Lifespan Module 8 - Late Adulthood and End of Life

Alzheimer's disease (AD)

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. 1. In the beginning stages, 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. 2. In the middle stages, 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. 3. If the elder survives to the final stages of Alzheimer's, 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. 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. Warning signs of Alzheimer's: - Memory loss that disrupts life - Challenges in planning or solving problems - Difficulty completing familiar tasks - Confusion with time or place - Trouble understanding visual images and spatial relationships - New problems with words in speaking or writing - Misplacing things and losing the ability to retrace steps - Decreased or poor judgement - Withdrawal from work or social activities - Changes in mood and personality Common myths about Alzheimer's: - Memory loss is a natural part of aging - Alzheimer's disease is not fatal - Only older people can get Alzheimer's - Drinking out of aluminum cans or cooking in aluminum pots and pans can lead to Alzheimer's - Aspartame causes memory loss - Flu shots increase risk of Alzheimer's disease - Silver dental fillings increase risk of Alzheimer's disease - There are treatments available to cure Alzheimer's disease Genetics of Alzheimer's disease Many people worry about developing Alzheimer's disease, especially if a family member has had it. Having a family history of the disease does not mean for sure that you'll have it, too. But it may mean you are more likely to develop it. People's genes, which are inherited from their biological parents, can affect how likely they are to develop Alzheimer's disease. Genetic risk factors are changes or differences in genes that can influence the chance of getting a disease. These risk factors are the reason some diseases run in families. There are two types of Alzheimer's—early-onset and late-onset. Both types have a genetic component. Late-onset Alzheimer's disease Most people with Alzheimer's have late-onset Alzheimer's disease, in which symptoms become apparent in their mid-60s. Researchers have not found a specific gene that directly causes the late-onset form of the disease. However, one genetic risk factor—having one form, or allele, of the apolipoprotein E (APOE) gene on chromosome 19—does increase a person's risk. APOE ɛ4 is called a risk-factor gene because it increases a person's risk of developing the disease. However, inheriting an APOE ɛ4 allele does not mean that a person will definitely develop Alzheimer's. Some people with an APOE ɛ4 allele never get the disease, and others who develop Alzheimer's do not have any APOE ɛ4 alleles. Early-onset Alzheimer's disease occurs between a person's 30s to mid-60s and represents less than 10 percent of all people with Alzheimer's. Some cases are caused by an inherited change in one of three genes. For other cases, research shows that other genetic components are involved. Researchers are working to identify additional genetic risk variants for early-onset Alzheimer's disease. Health, environmental, and lifestyle factors that may contribute to Alzheimer's disease Research suggests that a host of factors beyond genetics may play a role in the development and course of Alzheimer's disease. There is a great deal of interest, for example, in the relationship between cognitive decline and vascular conditions such as heart disease, stroke, and high blood pressure, as well as metabolic diseases, such as diabetes and obesity. Ongoing research will help us understand whether and how reducing risk factors for these conditions may also reduce the risk of Alzheimer's. A nutritious diet, physical activity, social engagement, sleep, and mentally stimulating pursuits have all been associated with helping people stay healthy as they age. These factors might also help reduce the risk of cognitive decline and Alzheimer's disease. Clinical trials are testing some of these possibilities. Early-life factors may also play a role. For example, studies have linked higher levels of education with a decreased risk of dementia. There are also differences in dementia risk among racial groups and sexes—all of which are being studied to better understand the causes of Alzheimer's disease and to develop effective treatments and preventions for all people. 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?"

Theories of aging: 3. 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. Due to some inevitable declines, older adults must be more selective in what they choose to do. They should not completely disengage (as disengagement theory says), but they may not be able to do the same activities in the same way as in their younger years. Secondly, as we first learned in Module 1, development is multidirectional—one can both improve and decline. Optimization, then, involves maintaining what you can through practice, even if there are declines in other areas. Finally, compensation occurs when an older adult simply cannot function as she used to and must learn to compensate accordingly (such as by resting after physical activity, driving more slowly, or watching peoples' lips while they talk). This is something that humans do all the time; it just may be more necessary in late adulthood. All three theories attempt to address 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.

