Ch.15
Quick Quiz
1. What is geropsychology? What kinds of special pressures and upsets are faced by elderly persons? (p 502-503) Geropsychology is the field of psychology concerned with the mental health of elderly people. Elderly persons become more susceptible to illness, stress (the loss of friends, family, spouces), hearing and vision becoming impared, the loss of being able to perform simple activities (driving, taking care of oneself, housework) being dependent on other people. 2. How common is depression among the elderly? What are the possible causes of the disorder in aged persons, and how do clinicians treat them? (p. 503-505) Depression is one of the most common mental health problems for the elderly. Again with the answer given in #1, depression is likely caused by the reasons listed prior. Clinicians treat this with cognitive-behavioral theropy, interpersonal theropy, antidepressant medications, or a combination of these approaches. 3. How prevalent are anxiety disorders among the elderly? How do theorists explain the onset of these disorders in aged persons, and how do clinicians treat them? (.505) Anxiety is also another common mental health concern among the elderly. Elderly persons with significant injuries/illnesses have shown greater levels of anxiety compared to others without. Clinicians treat them with various kinds of psychotherapy (Cognitive behavioral theropy) in addition to antianxiety or antidepression medication. 4. Describe and explain the kinds of substance abuse patterns that sometimes emerge among the elderly (p. 505-508) Substance abuse (primarily alcohol) declines amongst those 65 or older, declining health and reduced income are both possible reasons. Men under 30 are 4 times as likely to display behavioral changes due to alcohol use than those over 60. Other drug problems (antidepressants etc.) often lead to addiction, but most times unintentionally. People over the age of 50 buy 77% of all prescription drugs and 61 percent of all over the counter drugs. 5. What kinds of psychotic disorders may be experienced by elderly persons? (p. 508-509) Elderly are more likely to suffer from delusional disorder and schizophrenia, usually caused by neurocognitive disorders. Delusional disorder (where people develop beliefs that are false but not bizarre). 6. What is delirium? (p. 509-511) Delirium is a major disturbance in attention and orientation to a persons environment. A persons focus becomes less clear, with difficulty to concentrate, leading to misinterpretations, and occasionally hallucinations. 7. How common are neurocognitive disorders among the elderly? Describe the clinical features and course of Alzheimers disease. (p. 511—514) Neurocognitive disorders are common in persons 65 by 1-2 percent, increasing to as much as 50 percent by age 85. Alzheimers disease counts for about two thirds of all neurocognitive disorders. Memory imparment is the most prominent cognitive disfunction of those with Alzheimers. Atleast 17 percent of those with Alzheimers experience a major depressive disorder. 8. What are the possible causes of Alzheimers disease? (p. 513-516) Senile plaques, sphere-shaped deposits of a small molecule that form in spaces between the cells in the hippocampus, cerebral cortex, and certain other brain regions contribute to Alzheimers. Neurofibrillary triangles, which are twisted protein fibers found with the cells of the hippocampus and certain other brain areas, also contribute to Alzheimers. 9. Can Alzheimers disease be predicted? What kinds of interventions are applied in cases of this and other neurocongnitive disorders? (p. 516-521) There are several scanning tools being used and perfected than can identify degenerative brain patterns and irregularities. In 2013, one neuroscientist created her own PET scan that predicted persons with mild neurocognitive impairment with 71 percent accuracy and major neurocognitive impairment with an accuracy of 83 percent. 10. What issues regarding aging have raised particular concern among clinicians? (p. 522-524) Problems faced by elderly members of racial and ethnic minority groups, the inadequicies of long term care, and the need for a health maintenance approach to medical care are all concerns clinicians have.
neurocognitive disorder
A disorder marked by a significant decline in at least one area of cognitive functioning.
mild neurocognitive disorder
A neurocognitive disorder in which the decline in cognitive functioning is modest and does not interfere with a person's ability to be independent.
major neurocognitive disorder
A neurocognitive disorder in which the decline in cognitive functioning is substantial and interferes with a person's ability to be independent.
delirium
A rapidly developing, acute disturbance in attention and orientation that makes it very difficult to concentrate and think in a clear and organized manner.
