Psych of Aging-Chapter 11- Mental health

Obsessive-compulsive disorder

*A form of anxiety disorder in which people suffer from obsessions, or repetitive thoughts and compulsions, which are repetitive behaviors.

Late onset schizophrenia

*A form of the disorder was thought to originate in adults over the age of 45 years. *This condition is now thought not to be schizophrenia but rather some other phenotype of psychotic disorder, the risk factors for which many include sensory deficits, comorbid dementia and delirium, social isolation, and substance abuse.

Psychopathy

*A set of traits that are thought to lie at the disorder's very core.

Mood disorder stats

*About 18% of adults are estimated to meet the diagnostic criteria for MDD *At any time about 1 to 5% of adults in the US have major depression or its milder and more chronic form, dysthymia. *Rates for women and double that of men *People over age 65 are actually less likely to experience a depressive disorder than are people under the age of 65 *About 15 to 30% of older adults living in the community experience depressive symptoms with higher rates among those seen in medical settings. *Although women are more likely to experience the diagnosable condition of major depressive disorder, depressive symptoms are higher in men between the ages of 60 and 80. *Older adults are more likely to seek treatment for physical symptoms such as pain and abdominal disturbances rather than seeking treatment for what is really psychological symptoms • 18-25 have the highest rates of depression • 55+ have lowest rates • Child be less likely to seek treatment, less educated about mental health issues, could be too much stigma

Symptoms of alcohol dependence in older adults

*Alcohol use is thought to be relatively prevalent in settings in which only older adults live, such as nursing homes and retirement communities *The risk of alcohol abuse among this population are considerable, ranging from cirrhosis of the liver, to heightened rate of injury through hip fractures and motor vehicle accidents. *Long term alcohol use may lead to changes in the frontal lobes and cerebellum, exacerbating the effects of normal aging on cognitive and motor functioning. *In severe and prolonged alcohol abuse, dementia can develop, leading to permanent memory loss and early death.

Mini-Mental state exam

*An assessment instrument used extensively in the diagnostic process for older adults is the mental status examination. *Although the MMSE is quick, easy to administer, and useful for charting changes in dementing symptoms over time, it is not particularly specific to dementia and does not allow for precise measurement of cognitive functioning. *This is a less effective tool for African Americans and Mexican Americans

PTSD

*An individual suffers prolonged effects of exposure to a traumatic experience such as an earthquake, fire, physical assault, and war. *Likely to increase among older adults due to adults who served in the Iraq and Afghanistan wars grow older. *Heart disease can increase risk of PTSD and vice versa.

Health care professionals and mental health in older adults

*Are not well trained in recognizing the signs of depression in their older clients because older adults do no necessarily report their symptoms in a manner that allows for accurate diagnosis. *Physicians spend less time with their older patients than with their younger patients.

Exercise and meditation in mental health treatment for older adults

*Building on findings that physical fitness is inversely related to mental health, researchers have begun to use exercise as a therapeutic tool in the treatment of psychological disorders in later adulthood to supplant or replace medications *Meditation is another alternative approach that builds on the known association between pain and depressive symptoms in older adults.

Treatment issues in mental health care (Book)

*Clinicians who work with adult populations recognize the need to differentiate the approaches they take to young and middle aged adults from the approaches they take to older adults.

Delirium, dementia, and amnestic disorders

*Disorders involving significant loss of cognitive functioning as the result of neurological dysfunction or medical illness from the category in DSM-IV-TR

Self-report clinical inventories

*Easier to administer, but with a higher cost of placing greater burden on the test-taker. *Client answers a set of questions conceding the experience of particular symptoms related to a diagnostic criteria. *Many of these were developed for young or middle aged adults *Older adults and people from diverse backgrounds may not interpret the questions as the authors of the test had intended, leading to results that do not provide a valid indication of the clients psychological status.

