PSYCH chapter 24 SG

Senile simply means

"old." If the word senility is used to mean "severe mental impairment," that would imply that old age always brings intellectual failure—an ageist myth.

Elderly Artists

A well-known example of late creative development is Anna Moses, who was a farm wife in rural New York. For most of her life, she expressed her artistic impulses by stitching quilts and embroidering in winter, when farm work was slow. At age 75, arthritis made needlework impossible, so she took to "dabbling in oil." Four years later, three of her paintings, displayed in a local drugstore, caught the eye of a New York City art dealer who happened to be driving through town. He bought them, drove to her house, and bought 15 more. The following year, at age 80, "Grandma Moses" had a one-woman show, receiving international recognition for her unique "primitive" style. She continued to paint, and her work "developed and changed considerably over the course of her twenty-year career" (Cardinal, 2001). Anna Moses died at age 101. Other well-known artists continue to work in late adulthood, sometimes producing their best work. Michelangelo painted the awe-inspiring frescoes in the Sistine Chapel at age 75; Verdi composed the opera Falstaff when he was 80; Frank Lloyd Wright completed the design of New York City's Guggenheim Museum when he was 91. In a study of extraordinarily creative people, very few felt that their ability, their goals, or the quality of their work had been much impaired by age. The leader of that study observed, "in their seventies, eighties, and nineties, they may lack the fiery ambition of earlier years, but they are just as focused, efficient, and committed as before . . . perhaps more so" (Csikszentmihalyi, 2013, p. 207). But an older artist does not need to be extraordinarily talented. Some of the elderly learn to play an instrument, and many enjoy singing. In China, people gather spontaneously in public parks to sing together. The groups are intergenerational—but a disproportionate number are elderly (Wei, 2013). Music and singing are often used to reduce anxiety in those who suffer from neurocognitive impairment, because the ability to appreciate music is preserved in the brain when other functions fail (Sacks, 2008; Ueda et al., 2013). Many experts believe that creative activities—poetry and pottery, jewelry making and quilting, music and sculpture—can benefit all of the elderly (Flood & Phillips, 2007; Malchiodi, 2012). Artistic expression may aid social skills, resilience, and even brain health

Lewy body disease

Another 3 percent of people with NCD in the United States suffer from Lewy body disease excessive deposits of a particular kind of protein in their brains. Lewy bodies are also present in Parkinson's disease, but in Lewy body disease they are more numerous and dispersed throughout the brain, interfering with communication between neurons. The main symptom is loss of inhibition: A person might gamble or become hypersexual.

neurocognitive disorder (NCD)

Any of a number of brain diseases that affects a person's ability to remember, analyze, plan, or interact with other people. The DSM-5 now describes neurocognitive disorders, as either major (previously called dementia) or mild (previously called mild cognitive impairment). Memory problems occur in every cognitive disorder, although some people with NCDs have other notable symptoms, such as in judgment (they do foolish things) and moods (they are suddenly full of rage or sadness). The line between normal age-related changes, mild disorder, and major disorder is not clear, and symptoms vary depending on the specifics of brain loss as well as context. Even when the disorder is major, the individual's personality affects the symptoms.

