Lecture 11- Mental Disorders Overview

Lecture 11- Mental Disorders Overview
1. Defining Psychopathology 2. Cognitive Disorders Dementia Delirium 3. Other Mental Disorders Depression Anxiety (see text)

4. Clinical Concerns Elder Abuse Suicide (see text) 5. Psychological Issues in Long-Term Care 6. Myth Busting: Facts on Aging Revisited

Science of psychological disorders
Psychological Disorders in Adulthood Psychopathology= Science of psychological disorders Lie outside range of ordinary human experience Subjective distress Impaired in everyday life Cause risk to self or others Engage in socially or culturally unacceptable behavior

Psychological Disorders in Adulthood:
Diagnosis of Psychological Disorders Diagnostic and Statistical Manual of Mental Diseases (DSM-IV) Based on field studies of specific disorders Not developed specifically for older adults Diagnostic process Match symptoms to those in manual Must meet specific criteria Develop treatment plan

Psychological Disorders in Adulthood:
Diagnosis of Psychological Disorders DSM-IV Diagnostic Axes Axis I Clinical syndromes or disorders Personality disorders and mental retardation Axis II Axis III Medical conditions Axis IV Psychosocial stressors Axis V General level of functioning

Terminology Epidemiology
Lifetime prevalence- percentage of people who ever have had the disorder Incidence- new cases within given period

Cognitive Disorders (DSM-IV)
1. Dementia 2. Delirium 3. Amnestic Disorder 4.Cognitive Disorder Not Otherwise Specified

Cognitive Disorders: Dementia
Definition of Dementia Clinical condition/syndrome Loss of cognitive function Interferes with normal activities Interferes with social relationships Dementia Common signs 1. Impairment of memory 2. Multiple disturbances of cognition 3. Impairment of executive function. 4. Disorientation. 5. Behavioral changes.

Dementia: Causes 1. Reversible 2. Irreversible

Important to treat early
Reversible Dementia (some causes) Dementia due to treatable condition: infections toxic effects of drugs (polypharmacy) normal pressure hydrocephalus head injury nutritional deficiencies Korsakoff’s syndrome (vitamin B1) Wernicke’s disease metabolic problems (e.g., hypothyroidism) mental and sensory deprivation Depression (pseudodementia)* Delirium* Important to treat early Can become irreversible

Irreversible: Neurological Diseases that Can Cause Dementia
Disorder Cause Major symptoms Vascular dementia Transient ischemic attacks More rapid decline than AD, decline occurs in spurts Frontal lobe dementia Personality changes- apathy, lack of inhibition, obsessiveness, loss of judgment Damage to frontal lobes Parkinson’s disease Lack of dopamine in basal ganglia Tremors, shuffling gait, postural instability, speech problems Lewy Body dementia Accumulation of Lewy bodies Confusion, hallucinations, motor deficits Pick’s disease Accumulation of Pick bodies Frontal and temporal lobe deterioration, personality changes, loss of speech. Apathy, confusion, concentration problems, flattened emotions HIV dementia Final stages of AIDS

Irreversible: Neurological Diseases that Can Cause Dementia
Disorder Cause Major symptoms Choreiform movements, loss of detailed memories, decreased higher order executive skills Huntington’s Hereditary (chromosome 4) Creutzfeld- Jakob rapid dementia and decline Slow virus Down’s Syndrome Extra chromosome 21 Mental retardation Alzheimer’s Disease Detailed notes Detailed notes

Canadian Study of Health and Aging (1991-1992)
Prevalence Dementia Normal 8% of all Canadians aged 65+ meet the criteria for dementia.

Female to male ratio is 2:1 2.4 % for 65-74 years
Prevalence of dementia in Canada: Canadian Study of Health and Aging ( ) Female to male ratio is 2:1 2.4 % for years 34.5% for those aged 85+ If prevalence estimates remain constant, 592,000 persons will have dementia by 2021

Prevalence of Alzheimer’s Disease and Vascular Dementia in Canada
Alzheimer’s 5.1% for 65+ 1.0% for years 26% for 85+ years Vascular dementia 1.5% for 65+ 0.6 % for years 4.8 % for 85+ years

Dementia: Vascular Dementia
Features Associated with damage to the cerebral blood vessels through arteriosclerosis found in middle and later life (age of onset between 50-70) accumulated effect of multiple cortical and subcortical infarcts lead to clinical presentation incidence higher in men first sign delirium or small stroke