End-of-life terms

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). 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. 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, but palliative care can be used for patient groups beyond those experiencing a terminal illness. Palliative care can be for anyone living with a serious illness. A palliative care team can include doctors, nurses, social workers, chaplains, and nutritionists. Palliative care can be situated in hospitals and nursing homes, but also in outpatient palliative care clinics or in the patient's home. Grief: The psychological reaction to a loss. Grief is a normal and natural response to losing someone or something close to you. Typical aspects of grief include sadness, anxiety, and anger. However, every person's particular grief response is unique to them. It's been said that grief is universal and yet individual. There are many types of grief, and some types are more complicated. For example, some types of grief involve stigma and shame. Or, one can grieve in advance of someone's death, in the form of anticipatory grief. Contrary to what some may think, there is no particular timetable to grief. Mourning: Behaviors undertaken while grieving. Mourning behaviors are strongly culturally determined. For example, those mourning the loss of a loved one may cry, spend time alone in contemplation, or sit with close family members, all depending on what one's cultural practices are pertaining to mourning. Some may wear black clothing for a time or perform particular rituals pertaining to the funeral and burial. These behaviors help the grieving individuals to process their grief and do so in community with others. When comparing grief and mourning, grief is internal and mourning is external. Grief involves internal thoughts and feelings, while mourning is how these feelings are shown, which includes behavior. What grief and mourning look like for an individual is largely culturally influenced. Therefore, it's important for those studying grief as well as those working with grieving individuals to learn at least a little about how culture, as well as religious beliefs, intersects with grief and mourning. What people think and believe about death varies by culture and religion, and this will impact the meaning-making that is part of processing the loss. Various rituals may accompany end-of-life, including the moments shortly before and shortly after the death as well as how the body should be handled. How intensely someone grieves and how long one is expected to grieve is also partly culturally determined. Cultural sensitivity is important when working with grieving families. In some cultures, for example, mainstream American and Canadian culture, openly talking about grief in everyday conversation is somewhat taboo. Grief is often a private, family affair. But this is not the case worldwide or within some subcultures, where grief may be experienced more communally. It's important to note that practicing mourning rituals may provide grieving families with much comfort and needed social support, so supporting these practices can be essential for the family's coping and healing. Simple questions can be asked of grieving families in order to help support them in ways that they would find to be helpful. In conclusion, and as the lecture video describes, it's important for those in the helping professions to be familiar with the psychological reactions to loss. Whether it's the loss of a loved one, or a significant life change, the psychological reactions described here are a normal part of the human experience. This normalcy and ubiquity (i.e. appearing everywhere) means that we all will experience loss and will also be around others experiencing loss. Being prepared to understand one's own feelings in advance can be very helpful for healthy coping behaviors. This can also prepare us to provide loving care and concern toward others, whether these are close friends and family, students, or patients. Understanding and supporting the whole person, their physical and psychological needs and how they intertwine, has been a theme throughout this course. Life's changes provide us with the opportunity for growth, even amidst difficulty.

Subtypes 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. Parkinson's disease may cause a neurocognitive disorder. Symptoms include anxiety, depression, hallucinations, and personality changes. 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. 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. 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. 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. 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. 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.

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. Do most older adults develop dementia? Why do women typically outlive men? Are memory problems inevitable as we get older? Do most older adults need to live in a nursing home? We cannot spend extensive time answering these questions that hit on some very real fears about old age. However, a quick summary answer to each is below, and this module will continue to discuss typical development in late adulthood. 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. 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. 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. 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. The rest of this module will cover biological aging, neurocognitive disorders, and a variety of socioemotional topics pertaining to late adulthood. The module will close with end-of-life issues. 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. Primary aging is genetically influenced and thought to be unavoidable at this point. What triggers this process, however, is up for debate. 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. 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. 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: 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. After this limit is reached, the cells will begin to die. The free radicals theory would also be a cellular 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.

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 In many industrialized nations today, 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. It would take an entire course to adequately cover end-of-life (just as there are entire college courses to cover child development and adult development, separately). However, we will focus on the most well-known theory pertaining to death and dying: 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. Stop and think. Can you name Kubler-Ross's five stages of dying? See how many you can come up with and then read below. 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.

Theories of aging: 2. Activity 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.

Theories of aging: 1. 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.