Polypharmacy

At home as well as in the hospital, most elderly people take numerous drugs—not only prescribed medications but also over-the-counter preparations and herbal remedies—a situation known as polypharmacy. Excessive reliance on drugs can occur on doctor's orders as well as via patient ignorance. The rate of polypharmacy is increasing in the United States. For instance, in 1988 the number of people over age 65 who took five drugs or more was 13 percent; by 2010 that number had tripled to 39 percent (Charlesworth et al., 2015). Unfortunately, recommended doses of many drugs are determined primarily by clinical trials with younger adults, for whom homeostasis usually eliminates excess medication (Herrera et al., 2010). When homeostasis slows down, excess lingers. In addition, most trials to test the safety of a new drug exclude people who have more than one disease. That means drugs are not tested on the people who will use them most. The average elderly person in the United States sees a physician eight times a year (National Center for Health Statistics, 2014). Typically, each doctor follows "clinical practice guidelines," which are recommendations for one specific condition. A "prescribing cascade" (when many interacting drugs are prescribed) may occur. In one disturbing case, a doctor prescribed medication to raise his patient's blood pressure, and another doctor, noting the raised blood pressure, prescribed a drug to lower it (McLendon & Shelton, 2011-2012). Usually, doctors ask patients what medications they are taking and why, which could prevent such an error. However, people who are sick and confused may not give accurate responses. A related problem is that people of every age forget when to take which drugs (before, during, or after meals? after dinner or at bedtime?) (Bosworth & Ayotte, 2009). Short-term memory loss makes this worse, and poverty cuts down on pill purchases. Even when medications are taken as prescribed and the right dose reaches the bloodstream, drug interactions can cause confusion and memory loss. Cognitive side effects can occur with almost any drug, but especially with drugs intended to reduce anxiety and depression. Following recommendations from the radio, friends, and television ads, many of the elderly try supplements, compounds, and herbal preparations that contain mind-altering toxins. And finally, since some of the elderly believe that only illegal drugs are harmful to the mind, alcohol and pill addiction are harder to recognize in the elderly. The solution seems simple: Discontinue drugs. However, that may increase both disease and cognitive decline. One expert warns of polypharmacy but adds that "underuse of medications in older adults can have comparable adverse effects on quality of life" (Miller, 2011-2012, p. 21). For instance, untreated diabetes and hypertension cause cognitive loss. Lack of drug treatment for those conditions may be one reason why low-income elders experience more illness, more cognitive impairment, and earlier death than do high-income elders: They may not be able to afford good medical care or lifesaving drugs. Obviously, money complicates the issue: Prescription drugs are expensive, which increases profits for drug companies, but they can also reduce surgery and hospitalization, thus saving money. As one observer notes, the discussion about spending for prescription drugs is highly polarized, emotionally loaded, with little useful debate. A war is waged over the cost of prescriptions for older people, and it is a "gloves-off, stab-you-in-the-guts, struggle to the death"

Stage 4

At this stage, full-time care is needed. People cannot communicate well. They might not recognize their closest loved ones.

Reversible Neurocognitive Disease (?)

Care improves when everyone knows what disease is undermining intellectual capacity. Accurate diagnosis is even more crucial when memory problems do not arise from a neurocognitive disorder. Brain diseases destroy parts of the brain, but some people are thought to be permanently "losing their minds" when a reversible condition is really at fault.

Stage 5

Finally, people with AD become unresponsive. Identity and personality have disappeared. When former president Ronald Reagan was at this stage, a longtime friend who visited him was asked, "Did he recognize you?" The friend answered, "Worse than that—I didn't recognize him." Death comes 10 to 15 years after the first signs appear.

Stage 2

Generalized confusion develops, with deficits in concentration and short-term memory. Speech becomes aimless and repetitious, vocabulary is limited, words get mixed up. Personality traits are not curbed by rational thought. For example, suspicious people may decide that others have stolen the things that they themselves have mislaid.

The Life Review

In the life review, elders provide an account of their personal journey by writing or telling their story. They want others to know their history, not only their personal experiences but also those of their family, cohort, or ethnic group. According to Robert Butler: We have been taught that this nostalgia represents living in the past and a preoccupation with self and that it is generally boring, meaningless, and time-consuming. Yet as a natural healing process it represents one of the underlying human capacities on which all psychotherapy depends. The life review should be recognized as a necessary and healthy process in daily life as well as a useful tool in the mental health care of older people. [Butler et al., 1998, p. 91] Hundreds of developmentalists, picking up on Butler's suggestions, have guided elderly people in self-review. Sometimes the elderly write down their thoughts, and sometimes they simply tell their story, responding to questions from the listener. The result of the life review is almost always quite positive, especially for the person who tells the story. For instance, of 202 elderly people in the Netherlands, half were randomly assigned to a life review process. For them, depression and anxiety were markedly reduced compared to the control group (Korte et al., 2012).

major neurocognitive disorder (major NCD)

Irreversible loss of intellectual functioning caused by organic brain damage or disease. Formerly called dementia, major NCD becomes more common with age, but it is abnormal and pathological even in the very old.