Dementia: Vascular Dementia
Clinical Presentation Abrupt onset step-wise deterioration somatic complaints emotional incontinence history of hypertension history of cebrovascular accidents focal neurological symptoms focal neurological signs

Dementia:Alzheimer’s Disease History
Alois Alzheimer ( ) Patient Auguste D. had dementia symptoms Brain studies after her death revealed microscopic changes Symptoms due to neuronal changes

Dementia and Related Neurological Disorders: Alzheimer’s Disease
NINCDS/ADRDA Guidlines Criteria for probable Alzheimer’s diagnosis= Dementia Significant cognitive deficiencies Progressive deterioration No loss of consciousness 40-90 years of age No other diseases Medical tests Family history Brain scans Other symptoms Also includes

Psychological Symptoms
Alzheimer’s Disease: “Stages” of Progression Psychological Symptoms Early Memory loss for familiar objects and events Middle Regular progression of loss Personality changes Behavior changes Late Loss of ability to perform simple everyday functions People do not die of Alzheimer’s per se.

Clinical Presentation:
Memory loss Aphasia Apraxia Agnosia Disturbance in executive functioning Diagnosis done by exclusion Autopsy is only reliable method

Clinical Presentation

Amyloid Plaques Alzheimer’s Disease
Collection of waste products of dead neurons around a core of amyloid. Formation occurs long before symptoms are evident Amyloid-42 most common form found in plaques

Alzheimer’s Disease Formation of amyloid plaques Proteases snip the APP into fragments. If APP is snipped at wrong place, beta amyloid 42 is formed. Beta amyloid fragments eventually clump together.

Alzheimer’s Disease Tangles

Neurofibrillary Tangles
Alzheimer’s Disease Neurofibrillary Tangles Neurofibrillary tangle Made up of tau protein Tau maintains microtubules within axons Tangles form when tau changes chemically and can no longer support the microtubules Leads to collapse of transport system within neuron

Neurofibrillary Tangles
Alzheimer’s Disease Neurofibrillary Tangles

Causes of Alzheimer’s Disease
Familial Alzheimer’s Disease supports Genetic theory ApoE gene 19 APP gene 21 Presenilin 1 14 Presenilin 2 1 Gene Chromosome Early onset Late onset

Familial Alzheimer’s Disease supports Genetic theory ApoE gene 19 APP gene 21 Presenilin 1 14 Presenilin 2 1 Gene Chromosome Early onset Late onset Majority of early-onset cases

Environmental Life style Head injury Twin data Japanese men who moved to Hawaii Nun Study on mental activity Severe injuries involving loss of consciousness Causes damage to neurons

Treatment: Alzheimer’s Disease
Category Action Name Increases available acetylcholine Anticholinesterase Tacrine Glutamate enhancers Facilitate glutamate Labazimide No trade name Stimulate neuron growth Nerve growth factors Stop free radicals Antioxidants Seligiline Anti-inflammatory Not known Advil Estrogen HRT Not known

Alzheimer’s Disease: Care for Person and Caregiver
Psychosocial Treatments Person Prompts, cues, and guidance Modeling Positive reinforcement Structure daily activities modifications to environment Caregiver burden caregiver Respite care Provide education info on the disease progression communication strategies support groups

Delirium (confusional state)
Definition Fluctuating clinical state characterized by disturbances of attention, cognition, arousal, mood and self-awareness common in the elderly often undiagnosed

Symptoms Impairment in attention and disorientation -distracted, slowed, disorganized thinking Hallucinations may be present -usually more visual than auditory Fluctuating level of awareness -mild confusion to stupor or active delirium Speech may be incoherent Confusion regarding day-to-day procedures or roles Remote and recent memory impaired

Symptoms Restlessness, aggressiveness, frightened Delusions of persecution possible Disturbance of sleep-wake cycle Anxiety and lack of cooperativeness Fluctuations throughout day worse in the evening can be lucid intervals

Causes Infections or fever strokes/cardiovascular disorders drug intoxication (polypharmacy or abuse) or withdrawl exacerbation of underlying medical illness metabolic and nutritional disorders postoperative stress* or other factors related to hospitalization such as sleep loss, excessive sensory input

Course and Treatment Brief duration (usually less than a week) some forms resolve on own other forms, treatment depends on cause while delirious carefully-controlled environment (not too stimulating) brief and continued reassurance monitor nutritional and fluid status of person help the caregivers understand what is going

Differential Diagnosis Delirium Dementia
Rapid onset marked attentional disturbance confusion prominent/clouding of consciousness fluctuating clinical course agitation and behavioral symptoms potentially reversible Usually insidious onset memory systems impaired consciousness intact slower, progressive course subtle behavioral symptoms can be irreversible

