 85 years and older, prevalence is 32%

Certain brain structures seem to be esp. Important in memory

Prefrontal lobes: appear to hold info temporarily and to continue working with the info as long as it is needed (short-term memory) Temporal lobes (includes hippocampus and amygdala) and diencephalon (thalamus and hypothalamus): seem to help transform short-term memory into long-term memory Research indicates that cases of dementia involve damage to or improper functioning of one or more of these areas research suggests that excessive communication (hyperconnectivity) between some of the structures and deficient communication (hypoconnectivity) between other structures in the circuit may help produce the disease

Substance Misuse in Later Life

Prevalence of alc abuse and other forms of substance abuse appear to decline after age 65 particularly men, display alc-related disorders in a given year Differences btw older problem drinkers who have experienced significant alc-related problems for many years and those who do not start the pattern until their 50s and 60s (late-onset alcoholism) The latter group typically begins abusive drinking as a reaction to negative events (pressures of growing older; declining income and/or health) The majority of older adults do not misuse alcohol or other substances Older patients who are institutionalized, do display high rates of problem drinking. Treatment: detoxification, AA, cognitive-behavioral therapy

As the study and treatment of elderly ppl have progressed, 3 issues have raised concern among clinicians:

Problems faced by elderly members of racial and ethnic minority groups Inadequacies of long-term care Need for a health-maintenance approach to medical care in an aging world

depression in the elderly

Same features of depression for elderly ppl and younger ppl feelings of profound sadness and emptiness; low self-esteem, guilt, and pessimism; and loss of appetite and sleep disturbances. particularly common among those who have recently undergone a trauma, such as the loss of a spouse or close friend or the development of a serious physical illness more common in older women raises chances of developing significant medical problems

schizophrenia in the elderly

Schizophrenia is less common in older ppl than in younger ones Symptoms often lessen in later life; Improvement can occur in people who have had schizophrenia for 30 or more years, particularly in such areas as social skills and work capacity It is uncommon for new cases of schizophrenia to emerge in late life Antipsychotic drugs and psychotherapeutic interventions often continue from earlier life antipsychotic drugs may pose more dangers (cognitive impairment, stroke, seizures) for elderly people than younger people, given the metabolism changes in older people

Sociocultural approaches for treating alzheimers

Specialized day-care programs for outpatients: treatment programs and activities during the day and returning them to their homes and families at night. Assisted-living facilities: live in apartments and receive needed supervision and designed to meet the special needs of residents Practical devices: tracking beacons; shoes with GPS trackers

Neurocognitive disorder due to prion disease/creutzfeldt-Jakob disease

Symptoms include spasms of the body Caused by misshapen prion proteins Progresses rapidly and typically results in death

Drug Treatment for Alzheimer's disease

The drugs currently prescribed affect neurotransmitters (ACh and glutamate) known to play an important role in memory Such drugs include donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and memantine (Namenda) Short-term memory, reasoning ability, use of language, and ability to cope under pressure improve slightly Limited benefits, sometimes high risk of harmful side effects; FDA approval; most effective in early, mild stage Taking Vitamin E alone or in combo with one of the above drugs will help slow down some of the cognitive difficulties experienced by ppl in the mild stage Modestly supported Long term use of nonsteroidal anti-inflammatory drugs (ibuprofen and naprosyn) may help reduce the risk of alzheimer's Women taking estrogen years after menopause cut their risk of developing the disease in half

Alzheimer's disease

The most common type of neurocognitive disorder, usually occurring after the age of 65, marked most prominently by memory impairment. Gradual progressive disease sometimes appears in middle age (early onset) but most often occurs after the age of 65 (late onset) sufferers receive a DSM-5 diagnosis of mild neurocognitive disorder due to Alzheimer's disease during the early and mild stages of the syndrome and major neurocognitive disorder due to Alzheimer's disease during the later, more severe stages Prevalence increases markedly among ppl in late 70s and early 80s Gender and ethnic differences: more common in women, African americans and hispanics Racial and ethnic differences may be due to genetic factors or general health (cardiovascular disease and diabetes heightens a person's risk of developing this disease)