Wisdom

It is possible that "older adults . . . understand who they are in a newly emerging stage of life, and discovering the wisdom that they have to offer" (Bateson, 2011, p. 9). A massive international survey of 26 nations from every corner of the world found that most people everywhere agree that wisdom is a characteristic of the elderly (Löckenhoff et al., 2009). Contrary to these wishes and opinions, most objective research finds that wisdom does not necessarily increase with age. Starting at age 25 or so, some adults of every age are wise, but most, even at age 80, are not An underlying quandary is that a universal definition of wisdom is elusive: Each culture and each cohort has its own concept, with fools sometimes seeming wise (as happens in Shakespearean drama) and those who are supposed to be wise sometimes acting foolishly (provide your own examples). Older and younger adults differ in how they make decisions; one interpretation of these differences is that the older adults are wiser, but not every younger adult would agree One summary describes wisdom as an "expert knowledge system dealing with the conduct and understanding of life" (Baltes & Smith, 2008, p. 58). Several factors just mentioned, including self-reflective honesty (as in integrity), perspective on past living (the life review), and the ability to put aside one's personal needs (as in self-actualization), are considered part of wisdom. If this is true, the elderly may have an advantage in developing wisdom, particularly if they have (1) dedicated their lives to the "understanding of life," (2) learned from their experiences, and (3) become more mature and integrated (Ardelt, 2011, p. 283). That may be why popes and U.S. Supreme Court justices are usually quite old. As two psychologists explain: Wisdom is one domain in which some older individuals excel. . . . [They have] a combination of psychosocial characteristics and life history factors, including openness to experience, generativity, cognitive style, contact with excellent mentors, and some exposure to structured and critical life experiences. [Baltes & Smith, 2008, p. 60] These researchers posed life dilemmas to adults of various ages and asked others (who had no clue as to how old the participants were) to judge whether the responses were wise. They found that wisdom is rare at any age, but, unlike physical strength and cognitive quickness, wisdom does not fade with maturity. Thus, some people of every age were judged as wise. Similarly, the author of a detailed longitudinal study of 814 people concludes that wisdom is not reserved for the old, but humor, perspective, and altruism increase over the decades, gradually making people wiser. He then wrote: To be wise about wisdom we need to accept that wisdom does—and wisdom does not—increase with age. . . . Winston Churchill, that master of wise simplicity and simple wisdom, reminds us, "We are all happier in many ways when we are old than when we are young. The young sow wild oats. The old grow sage."

Malnutrition

Malnutrition and dehydration can also cause symptoms that may seem like brain disease. The aging digestive system is less efficient but needs more nutrients and fewer calories. This requires new habits, less fast food, and more grocery money (which many do not have). Some elderly people deliberately drink less liquid because they want to avoid frequent urination, yet adequate water in the body is needed for cell health. Since homeostasis slows with age, older people are less likely to recognize and remedy their hunger and thirst, and thus they may inadvertently impair their cognition. Beyond the need to drink water and eat vegetables, several specific vitamins may stave off cognitive impairment. Among the suggested foods to add are those containing antioxidants (vitamins C, A, E) and vitamin B-12. Homocysteine (from animal fat) may need to be avoided, since high levels correlate with major NCD (Perez et al., 2012; Whalley et al., 2014). Psychoactive drugs, especially alcohol, can cause confusion and hallucinations at much lower doses than in the young. Obviously, any food that increases the risk of heart disease and stroke also increases the risk of vascular disease. In addition, some prescribed drugs destroy certain nutrients, although specifics require more research (Jyrkkä et al., 2012). Indeed, well-controlled longitudinal research on the relationship between particular aspects of nutrition and NCD has not been done (Coley et al., 2015). It is known, however, that people who already suffer from NCD tend to forget to eat or tend to choose unhealthy foods, hastening their mental deterioration. It is also known that alcohol abuse interferes with nutrition, directly (reducing eating and hydration) and indirectly (blocking vitamin absorption).

Parkinson's disease

Many other brain diseases begin with impaired motor control (shaking when picking up a coffee cup, falling when trying to walk), not with impaired thinking. The most common of these is Parkinson's disease, the cause of about 3 percent of all cases of NCDs. Parkinson's disease starts with rigidity or tremor of the muscles as dopamine-producing neurons degenerate, affecting movement long before cognition. Middle-aged adults with Parkinson's disease usually have sufficient cognitive reserve to avoid major intellectual loss, although about one-third have mild cognitive decline (S. Gao et al., 2014). Older people with Parkinson's develop cognitive problems sooner (Pfeiffer & Bodis-Wollner, 2012). If people with Parkinson's live 10 years or more, almost always major neurocognitive impairment occurs

Stage 3

Memory loss becomes dangerous. Although people at stage 3 can care for themselves, they might leave a lit stove or hot iron on or might forget whether they took essential medicine and thus take it twice—or not at all.