Disorders of Aging and Cognition chapter fifteen
Neurocognitive Disorders *primary clinical deficit is in cognitive function A. Major Neurocognitive Disorder, due to... i. Significant decline in functioning... ii. Dementia: marked cognitive decline, due to... B. Mild Neurocognitive Disorder, due to... i. Mild or subtle decline in functioning... ii. Often precedes Major Neurocognitive Disorder C. Delirium, due to... i. Acute, rapid onset, obvious confusion/disorientation ii. Reversible, time limited, treatable iii. Disorientation: impaired awareness, attention; disturbed perception/sensory inputs 2 Dementia • Dementia: - Decline in cognitive mental function and ADLs - Examples of affected areas: • memory, problem solving, language, mood, and impulse control; behavior; personality - Gradual onset and continuing cognitive decline • Age is strongest risk factor for dementia - Afflicts 15% of those over age 70 - Prominent feature of many MNDs - Not a standalone diagnosis Major and Mild Neurocognitive Disorders (MNDs) Diagnosing with DSM 5 a) Specify: "Possible" or "Probable" designation - e.g., "MND probably due to vascular disease" b) Specify due to: (Etiology/Cause) - Alzheimer's disease, Frontotemporal lobar degeneration, Lewy body disease, Vascular disease, Traumatic brain injury (TBI), Substance or medication use/abuse, HIV infection, Prion disease, Parkinson's disease, Huntington's disease, Another medical condition, Multiple etiologies, Unspecified c) Specify: behavioral disturbance, - With or without behavioral disturbance. d) Specify current severity: - Mild, Moderate, Severe. This specifier applies only to major neurocognitive disorders (including probable and possible). 3 Importance of Specifiers MND due to _____ Parkinson's Disease Alzheimer's Disease Dementia with Lewy bodies Huntington's Disease Frontotemporal lobar degeneration (Pick's) Prion Disease (CreutzfeldtJakob) Vascular Disease Substance Use AIDS-related Dementia TBI Unknown Assessment Assessment of Major/Mild Neurocognitive Disorder: 1. Gather extensive background information in clinical interview 2. Evaluate overall mental functioning, personality characteristics, and coping skills 3. Attempt to rule out sensory conditions, medical, or emotional factors 4. Test to pinpoint areas of cognitive difficulty or deficits (see MMSE or MoCA posted online) 5. If possible: Imaging (PET, CT, MRI, EEG) 6. Invite input from others (with permission) who have observed the decline in patients' cognitive function (collateral information; corroborative baseline data) A. Major Neurocognitive Disorder For a diagnosis, a person must show significant decline in: 1. One or more cognitive areas • Attention and focus; decision-making and judgment; language, learning and memory; visual perception; or social understanding (deficits in multiple areas are common) -and- 2. Ability to independently meet daily living demands (ADLs - 6 domains) • eating, bathing, dressing, toileting, mobility and continence B. Mild Neurocognitive Disorder For diagnosis, one must show mild/subtle decline in: 1. at least one major cognitive area • Attention and focus; decision-making and judgment; language, learning and memory; visual perception; or social understanding Individuals are able to participate in normal activities; May require extra time to complete tasks Overall independent functioning not compromised - Often undiagnosed; difficult to distinguish from normal aging Early detection can allow individual to plan for future care before the disorder progresses • Sometimes a major ND is downgraded to a mild one As a result of recovery from stroke or TBI 6 Normal Aging or Neurocognitive Disorder? C. Delirium • Acute onset; state of confusion characterized by disorientation and impaired attentional skills - Abrupt onset • Develops over a period of several hours or days - Symptoms can be mild to severe - Transient psychotic symptoms may be present - Treatment: identify underlying cause treat - Hospitalized individuals and the elderly at increased risk - Resolved relatively easily; temporary condition 7 Etiology of Neurocognitive Disorders MNDs result from WIDE variety of medical conditions • Specific injury events, for example: • Stroke ("cerebrovascular accident" - CVA) • Head injury (TBI) - Some become worse over