Mood disorders (Book)

*Essentially 2 categories: 1) Depressive disorders 2) Bipolar disorder

Bipolar disorder

*Formerly known as manic depression *People with this disorder experience what is known as a manic episode, a period typically lasting at least 1 week.

Life review therapy

*Geared specifically toward older adults *Variant of traditional psychodynamic therapy, which typically focuses on unresolved issues from early life -involves helping the older adult rework past experience, both pleasant and unpleasant, with the goal of gaining greater acceptance of the past. *This process facilitates the natural reminiscence process that accompanies resolution of the ego integrity vs despair psychosocial issue

Specific phobia

*Have an irrational fear of a particular object or situation -most commonly fear snakes, enclosed places, and seeing blood.

Psychological disorders

*Includes the range of behaviors and experiences that fall outside of social norms, create adaptational difficulty for the individual on a daily basis, and put the individual or others at risk of harm.

Interpersonal Therapy

*Integrates cognitive methods with a focus on social factors that contribute to psychological disturbance *Main focus on training in social skills, interpersonal relationships, and methods of conflict resolution.

Social phobia

*Involves anxiety in situations in which a person must perform some action in front of others. *Fear of being publicly embarrassed or made to look foolish, not people. *12% of adults, peak in 30s *Women are most likely to suffer

Panic disorder

*Involves the experience of panic attacks in which people have the physical sensation that they are about to die -may lead to agoraphobia *Unlike younger adults, who may develop agoraphobia following a panic attack, it is more likely that this condition in older adults is related to fear of harm or embarrassment.

Delirium

*Is an acute state in which the individual experiences a disturbance in consciousness and attention, as well as memory loss, disorientation, and an inability to use language *Causes: -Substance use -medications -head injury -high fever -vitamin deficiency

GAD

*Is associated with an overall sense of uneasiness and concern without specific focus. *Very prone to worrying, especially over minor problems

Biopolar disorder in later adulthood

*Lower in older adults (1%) *Younger population (1.4%) *May be neurological contributions as suggested by the fact that bipolar disorder in older adults is related to a higher risk for cerebrovascular disease and white matter hyper intensities.

Axis II disorders in adulthood Facts

*Personality disorder is a condition diagnosed on this axis to apply to long standing and maladaptive dispositions. • Personality disorders: Lifetime prevalence: 9%, fairly stable over life course • Antisocial personality disorder - Psychopathy • Factor 1: Disposition - Disturbed capacity to experience "social" emotions like empathy, guilt, remorse - Manipulativeness, egocentricity, callousness - Stable over time • Factor 2: Behavior - Socially deviant and impulsive behaviors - Decrease over time *Rate of imprisonment drastically decreases after the age of 45

Assessment in mental health care for older adults

*Procedure that involves evaluation of the psychological, physiological, and social factors that potentially affect the individuals current state of functioning. *All clinical assessment involves differential diagnosis: the process of ruling out alternative diagnoses *A key area of differential diagnosis is distinguishing between dementia and other psychological disorders, particularly depression. -depression can cause pseudodementia, which is memory loss and difficulties in concentration leading to symptoms that closely resemble dementia. *If the cognitive symptoms persist after the depression has been treated, then the dementia is more likely the cause. *These differences are important to catch early because if depression is caught in time there is a good chance of successful treatment.

DSM-IV-TR

*Psychiatric manuel for abnormality *Was not developed with consideration of how the diagnostic categories for psychological disorders might change over the adult years.

Late-onset stress symptomology (LOSS)

*Refers to a phenomenon observed in aging veterans who were exposed to stressful combat situations in young adulthood. *Symptoms of LOSS are similar to those of PTSD, but the progression is distinct in that it develops later in life.

