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Disorders of Aging and Cognition

Chapter 18

Slides & Handouts by Karen Clay Rhines, Ph.D.


American Public University System

Comer, Abnormal
Psychology, 8e
DSM-5 Update

Disorders of Aging
and Cognition
Neurocognitive disorders are currently the most
publicized and feared psychological problems
among the elderly
They are, however, hardly the only ones
A variety of psychological disorders are tied closely to later
life

As with childhood disorders, some of the disorders of


old age are caused primarily by pressures that are
particularly likely to appear at that time of life, others
by unique traumatic experiences, and still others like
neurocognitive disorders by biological abnormalities
Comer, Abnormal Psychology, 8e
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Old Age and Stress


Old age is usually defined in our society as the
years past age 65
Around 36 million people in the U.S. are old
12% of the population and growing
Older women outnumber older men by 3 to 2

Like childhood, old age brings special


pressure, unique upsets, and profound
biological changes
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Old Age and Stress


The stresses of elderly people need not result
in psychological disorders; however, studies
indicate that as many as 50% of elderly people
would benefit from mental health services
Fewer than 20% actually receive them
Geropsychology is the field of psychology dedicated to
the mental health of elderly people

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Old Age and Stress


The psychological problems of elderly persons
may be divided into two groups:
Disorders that may be common in people of all
ages but are connected to the process of aging
Depressive, anxiety, and substance use disorders

Disorders of cognition that result from brain


abnormalities
Delirium, mild neurocognitive disorders, and major
neurocognitive disorders
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Depression in Later Life


Depression is one of the most common mental
health problems of older adults
The features of depression are the same for
elderly people as for younger people
As many as 20% of people experience this disorder at
some point during old age
The rate is highest in older women

Several studies suggest that depression among


older people raises their chances of developing
significant medical problems
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Depression in Later Life


Elderly persons are also more likely to die by
suicide than younger ones, and often their
suicides are related to depression

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Depression in Later Life


Like younger adults, older people who are
depressed may be helped by cognitivebehavioral therapy, interpersonal therapy,
antidepressant medications, or a combination
of these approaches

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Depression in Later Life


More than half of older patients with depression
improve with these treatments
It is sometimes difficult for elderly people to use
antidepressant drugs effectively and safely
because the bodys metabolism works differently
in later life
Moreover, among elderly people, antidepressant
drugs have a higher risk of causing some
cognitive impairment
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Anxiety Disorders in
Later Life
Anxiety is also common among the elderly
At any given time, around 6% of elderly men and
11% of elderly women in the U.S. experience at
least one of the anxiety disorders
GAD is particularly common, experienced by up to 7%
of all elderly persons
The prevalence of anxiety increases throughout old
age

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Anxiety Disorders in
Later Life
There are many things about aging that may heighten
anxiety levels, including declining health

Researchers have not, however, been able to determine


why certain individuals who experience such problems in
old age become anxious while others who face similar
circumstances remain relatively calm

Older adults with anxiety disorders are often treated


with psychotherapy of various kinds, particularly
cognitive-behavior therapy
Many also receive antianxiety medications

Again, all such drugs must be used cautiously with older people

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Substance Misuse in Later Life


Although alcohol use disorder and other
substance use disorders are significant
problems for many older persons, the
prevalence of such patterns actually appears
to decline after age 60
Accurate data about the rate of substance abuse
among older adults is difficult to obtain because
many elderly persons do not suspect or admit
they have such a problem

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Substance Misuse in Later Life


Surveys find that 4% to 7% of older people,
particularly men, have alcohol use disorder in a
given year
Researchers often distinguish between older
problem drinkers who have had alcohol use
disorder for many years and those who do not
start the pattern until their 50s and 60s

The latter group typically begins abusive drinking as a


reaction to the negatives events and pressures of
growing older

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Substance Misuse in Later Life


Alcohol use disorder in elderly people is
treated much as in younger adults
Approaches include detoxification, Antabuse,
Alcoholics Anonymous (AA), and cognitivebehavioral therapy

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Substance Misuse in Later Life


A leading kind of substance problem in the
elderly is the misuse of prescription drugs
Most often it is unintentional

Yet another drug-related problem is the


misuse of powerful medications at nursing
homes

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Psychotic Disorders in
Later Life
Elderly people have a higher rate of psychotic
symptoms than younger persons
Among aged people, these symptoms are usually
due to underlying medical conditions such as
delirium and Alzheimers disease
However, some elderly persons suffer from
schizophrenia or delusional disorder