time; others recover • Neurodegeneration - Progressive brain damage involving death or destruction of brain cells; often cause unknown or difficult to verify (ALZ) • decline, never improvement But Neurogenesis Does Occur! - Stimulation of new neural cell growth; hope for future cure stem cell research - Very limited in adult brain (hippocampus; olfactory bulb) Importance of Specifiers MND due to _____ Vascular Disease TBI Substance Abuse 8 Specifiers: Neurodegenerative Disorders (the "due to_____" part) -TIA Vascular Neurocognitive Disorder due to: Cerebrovascular Events Can result from a one-time CVA or from unnoticed, ongoing disruptions to vascular system • Often begin with atherosclerosis; plaque buildup • Correlates: Smoking; stress; poor diet; depression Cerebrovascular Accident (CVA) "Stroke": Obstruction of blood flow to or within the brain, leading to loss of brain function o Hemorrhagic: Involves leakage of blood into the brain o Ischemic: Caused by a clot or severe narrowing of the arteries supplying blood to the brain (87%) o Transient ischemic attack (TIA): "Mini-stroke" resulting from temporary blockage of arteries o Symptoms often precede ischemic stroke 9 Neurocognitive Disorder due to: Traumatic Brain Injury (TBI) • Traumatic brain injury (TBI; mTBI) - Can result from bump, jolt, blow, blast, or physical wound to the head - Mild, Moderate, Severe (based on initial injury) • Most are mild (mTBI) 75-95% • But every single case is different - 2 TYPES: • Penetrating (e.g., GSW; shrapnel; Phineas Gage...) • Closed Head (stroke; blast, bump, hypoxic/anoxic injuries) - 1.7 million people per year receive emergency care for traumatic brain injury (does not include military #s) • Most effects are temporary; but can be permanent • Most with mTBI recover function (weeks to months) - BUT: repeated TBIs, make recovery more complicated Neurocognitive Disorder due to: Substance Abuse • Use of drugs or alcohol - Can result in delirium, temporary cognitive impairment, or chronic brain dysfunction (Korsakoff's) • Mild neurocognitive disorder common with history of heavy substance use - Symptoms continue with initial abstinence but can improve over time - Possibility of treating (e.g., thiamine deficiency treated with massive vitamin dose - alcoholics) 10 Importance of Specifiers MND due to _____ Alzheimer's Disease Parkinson's Disease Dementia with Lewy bodies Huntington's Disease Frontotemporal lobar degeneration AIDS-related Dementia Unknown Specifiers: Neurodegenerative Disorders ("due to_____") 11 Neurocognitive Disorder due to: Alzheimer's Disease #1 -Most prevalent neurodegenerative disorder - Affects more than 5 million Americans • Involves progressive cognitive decline - Early symptoms • Memory dysfunction, irritability, and cognitive impairment - Other symptoms that often appear • Social withdrawal, depression, apathy, delusions, impulsive behaviors, neglect of personal hygiene • Age a major risk factor • Clear physiological indicators required to predict whether patients with mild memory impairment will likely develop AD • No cure Alzheimer's Disease and the Brain • Shrinkage of brain tissue (cell death due to tau & plaques) • Abnormal structures 1. Neurofibrillary tangles (tau) • Twisted fibers of tau found inside nerve cells 2. Beta-amyloid plaques • Beta-amyloid proteins aggregate in spaces between neurons; sticky; prevent communication • Brain changes appear years before dementia appears • Influenced by hereditary and environmental factors - APOE-e4 allele of the APOE gene increases risk for AD - Link between sleep and amount of beta-amyloid in the brain - Same factors that elevate risk for CVD (diet; smoking; sedentary; depression; sleep; stress) 12 Senile Plaques and Neurofibrillary Tangles Alzheimer's Disease Progression (8-10yrs) Mild memory problems, lapses of attention, and mild difficulties in language and communication Trouble completing complicated tasks and remembering important appointments Difficulty with simple tasks, distant memories, and changes in personality become noticeable Less and less awareness of limitations shown; can be angry, irritable, confused, violent Eventually fully dependent with no knowledge of past and failure to recognize familiar faces Usually in good physical health until later stages of disease