Dysphoria

*Sad mood *Lasting varying amounts of time and varying degrees of severity

Interview measures for specific disorders

*Several interview based measures exists for the assessment of specific symptoms in older adults: 1) The Geriatric Depression Scale (GDS) -validity is well established with older adult population 2) The Anxiety Disorders Interview Schedule (ADIS-R) -Useful in assessing social phobia, GAD, simple phobia, and panic disorder. 3) The Hamilton Rating scale of Depression 4) The Hamilton Anxiety Rating Scale -have also been tested with older adults and are useful in evaluating both the severity and number of the individual's symptoms.

Major depressive disorder

*The major symptom is an extremely sad mood (lasting at least 2 weeks) *Other symptoms include appetite and sleep disturbances, feelings of guilt, and a low sense of self-worth.

Mood disorders

*The most common among older adults is depression *Abnormalities in the individual's experience of emotion •Depressive disorders: 1) Major depressive disorder (MDD) 2) Dysthymia (D) -Not quite as severe as depression, but more severe than your average day 3) Depressive symptoms (DS) -Sub clinical, we all experience depressive symptoms, but we perhaps don't have a collection of these symptoms that would be severe enough to be diagnosed.

Dementia

*This term is used to apply to a change in cognitive functioning that occurs progressively over time. *Symptoms -aphasia -apraxia *Causes: -Alzheimer's -Substance abuse -Vascular disease -Parkinson's disease

Elder abuse facts

*To protect vulnerable adults, Adult Protective Services (APS) were mandated by Title XX of the Social Security Act in 1975 -little to no funding which makes states responsible for enforcing the regulations and so there is considerable variations in definitions and reporting mechanisms for abuse. *Most recent studies show that people 60 and older 4.6% are emotionally abused, 1.6% for physical abuse, and 5.2% for financial abuse *Up to 10% of all respondents surveyed indicated that they had been abused or neglected within the past year. *Targeting their caregivers, and providing them with better coping skills as well as adequate reimbursement and social support, are important preventive strategies to reduce the incidence of this very tragic situation.

Depressive symptoms risk factors

- Hearing or visual impairments - Functional disability, hip fracture - Loneliness, bereavement, stress - Unsuccessful coping - Physical disability, poor fitness - Tooth loss - Memory and cognition problems, Vitamin D deficiency - Medical disorders (e.g., obesity, ulcers, diabetes, heart disease, asthma, back/neck pain, hypertension, chronic headache, arthritis) - Spouse's physical disorders (e.g., urinary incontinence)

Treatment for Alcoholics in older population

1) AA 2) Context of drinking 3) New network of friends

Medical disorders and risk factors for depression

1) Arthritis-related activated limitations 2) Diabetes 3) Metabolic syndrome 4) Stroke 5) Hypertension 6) Tooth loss -depressed older adults are more likely to experience tooth loss 7) Lack of vitamin D may also present a risk factor for cognitive impairment

Treatment issues in mental health care (In class notes)

1) Assessment - Differential diagnosis • Clinical Interview • Mental Status Examination • Self-report clinical Inventories 2) Treatment - Medically based treatments - Psychologically based treatments • Cognitive Behavioral Therapy • Life Review Therapy • Interpersonal Therapy - Exercise and meditation

Psychologically based treatments in mental health treatment for older adults

1) Behavioral treatment -Focusing on increasing the number of positive reinforcements in the individual's life 2) Cognitive-behavioral therapy -Clinician encourages the client to develop new behaviors and constructive ways of thinking about the self. -This approach appears to have considerable relevance to work with older depressed clients, particularly for those who have a tendency to focus excessively on age-related changes in physical functioning, memory, and health. -Increasingly is seen as an effective treatment but not for individuals high in neuroticism and self-percieved health problems. 3) Life review therapy 4) Interpersonal therapy

Anxiety disorders facts:

1) Each year 12% diagnosed • Age 7% among older adults, 19% middle aged, 21% younger • Gender: women are 5 times more likely to have an anxiety diagnosis than men 2) Under diagnosed among older adults • Medical condition • More heavily tied to medical disorders, 3) Mortality and physical functioning risk • People with an anxiety disorder are more likely to die and have trouble functions (particularly african americans)