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Psychotic Disorders in
Later Life
Schizophrenia is less common in older persons
than in younger ones
Many people with schizophrenia find that their
symptoms lessen in later life
It is uncommon for new cases of schizophrenia to
emerge in later life

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Psychotic Disorders in
Later Life
Another kind of psychotic disorder found among
the elderly is delusional disorder, in which
individuals develop beliefs that are false but not
bizarre
This disorder is rare in most age groups, but its
prevalence appears to increase in the elderly
population
Some clinicians suggest that the rise is related to the
deficiencies in hearing, social isolation, greater stress, or
heightened poverty experienced by many elderly persons

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Disorders of Cognition
Cognitive mishaps (e.g., leaving without keys,
forgetting someones name) are a common and
quite normal feature of stress or aging

As people move through middle age, these memory


difficulties and lapses of attention increase, and they
may occur regularly by age 60 or 70
Sometimes, however, people experience memory and
other cognitive changes that are far more extensive
and problematic

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Disorders of Cognition
While problems in memory and related
cognitive processes can occur without
biological causes (in the form of dissociative
disorders), more often, cognitive problems
have organic roots, particularly when they
appear in later life
The leading cognitive disorders among elderly
persons are delirium and neurocognitive disorders

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Delirium
Delirium is a major disturbance in attention
and orientation to the environment
As a persons focus becomes less clear, he or she
has great difficulty concentrating and thinking in
an organized way
This leads to misinterpretations, illusions, and, on
occasion, hallucinations

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Delirium
This state of massive confusion typically develops over
a short period of time, usually hours or days
It may occur in any age group, including children, but it is
most common in elderly persons
Delirium affects fewer than 0.5% of the nonelderly
population, 1% of people over 55, and 14% of those over
85 years of age

Fever, certain diseases and infections, poor nutrition,


head injuries, strokes, stress (including the trauma of
surgery), and intoxication by certain substances may all
cause delirium

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Alzheimers Disease and Other


Neurocognitive Disorders
People with a neurocognitive disorder experience a
significant decline in at least one (often more than one)
area of cognitive functioning, such as memory and
learning, attention, visual perception, planning and
decision making, language ability, or social awareness
In certain types of neurocognitive disorder, individuals may
also experience changes in personality and behavior

At any given time, around 3% to 9% of the worlds


adult population are suffering from a neurocognitive
disorder

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Alzheimers Disease and Other


Neurocognitive Disorders
If a persons cognitive decline is substantial
and interferes significantly with his or her
ability to be independent, a diagnosis of major
neurocognitive disorder is in order
If, however, the decline is modest and does not
interfere with independent functioning, the
appropriate diagnosis is mild neurocognitive
disorder

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Alzheimers Disease and Other


Neurocognitive Disorders
At any given time, around 3 to 9 percent of
the worlds adult population are suffering
from such disorders
Their experience is closely related to age
Among people 65 years of age, the prevalence is
around 1 to 2%, increasing to as much as 50%
among those over the age of 85

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Alzheimers Disease
This disease is the most common type of
neurocognitive disorder, accounting for as many
as two-thirds of all cases

Around 5 million people in the U.S. currently have this


disease

This disease sometimes appears in middle age


(early onset), but most often occurs after the age
of 65 (late onset)
Its prevalence increases markedly among people in
their late 70s and early 80s

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Alzheimers Disease
This is a gradually progressive disease in which
memory impairment is the most prominent
cognitive dysfunction
Technically, suffers receive a DSM-5 diagnosis of
mild neurocognitive disorder due to Alzheimers
disease during the early stages and major
neurocognitive disorder due to Alzheimers disease
during the later stages

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Alzheimers Disease
The time between onset and death is typically
8 to 10 years, although some people may
survive for as many as 20 years
It usually begins with mild memory problems,
lapses of attention, and difficulties in language
and communication

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Alzheimers Disease
As symptoms worsen, the person has trouble
completing complicated tasks and
remembering important appointments
Eventually sufferers also have difficulty with
simple tasks, distant memories are forgotten,
and changes in personality often become very
noticeable

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Alzheimers Disease
As the the neurocognitive symptoms intensify,
people show less and less awareness of their
limitations
Eventually they become fully dependent on other
people, they lose almost all knowledge of the past and
fail to recognize the faces of even close relatives