Death typically from infection (pneumonia) Can we predict Alzheimer's disease? • Most cases of Alzheimer's disease can be diagnosed with certainty only after death, when an autopsy is performed • Brain scans, which reveal structural abnormalities in the brain, now are commonly viewed as assessment tools - PET scans (Mosconi and colleagues) - Overall, the PET scans, administered years before the onset of symptoms, predicted mild neurocognitive impairment with an accuracy rate of 71% and major neurocognitive impairment with an accuracy rate of 83% 15 Assessing and Predicting Alzheimer's Disease • Most effective interventions - Prevention and Early intervention - Diet - Exercise - Social Support - Optimism - Healthy lifestyle - Education (yay, you!) What Biochemical Changes in the Brain Relate to Alzheimer's Disease? • Certain biochemical activities seem to be especially important in memory - For new information to be acquired and stored, certain proteins must be produced in key brain cells - Several chemicals are responsible for the production of these memory-linked proteins; research suggests that abnormal activity by these various chemicals may contribute to the symptoms of Alzheimer's disease • Acetylcholine, glutamate, RNA (ribonucleic acid), and calcium 16 Other Explanations of Alzheimer's Disease • Explanations - Zinc - Environmental toxin lead - Autoimmune theory - Viral theory Slipping away Neurocognitive Disorder due to: Parkinson's Disease 2 nd most common neurodegenerative disorder • 4 symptoms: psychomotor primarily - Tremor of the hands, arms, legs, jaw, or face - Rigidity of the limbs and trunk - Slowness in initiating movement - Drooping posture, or impaired balance and coordination - Motor sx evident at least 1yr prior to cognitive decline ** Only mild cognitive disorder - 27% of those with PD • Later stages of PD similar to those of DLB • More common in Northern Midwest and the Northeast in urban settings - Raises questions about environmental toxins 17 Neurocognitive Disorder due to: Dementia with Lewy Bodies • 2nd most common cause of dementia in NDs • Characteristics - Progressive cognitive decline - Unusual movements seen in Parkinson's disease; Significant fluctuations in attention and alertness; Hallucinations; Impaired mobility; Sleep disturbance • Lewy bodies - Brain cell irregularities - Result from the buildup of abnormal proteins in the nuclei of neurons - Also present in Parkinson's disease - When present in the cortex • Deplete the neurotransmitter acetylcholine - When present in the brain stem • Deplete dopamine Neurocognitive Disorder due to: Huntington's Disease • Rare, genetically-transmitted degenerative disorder • Symptoms - Involuntary twitching movements - Eventual dementia and death • Early symptoms - Difficulty in executive functioning (frontal lobes); memory; problem-solving; decision making; emotion/behavioral control • No effective treatment; No cure • Death occurs 15-20 years after symptom onset 18 Neurocognitive Disorder due to: Frontotemporal Lobar Degeneration (Pick's) • 4th leading cause of dementia • Degeneration/atrophy in the frontal (behavior) and temporal (communication) lobes • 40% have hx of neurodegenerative disorders in the family • Symptoms - Changes in behavior, personality, and social skills - Difficulty with fluent speech or word meaning - Muscle weakness - Average age of onset is between 45 and 64 yrs Neurocognitive Disorder due to: PRION DISEASE (CREUTZFELDT-JAKOB DISEASE) • Early onset: 60yrs; • extremely rare (1/1,000,000); • rapid development of dementia; spasms • Theories: - slow-acting virus that may lie dormant for decades (majority), or - familial transmission (rare) - Contamination by virii (very rare) • 75% mortality in 6mos; 90% dead in 1yr. • No cure; impossible to kill Neurocognitive Disorder due to: HIV- AIDS • Cognitive impairment sometimes the first sign of untreated HIV-AIDS - Slower mental processing; difficulty concentrating; memory problems "fuzzy thinking" • AIDS dementia complex (ADC) - HIV becomes active in the brain • Antiretroviral therapies can prevent or delay onset (but not cure) - Brain changes still occur in half of those taking antiretroviral medications Neurocognitive Disorder due to: VASCULAR DISORDER • follows a cerebrovascular accident, or