Stage 1 of Alzheimer's disease

People in the first stage forget recent events or new information, particularly names and places. For example, they might forget the name of a famous film star or how to get home from a familiar place. This first stage is similar to mild cognitive impairment—even experts cannot always tell the difference. In retrospect, it seems clear that President Ronald Reagan had early AD while in office, but no doctor diagnosed it.

Aesthetic Sense and Creativity

Robert Butler was a geriatrician responsible for popularizing the study of aging in the United States. He coined the word "ageism" and wrote a book titled Why Survive: Being Old in America, first published in 1975. Partly because his grandparents were crucial in his life, Butler understood that society needs to recognize the potential of the elderly. Butler explained that "old age can be a time of emotional sensory awareness and enjoyment" (Butler et al., 1998, p. 65). For example, some of the elderly take up gardening, bird-watching, sculpting, painting, or making music, even if they have never done so before.

Frontotemporal NCDs

Several types of neurocognitive disorders affect the frontal lobes and thus are called frontotemporal NCDs, or frontotemporal lobar degeneration. (Pick disease is the most common form.) These disorders cause perhaps 15 percent of all cases of NCDs in the United States. Frontotemporal NCDs tend to occur before age 70, unlike Alzheimer's or vascular disease (Seelaar et al., 2011). In frontotemporal NCDs, parts of the brain that regulate emotions and social behavior (especially the amygdala and prefrontal cortex) deteriorate. Emotional and personality changes are the main symptoms (Seelaar et al., 2011). A loving mother with a frontotemporal NCD might reject her children, or a formerly astute businessman might invest in a foolish scheme Frontal lobe problems may be worse than more obvious types of neurocognitive disorders, in that compassion, self-awareness, and judgment fade in a person who otherwise seems normal. One wife, Ruth French, was furious because her husband threw away tax documents, got a ticket for trying to pass an ambulance and bought stock in companies that were obviously in trouble. Once a good cook, he burned every pot in the house. He became withdrawn and silent, and no longer spoke to his wife over dinner. That same failure to communicate got him fired from his job. [D. Grady, 2012, p. A1] Finally, he was diagnosed with a frontotemporal NCD. Ruth asked him to forgive her fury. It is not clear that he understood either her anger or her apology. Although there are many forms and causes of frontotemporal NCDs—including a dozen or so alleles—they usually progress rapidly, leading to death in about five years

Self-actualization

The final stage in Maslow's hierarchy of needs, characterized by aesthetic, creative, philosophical, and spiritual understanding. Maslow maintained that older adults are more likely than younger people to reach what he originally thought was the highest stage of development, self-actualization. In his later years, Maslow suggested a stage even higher than self-actualization, called self-transcendence (Maslow, 1971/1993). Remember that Maslow rejected an age-based sequence of life, refusing to confine self-actualization to the old. However, Maslow also believed that life experience helps people move forward, so more of the old reach the final stage (D'Souza & Gurin, 2016). The stage of self-actualization is characterized by aesthetic, creative, philosophical, and spiritual understanding (Maslow, 1954/1997). A self-actualized person might have a deeper spirituality than ever; might be especially appreciative of nature; or might find life more amusing, laughing often at himself or herself. This seems characteristic of many of the elderly. Studies of centenarians find that they often have a deep spiritual grounding and a surprising sense of humor—surprising, that is, if one assumes that people with limited sight, poor hearing, and frequent pain have nothing to laugh about.