Alzheimers victims usually remain in fairly good


health until the later stages of the disease

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Alzheimers Disease
In most cases, Alzheimers can be diagnosed with
certainty only after death, when structural
changes in the brain can be fully examined
Senile plaques are sphere-shaped deposits of a small
molecule known as the beta-amyloid protein that
form in the spaces between cells in the hippocampus,
cerebral cortex, and certain other brain regions and
blood vessels
Neurofibrillary tangles are twisted protein fibers
found within the cells of the hippocampus

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Alzheimers Disease
Scientists do not fully understand what role
excessive numbers of plaques and tangles play
in Alzheimers disease, but they suspect they
are very important
Todays leading explanations for this disease
center on these plaques and tangles and on
factors that may contribute to their formation

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What Are the Genetic Causes of


Alzheimers Disease?
It appears that Alzheimers disease often has a
genetic basis
Clinicians now distinguish between early-onset
(familial) Alzheimers disease and late-onset
(sporadic) Alzheimers disease

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What Are the Genetic Causes of


Alzheimers Disease?
Early-Onset
Researchers have found that this form of
Alzheimers disease can be caused by
abnormalities in the genes responsible for the
production of two proteins
Apparently some families transmit these
mutations and the onset of the disease is set into
motion

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What Are the Genetic Causes of


Alzheimers Disease?
Late-Onset
This form of the disease appears to result from a
combination of genetic, environmental, and
lifestyle factors
The genetic factor at play in sporadic Alzheimers
Disease is different from the ones involved in
familial Alzheimers disease

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How Does Brain Structure Relate to


Alzheimers Disease?
Researchers have identified a number of
biological factors related to the brain
abnormalities seen in Alzheimers disease
To understand the role of these factors, an
understanding of the operation and biology of
memory is necessary

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How Does Brain Structure Relate to


Alzheimers Disease?
The human brain has two memory systems that
work together to help us learn and recall

Short-term memory, or working memory, gathers new


information
Information held in short-term memory must be
transformed, or consolidated, into long-term memory if we
are to hold on to it

Long-term memory is the accumulation of information


that we have stored over the years
Remembering information stored in long-term memory is
called retrieval

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How Does Brain Structure Relate to


Alzheimers Disease?
Certain brain structures seem to be especially
important in memory, including:
The prefrontal lobes

Appear to hold information temporarily and to continue


working with the information as long as it is needed

The temporal lobes and the diencephalon

Seem to help transform short-term memory into


long-term memory

Research indicates that cases of Alzheimers disease


involve damage to or improper functioning of one or
more of these areas

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What Biochemical Changes in the Brain


Relate to Alzheimers Disease?
Memory researchers have also identified biochemical
changes that occur in cells as memories form

For example, several chemicals are responsible for the


production of proteins in key cells when new information
is acquired and stored
If the activity of these chemicals is disturbed, the proper
production of proteins may be prevented and the
formation of memories interrupted
Some research suggests that abnormal activity by these
chemicals may contribute to the symptoms of Alzheimers
Disease

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Other Explanations
of Alzheimers Disease
In addition to these two explanations,
researchers offer additional possibilities:
Several lines of research suggest that certain
substances found in nature, including zinc, may
produce brain toxicity, which may contribute to
the development of the disease
Another line of research suggests that the
environmental toxin lead may contribute to the
development of Alzheimers disease

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Other Explanations
of Alzheimers Disease
Another explanation is the autoimmune theory:
Changes in aging brain cells may trigger an autoimmune
response, leading to the disease

A final explanation is a viral theory


Because Alzheimers disease resembles Creutzfeldt-Jakob
disease (a form of neurocognitive disorder caused by a
virus), some researchers propose that a similar virus may
cause Alzheimers disease
To date, no such virus has been detected in the brains of
Alzheimers victims

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Assessing and Predicting Alzheimers


Disease
Most cases of Alzheimers disease can be
diagnosed with certainty only after death,
when autopsy is performed
However, brain scans, which reveal structural
abnormalities in the brain, now are commonly
viewed as assessment tools

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Assessing and Predicting Alzheimers


Disease
Several research teams are currently trying to
create tools that can identify persons likely to
develop Alzheimers disease
One research team is using PET scans

The most effective interventions for Alzheimers


disease and other neurocognitive are those that
help prevent problems or, at the very least, are
applied early, so it is essential to have tools that
identify the disorders as early as possible