Other factors that contribute to mental health treatments:

1) Over the age of 75, have greater probability of physical health impairments that can compromise their effectiveness of therapy because these conditions represent a significant threat to quality of life. -boosting an individual's sense of mastery can alleviate depressive symptoms 2) Loser social classes were found to be less responsive to a combination of psychotherapy and medication than individuals in middle and high income brackets. 3) family issues may be alleviated through the provision of therapy for older adults experiencing symptoms of depression 4) Generational differences between current cohorts of older adults and the middle aged individuals more commonly seen in psychotherapy must be taken into account by clinicians as well. 5) Black adults are less likely than whites to use psychotherapy when it is offered due to embarrassment or stigmatization of the process. 6) Prevention is very important!! (Pg 257)

Schizophrenia

1) Positive symptoms • Ex: hallucinations, delusions • You have more or excess of something 2) Negative symptoms • Ex: apathy, withdrawal, lack of emotional expression • Negative because they are lacking, or less present 3) Speech and motor disturbances • Tend to have different patterns if speech and motor response that help us to differentiate between people who have this diagnosis and who does not 4) 1% lifetime prevalence rate • Not very common • Rates are about 1.5% among those between age of 30-44 • Rates are about .2% among those who are 65 and older. -Explanation: schizophrenia is associated with really dangerous behavior so they often die before they reach old age, also high substance abuse, these people are just not surviving to be old • Ones that make to older age have developed good coping skills • See a shift of symptomology as people progress, we see fewer positive symptoms and more negative symptoms as people with this disorder get older. • Also a mental health disorder that tends to have a highly variable outcome • About 20-25% are able to improve to complete remission • About 10% chronically impaired • About 50-70% show gradual remission.

Medically based treatments in mental health care in older adults

1) Psychotherapeutic medications -Substances that by their chemical nature target the central nervous system -medications take longer to clear the excretory system of the kidneys, so unless prescribed in lower doses, older adults are at risk of accumulating toxic levels in the blood. -polypharmacy *In the case of MDD, psychotherapeutic medications are highly effective (50-70%) for older adults. -most common are SSRIs *Lithium carbonate is effective for bipolar disorder. *ECT is effective for severe depression -method of last resort *Benzos, busiprone, beta-blockers, SSRIs effective for anxiety *Neuroleptics for schizophrenia -most serious side effect is tar dive dyskinesia and is higher in older adults vs younger adults.

Possible causes of an older adult's depression

1) Sensory impairments 2) The inability to provide basic self-care tasks 3) Pain 4) Institutionalization 5) Changes in cognition and personality 6) Psychosocial issues -bereavement -loneliness -stressful life events *An inability to employ successful coping strategies -avoidance vs, direct-problem focused coping methods.

Amnesia

Causes: -Chronic substance use -Medications -Exposure to environmental toxins -head trauma -loss of oxygen supply -STD Herpes simplex

Professional Geropsychology

The application of gerontology to the psychological treatment of older adults.

Clinical interview

The clinician asks questions of the client to establish insight into the client's psychological processes. *An unstructured interview can also be beneficial when it is difficult for older adult due to cognitive difficulties who find it difficult to concentrate or need help maintaing their focus. *To be most useful, the clinical interview should also be combined with more structured instruments.

Depression may activates:

cytokines that eventually increase the risk of cardiovascular disease, osteoporosis, arthritis, type 2 diabetes, caners, periodontal disease, frailty, and functional decline.

Suicide facts

• 90% who complete suicide have a diagnosable psychiatric disorder - MDD - Alcohol abuse - Schizophrenia • 33,000 Americans each year - Majority of suicides: 25-54 - Highest rate: white males 85+ • 43-76% of suicide victims had seen a health care provider within a month of their death -Highest risk of suicide completion are white male widowers, cardiovascular disease, and cancer.