Progression and onset of alzheimers

Time btw onset and death is typically 4-8 years, although some ppl may survive 20 years Usually begins with mild memory problems, lapses of attention, and difficulties in language and communication → less awareness of limitations → confusion, withdrawal, loss of knowledge of past and faces → disturbed sleep patterns → fully dependent Usually remain in good health until the later stages of the disease - many develop a depressive disorder

Many Alzheimer's caregivers experience

anger and depression, and their own physical and mental health often declines

Leading explanation for alzheimer's

center on plaques and tangles and on the various factors that may contribute to their formation and excessive buildup.

neurocognitive disorder due to Lewy body disease.

characterized by the buildup of clumps of protein deposits, called Lewy bodies, within many neurons. progressive cognitive problems and significant movement difficulties, visual hallucinations, and sleep disturbances.

anxiety disorders are (common/uncommon) in the elderly

common

Many things about aging may heighten anxiety levels, including

declining health

Leading cognitive disorders among the elderly:

delirium, major neurocognitive disorder, mild neurocognitive disorder

Mild neurocognitive disorder:

disorder in which decline in cognitive functioning is modest and doesn't interfere with a person's ability to be independent

Major neurocognitive disorder:

disorder in which decline in cognitive functioning is substantial and interferes with a person's ability to be independent

proteins

fundamental components of all living cells, including, of course, brain cells. They are large molecules made up of chains of carbon, hydrogen, oxygen, nitrogen, and sulfur Essential for the proper functioning of an organism

The prevalence of anxiety (increases/decreases) throughout old age

increases - people over 85 years of age report higher rates of anxiety than those between 65 and 84 years

Delusional disorder in the elderly

increases in elderly population Ppl develop False, but not bizarre beliefs Deeply held persecutions suspicions; they believe that other people (often family members, doctors, or friends) are conspiring against, cheating, spying on, or maligning them. They may become irritable, angry, or depressed or pursue legal action because of such ideas May be due to hearing deficiencies, social isolation, greater stress, heightened poverty

One important biomarker is the ____ in alzheimers

indication of a large number of beta-amyloid proteins and tau proteins (the building blocks for plaques and tangles

And at least half of elderly people have some measure of ___

insomnia or other sleep problems

The environmental toxin ___ may contribute to the development of Alzheimer's disease

lead

A leading kind of substance abuse in the elderly is

misuse of prescription drugs Most often unintentional their risk of confusing medications or skipping doses is high.

Alzheimer's disease can be diagnosed with certainty

only after death, when structural changes in the brain such as excessive senile plaques and neurofibrillary tangles, can be fully examined

Treatments for the cognitive features of Alzheimer's disease and most other types of neurocognitive disorders have been

only modestly helpful

Older adults with anxiety disorders are often treated with

psychotherapy of various kinds, particularly cognitive-behavioral therapy Many receive antianxiety drugs - benzodiazepines Or serotonin-enhancing antidepressants Such drugs must be used to cautiously in older ppl

Frontotemporal neurocognitive disorder/Pick's disease

rare disorder that affects the frontal and temporal lobes Similar to alzheimer's but can be distinguished at autopsy

Parkinson's disease

slowly progressive neurological disorder marked by tremors, rigidity, and unsteadiness, can result in neurocognitive disorder due to Parkinson's disease, particularly in older people or those whose cases are advanced

Senile plaques:

sphere-shaped deposits of beta-amyloid protein that form in the spaces btw neurons in the hippocampus, cerebral cortex, and certain other brain regions and blood vessels

Another drug-related problem in the elderly is

the misuse of powerful meds at nursing homes 22% are given antipsychotic medications and yet many don't display psychotic functioning

old age is usually defined in society as

the years past age 65; older women outnumber older men

Neurofibrillary tangles:

twisted protein fibers found within the cells of the hippocampus

Certain substances found in nature such as____ may produce brain toxicity, which may contribute to the development of alzheimer's disease

zinc - Have found high levels of zinc in the brains of some Alzheimer's patients