Depression Mood Disorders and features Depressive disorders- sad mood
Bipolar disorders- involve manic episode Dysthymic Disorder-chronic but less severe Mood disorders due to a general medical condition

Diagnostic Features of Major Depressive Episode (DSM-IV) Essential Features Associated Symptoms (1 of 2 required) (5 of 9 required) Depressed mood for most of the day marked reduction in interest in daily activities 5% weight loss or significant change in appetite (increase or decrease) almost daily insomnia or hypersomnia almost daily physical agitation or retardation almost daily decreased energy or fatigue almost daily feelings of worthlessness or feelings of guilt almost daily decreased concentration or decreased decisiveness frequent thoughts of death or suicide Depressed mood Loss of interest or pleasure

Depression Prevalence of Depressive DIsorders Lifetime prevalence:
NCS= 13% men 21% women Persons over 65: 1% major depressive disorder 2% dysthymia (chronic but less severe depression) However, 8-20% of older adults report symptoms

Depression Higher Prevalence of Mood Disorders in Medical Settings:
12-20% in clinics and hospitals 30% in long-term care settings Can lead to greater risk of more serious disorder and even fatal impairment

Depression Prevalence of Depressive DIsorders
Myth: aging leads to depression- old age is depressing Reality: rates for major depression are lower in the elderly compared to younger adults

Depression Features of Mood Disorders in Older Adults
Less likely to report traditional symptoms involving negative feelings More likely to seek treatment for bodily complaints Seek treatment for disorders other than mood (anxiety, cognitive, bodily delusions)

Depression Features of Mood Disorders in Older Adults/causes
Lack of energy Hopelessness Loss of appetite Depletion syndrome Mild or moderate First appears after age 65 Late-onset depression

Depression Causes of Age Differences in Mood Disorders
Personality and emotional changes associated with aging Cohort differences in experience of depression

Problems in Diagnosis of Mood Disorders:
Depression Problems in Diagnosis of Mood Disorders: Older adults do not report symptoms accurately Professionals not attuned to diagnosis of older adults Not enough time spent with older adults Wish to avoid stigmatization Therapists unaware of benefits cognitive difficulty can accompany depression dementia and depression can both be present “pseudodementia”

Differentiating Dementia and Pseudodementia
Depression Differentiating Dementia and Pseudodementia Dementia has insidious onset (years) history of psychiatric problems more common in pseudodementia dementia (mild) complains little about memory/concealment depressive pseudodementia complains dementia- behavior in line with clinical severity depression- incongruities between behavior and severity of cognitive deficit

Depression Treatment Drug therapies Psychotherapy

Elder Abuse Actions taken against older adults through inflicting psychological or physical harm Physical Sexual Emotional or psychological Neglect Abandonment Financial or material Types of Abuse

Elder Abuse Prevalence Estimates in Canada
Podnieks et al. (1989) interviewed (by phone) community dwelling seniors Rate for abuse and neglect among seniors is 4% overall material abuse (2.5%) chronic verbal agression (1.4%) physical violence (.5%) neglect (.4%)

Elder Abuse Prevalence Estimates in Canada (region) B.C. 5.3%
Prairies 3.0% Ontario 4.0% Quebec 4.0% Atlantic 3.8%

Elder Abuse (see this table in the text)
Highest risk for oldest old Children most frequent abusers

Psychological Issues in Long-Term Care
Biopsychosocial Factors Differences among residents in physical functioning BIO- Variations in psychological resources and needs PSYCHO- SOCIAL Cultural factors further influence relationships

Psychological Issues in Long-Term Care
Competence-Press Model of Environmental Adaptation Positive affect Adaptive behavior Negative affect Maladaptive behavior Marginally adaptive behavior Tolerable affect Marginally adaptive behavior Tolerable affect Adaptation Level Competence Zone of maximum performance potential Negative affect Maladaptive behavior Press

Myth Busting: Facts on Aging Revisited
#1 The majority of old people (age 65+) are senile (have defective memory, are disoriented, or demented) False

#5 The majority of old people feel miserable most of the time. False

#7 At least one tenth of the aged are living in long-stay institutions (such as nursing homes, mental hospitals, homes for the aged, etc.) False (see text)

#10 Over three fourths of the aged are healthy enough to do their normal activities without help. True

#13 Depression is more frequent among the elderly than among younger people. False

Lecture 11- Mental Disorders Overview

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