stroke, during which blood flow to specific areas of the brain was cut off, with resultant damage • This disorder is progressive but its symptoms begin suddenly, rather than gradually • Cognitive functioning may continue to be normal in the areas of the brain not affected by the stroke 20 Who Cares for Them? Home care by relatives - Caregiving can take a heavy toll on the close relatives of people with Alzheimer's disease and other types of neurocognitive disorders. • Almost 90% of all people with Alzheimer's disease are cared for by their relatives. • One of the most frequent reasons for the institutionalization of people suffering from Alzheimer's is that overwhelmed caregivers can no longer cope with the difficulties of keeping them at home. Sociocultural approaches including day-care and assisted-living facilities What Treatments Are Currently Available? • Treatments and approaches • Drug therapy • Vitamin therapy • Cognitive techniques • Behavioral interventions • Lifestyle changes • Support for caregivers • Sociocultural approaches 21 Treatment: Neurocognitive Disorders Treatment approaches vary widely due to different causes, symptoms, and dysfunctions Major interventions 1. Rehabilitative services 2. Biological interventions 3. Cognitive and behavioral treatment 4. Lifestyle changes 5. Environmental support Rehabilitation Services • Must be comprehensive and sustained • Physical, occupational, speech, and language therapy - Individual's commitment and participation in therapy plays an important role - Depression, pessimism, and anxiety can stall progress • Constraint-induced therapy - Repeated and intensive use of affected side of the body 22 Biological & Lifestyle Treatment • Medication (e.g., Alzheimer's) - Levodopa increases dopamine availability - High doses of vitamin E can slow AD progression; high dose of thiamine for deficient alcoholics (with cognitive sxs) - Antidepressants; antipsychotics; anxiolytics - Early stages of research into deep brain stimulation • Importance of lifestyle "treatment": sufficient sleep; healthy diet; exercise (oxygen!); weight loss; smoking cessation; hypertension; social support; optimism; meditation; mindfulness; keeping cognitively active (learn something!) Cognitive and Behavioral Treatment • Psychotherapy - Enhance coping and participation in rehabilitation efforts - Reduce frequency and severity of problem behaviors - Teach coping strategies to deal with changes • Meditation and mindfulness-based stress reduction (early stages) - Reduced brain atrophy - Slow down progression of disease 23 Environmental Support • MNDs involving dementia are: irreversible; best managed with supportive people and environment • Exposure to bright lighting - Improve sleep and decrease agitation and depression • Family visits; encourage recall of past happy times • Labeling family photos • Make memory notes; put post-its around to aid • Remove anything that seems disturbing **Remember to support caregivers: extremely high levels of "caregiver exhaustion/burnout" with MNDs ** Assisted living/care for final stages Still Alice...... • The word she was searching for was "pariah." Alzheimer's is like cancer used to be. People don't understand it, they're afraid of it. • But when you ask people over 65 what disease they're most concerned about -- it's Alzheimer's. Alice: "You know, I'd rather have cancer. Because then I wouldn't be such a Cost of Living Longer....... • In 2014, the cost of caring for those with Alzheimer's was an estimated $214 billion, according to the Alzheimer's Association. • By 2050, unless better treatments are found, it will cost around $1.2 trillion. To compare: $4.8 trillion - cost of all efforts for all wars fought since 2001 (Iraq, Afghanistan, Pakistan), and ongoing/future care of veterans
senile plaques
Sphere-shaped deposits of beta-amyloid protein that form in the spaces between certain brain cells and in certain blood vessels as people age. People with Alzheimer's disease have an excessive number of such plaques.
Alzheimer's disease
The most common type of neurocognitive disorder, marked most prominently by memory impairment.
neurofibrillary tangles
Twisted protein fibers that form within certain brain cells as people age. People with Alzheimer's disease have an excessive number of such tangles.