Elder abuse

• Actions taken directly against older adults that inflict physical or psychological harm • Difficult to document • Perpetrator usually child or other relative under age 60 • Associated with higher mortality and more psychological distress • Older adults in poor health are at particular risk

Diagnostic and Statistical Manual (DSM-IV-TR)

• Axis I: clinical syndromes or disorders • Axis II: personality disorders and mental retardation • Axis III: medical conditions • Axis IV: psychosocial stressors and environmental problems • Axis V: overall rating of functioning (1-100) (1 being suicidal and 100 being superior functioning) • Older adults in particular: physical symptoms might mask psychological disorders • They feel comfortable seeking medical assistance for pain but not for depression • Physical symptoms are often the (?impotence?) for seeking treatment for older adults • Until recently. Medicare did not re-imburse for psychological treatment the same as it did for medical treatments.

Delirium, dementia, and amnestic disorders facts

• Dementia: progressive change in cognitive functioning • Delirium: disturbance in consciousness and attention • Amnesia: profound memory loss • Anterograde: inability to learn or remember information encountered after the damage (i.e., into the future) • Retrograde: inability to recall information learned prior to the damage (i.e., going back into the past)

Anxiety disorders

• Generalized anxiety disorder - 2-5% -Lower among older adults • Panic disorder - 4.7% (1.4% agoraphobia) -Are both higher among younger adults than older adults • Phobia - 12.5% -Less common among older adults (7.5%) • Obsessive-compulsive disorder - 1.6% -Pretty rare among older adults (0.7%) • Post-traumatic stress disorder - Rates vary -These rates fluctuate through out the life course because they are so strongly linked to experience.

Axis II disorders

• Maturation hypothesis: "immature" personality types (histrionic, borderline, narcissistic, and antisocial personality disorders) improve or become more treatable by older adulthood than "mature" types (obsessive-compulsive, schizoid, and paranoid personality disorders), which become more symptomatic over time • Brain injury • Disease • Life stress • Social support • Coping resources *These are axis III and IV things that might influence axis II

Major Axis I disorders

• Mood disorders • Anxiety disorders • Psychotic disorders • Delirium, dementia, and amnestic disorders • Substance-related disorders

Suicide

• Risk factors among older adults - Psychological disorders - Health problems • Chronic illness, pain, incapacitation - Social isolation, loneliness - Boredom, depression, sense of uselessness - Loss of purpose and meaning - Financial hardship - Multiple losses - Alcohol abuse, drug dependence - Burden avoidance

Serious psychological distress

• Selective survival • Coping • Optimism • Treatment *Majority of older adults do not experience significant distress. *Adults 65 (2.3%) years and older are less distressed than younger adults who are 18-24 (2.8%)

Psychological disorders in adulthood

• Significantly alter adaptation - Subjective distress - Impairment - Risk to self or others - Socially or culturally unacceptable behavior

Substance-related disorders

• Substance abuse -2-5% men, 1% women • Alcohol abuse -1-2% men, .3% women • Estimates of substance use and abuse projected to rise as boomers age • Approximately 14% of older adults seeking hospital or emergency room treatment show signs of dependence • Cognitive and health consequences *Rates are much lower for people who are 65+ compared to younger people *Among older adults, recreational use of prescription drugs is most common

Depression often misdiagnosed

• Symptom reporting -older may report more somatic complaints • Physical time -less spent with older patients • Physical reimbursement -reimburse at a lower rate than for physical disorders • Assumptions about aging -assumption that depression is a natural consequence of aging • Fear of stigmatization -physician may wish to avoid stigmatizing older clients by diagnosing them with a psychological disorder. • Co-morbid medical condition -misdiagnosis may occur because the symptoms of mood disorders occur in conjunction with a medical condition *Untreated older adults are at greater risk for a variety of physical, immune functioning, and cognitive impairments.