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Other Types of Neurocognitive


Disorders
There are a number of other neurocognitive
disorders, including:
Vascular neurocognitive 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

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Other Types of Neurocognitive


Disorders
There are a number of other neurocognitive
disorders, including:
Frontotemproal neurocognitive disorder also known
as Picks disease a rare disorder that affects the
frontal and temporal lobes and is clinically similar to
Alzheimers disease
Neurocognitive disorder due to prion disease also
called Creutzfeldt-Jakob disease has symptoms that
include spasms of the body
This disorder is caused by a slow-acting virus

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Other Types of Neurocognitive


Disorders
There are a number of other neurocognitive
disorders, including:

Neurocognitive disorder due to Huntingtons disease


an inherited progressive disease in which memory
problems worsen over time, along with personality
changes, mood difficulties, and movement problems
Parkinsons disease a slowly progressive neurological
disorder marked by tremors, rigidity, and unsteadiness
that can cause neurocognitive disorder due to
Parkinsons disease

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Other Types of Neurocognitive


Disorders
Finally, yet other neurocognitive disorders
may be caused by:
HIV infections
Traumatic brain injury
Substance abuse
Various medical conditions such as meningitis or
advanced syphilis

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What Treatments Are Currently


Available?
Treatments for the cognitive features of
Alzheimer's disease and most other types of
neurocognitive disorder have been at best
modestly helpful
A number of approaches have been applied,
including drug therapy, cognitive techniques,
behavioral interventions, support for
caregivers, and sociocultural approaches

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What Treatments Are Currently


Available?
The drugs currently prescribed affect
acetylcholine and glutamate, the
neurotransmitters known to play an important
role in memory

Although the benefits of the drugs are limited and the


risk of harmful side effects is sometimes high, the
drugs have been approved by the FDA
Another approach, taking Vitamin E, seems to help prevent
or slow down further cognitive decline

These drugs are administered after a person has


developed Alzheimers disease
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What Treatments Are Currently


Available?
Some studies suggest that certain substances now on
the market for other problems (e.g., estrogen) may
prevent or delay the onset of Alzheimers disease
A number of studies also seem to suggest that certain
substances (e.g., estrogen, ibuprofen) may reduce the
risk of Alzheimers disease
Cognitive treatments have been tried with some
temporary success
Behavioral interventions have been tried with modest
success

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What Treatments Are Currently


Available?
Caregiving can take a heavy toll on the close
relatives of people with Alzheimers disease and
other types of neurocognitive disorders
Almost 90% of all people with Alzheimers disease are
cared for by their relatives
One of the most frequent reasons for the
institutionalization of people suffering from
Alzheimers is that overwhelmed caregivers can no
longer cope with the difficulties of keeping them at
home

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What Treatments Are Currently


Available?
Sociocultural approaches have begun to play
an important role in treatment
A number of day-care and assisted-living facilities
have been opened to provide care for those with
Alzheimers disease
Studies suggest that such facilities often help slow
the cognitive decline of residents and enhance
their enjoyment of life

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Issues Affecting the


Mental Health of the Elderly
As the study and treatment of elderly people
have progressed, three issues have raised
concern among clinicians:
The problems faced by elderly members of racial
and ethnic minority groups
The inadequacies of long-term care
The need for a health-maintenance approach to
medical care in an aging world

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Issues Affecting the


Mental Health of the Elderly
Discrimination because of race and ethnicity has long
been a problem in the U.S., particularly for those who
are old

To be both old and a member of a minority group is


considered to be in double jeopardy by many observers
Older women in minority groups are considered to be in triple
jeopardy

Because of language barriers and cultural issues, it is


common for elderly members of ethnic minority groups to
rely solely on family members or friends for remedies and
health care

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Issues Affecting the


Mental Health of the Elderly
Many older people require long-term care outside the
family
Long-term care may refer variously to the services
offered in a partially supervised apartment, in a senior
housing complex, or in a nursing home
The quality of care at such residences varies widely

Many worry about being put away and about the costs
of long-term care
Worry over these issues can greatly harm the mental health of
older adults, perhaps leading to depression and anxiety, as well as
family conflict

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Issues Affecting the


Mental Health of the Elderly
Medical scientists suggest that the current
generation of young adults should take a
health-maintenance, or wellness promotion,
approach to their own aging process
There is a growing belief that older adults will
adapt more readily to changes and negative
events if their physical and psychological health is
good

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