Alzheimer's Disease

The most common cause of major NCD, characterized by gradual deterioration of memory and personality and marked by the formation of plaques of beta-amyloid protein and tangles of tau in the brain. In the past century, millions of people in every large nation have been diagnosed with Alzheimer's disease (AD) (now formally referred to as major NCD due to Alzheimer's disease). Severe and worsening memory loss is the main symptom, but the diagnosis is not definitive until an autopsy finds extensive plaques and tangles in the cerebral cortex

Depression

The most common reversible condition that is mistaken for major NCD is depression. Normally, older people tend to be quite happy; frequent sadness or anxiety is not normal. Ongoing, untreated depression increases the risk of major NCD (Y. Gao et al., 2013). Ironically, people with untreated anxiety or depression may exaggerate minor memory losses or refuse to talk. Quite the opposite reaction occurs with early Alzheimer's disease, when victims are often surprised that they cannot answer questions, or with Lewy body disease or frontotemporal NCDs, when people talk too much without thinking. Talk, or lack of it, provides an important clue. Specifics provide other clues. People with neurocognitive loss might forget what they just said, heard, or did because current brain activity is impaired, but they might repeatedly describe details of something that happened long ago. The opposite may be true for emotional disorders, when memory of the past is impaired but short-term memory is not.

Vascular Disease

The second most common cause of neurocognitive disorder is a stroke (a temporary obstruction of a blood vessel in the brain) or a series of strokes, called transient ischemic attacks (TIAs, or ministrokes). The interruption in blood flow reduces oxygen, destroying part of the brain. Symptoms (blurred vision, weak or paralyzed limbs, slurred speech, and mental confusion) suddenly appear. In a TIA, symptoms may vanish quickly, unnoticed. However, unless recognized and prevented, another TIA is likely, eventually causing vascular disease, commonly referred to as vascular or multi-infarct dementia ( Formerly called vascular or multi-infarct dementia, vascular disease is characterized by sporadic, and progressive, loss of intellectual functioning caused by repeated infarcts, or temporary obstructions of blood vessels, which prevent sufficient blood from reaching the brain. Vascular disease also correlates with the ApoE4 allele (Cramer & Procaccio, 2012). For some of the elderly, it is caused by surgery that requires general anesthesia. They suffer a ministroke, which, added to reduced cognitive reserve, damages their brain

An autopsy that finds massive plaques and tangles proves that

a person had Alzheimer's disease. However, between 20 and 30 percent of cognitively typical elders have, at autopsy, extensive plaques in their brains (Jack et al., 2009). One explanation is that cognitive reserve enables some people to bypass the disconnections caused by plaques. Education does seem to prevent, or modify, AD (Langa, 2015). Alzheimer's disease is partly genetic. If it develops in middle age, the affected person either has trisomy-21 (Down syndrome) or has inherited one of three genes: amyloid precursor protein (APP), presenilin 1, or presenilin 2. For these people, the disease progresses quickly, reaching the last phase within three to five years. Most cases begin much later, at age 75 or so. Many genes have some impact, including SORL1 and ApoE4 (allele 4 of the ApoE gene). People who inherit one copy of ApoE4 (as about one-fifth of all U.S. residents do) have about a 50/50 chance of developing AD. Those who inherit two copies almost always develop the disorder if they live long enough, but they may not live long enough, because ApoE4 also predicts a stroke.

Plaques are

clumps of a protein called beta-amyloid in tissues surrounding the neurons;

Dementia (used in DSM-IV) was a more precise term than senility for

irreversible, pathological loss of brain functioning, but dementia has the same root as demon, and thus it has inaccurate connotations.

Many scientists seek biological indicators (called biomarkers, as in the blood or cerebrospinal fluid) or brain indicators (as on brain scans) that

predict major memory loss. However, although abnormal scores on many tests (biological, neurological, or psychological) indicate possible problems, an examination of 24 such measures found that no single test, or combination of tests, is 100 percent accurate Two new and promising tests, a PET scan or a blood assay that reveals amyloid plaques which indicate Alzheimer's disease, are not reimbursed by Medicaid because the link between presence of amyloid and effective treatment is "insufficient." More research is needed

A normal brain contains some beta-amyloid and some tau, but in brains with AD these plaques and tangles

proliferate, especially in the hippocampus, a brain structure that is crucial for memory. Forgetfulness is the dominant symptom, from momentary lapses to—after years of progressive disease—forgetting the names and faces of one's own children.

Cognitive decline is apparent in both Alzheimer's disease (AD) and vascular disease (VaD). However

the pattern of decline for each disease is different. Victims of AD show steady, gradual decline, while those who suffer from VaD get suddenly much worse, improve somewhat, and then experience another serious loss.

tangles are

twisted masses of threads made of a protein called tau within the neurons.