1. Chapter 16 Aging and Psychological Disorders

2. Issues, concepts, and methods in the study of older adults, old age, and brain disorders Old age and psychological disorders Treatment and care of older adults Issues specific to therapy with older adults Chapter Outline

3. Facts About Aging Population 65 years old and older: Young-old: 65-74 Old-old: 75-84 Oldest-old: 85 and over Changing demographics in Canada In 1998, 3.7 million (12.3%) of population were 65 and over In 2011, over 5 million (14.8%) of Canadians In 2041, expectation are 10 million Canadians In 2015, more senior citizens than children In 2050, 1 in 5 people in the world will be 60 and older

4. Issues, Concepts and Methods in the Study of Older Adults

5. Dementia Dementia— term for gradual deterioration of intellectual abilities to the point that social and occupational functions are impaired Course may be progressive, static, or remitting Prevalence of dementia  with advancing age 13.9% in people aged 71 and older 37.4% in people aged 90 and older Incidence of cognitive impairment without dementia occurs in 22.2% of people age 71 or older

6. Symptoms of Dementia Difficulty remembering things Especially recent events Leaving tasks unfinished Hygiene may be poor and appearance sloppy Getting lost Difficulty comprehending making plans or decisions Poor impulse control May use coarse language, tell inappropriate jokes, or shoplift Deterioration of abstract ideas, make faulty judgments Disturbances in emotions, including outbursts, depression

7. Classification of Dementias Alzheimer’s Disease Frontal-temporal Dementias Frontal-subcortical Dementias

8. Alzheimer’s Disease (AD) Described by German neurologist Alois Alzheimer (1906) Accounts for about 50% of dementia in older people Prevalence in Canada: 1.5% of population (2010) Estimated prevalence 2.8% of population (2038) 1/13 Canadians over age 65 has AD or related dementia Death usually occurs 10 or 12 years after onset Although women live longer, more die as a result of AD than men Promoting mental and physical exercise could reduce risks by 10%

9. Alzheimer’s Disease (cont.) Main neurological changes: Atrophy of cerebral cortex Begins with entorhinal cortex and hippocampus, then frontal, temporal, and parietal lobes As neurons and synapses are lost, fissures widen and ridges become narrower and flatter Ventricles also become enlarged Plaques— small, round areas comprising remnants of lost neurons and b-amyloid are scattered throughout cortex Neurofibrillary tangles— tangled, abnormal protein filaments accumulate within cell bodies of neurons Plaques and tangles are present throughout cerebral cortex and hippocampus

10. Alzheimer’s Disease (cont.)

11. Causes of Alzheimer’s Disease Genetics – strong evidence Risk  first-degree relatives of afflicted individuals Concordance for MZ twins is greater than for DZ twins Environmental role ‘Use it or lose it’ Research shows: Engaging in cognitive activities helps to preserve intellectual functioning Cognitive activity preserves crystallized intelligence more than fluid intelligence (new learning) Cognitive reserve hypothesis that high education levels help to delay onset of dementia

12. Frontal-Temporal Dementias Accounts for 10 to 15% of cases Typical age of onset is late fifties Marked by extreme behavioural and personality changes Not closely linked to loss of cholinergic neurons Pick’s disease is one cause of frontal-temporal dementia Degenerative disorder where spherical inclusions (known as Pick bodies) are present in neurons

13. Frontal-Subcortical Dementias Types include: Huntington’s chorea —caused by single dominant gene located on chromosome 4 Major behavioural feature presence of writhing (choreiform) movements Parkinson’s disease — marked by muscle tremors, muscularrigidity, and akinesia an inability to initiate movement Vascular dementia — diagnosed when patient with dementia has neurological signs or when brain scans show evidence of cerebrovascular disease

14. Other Causes of Dementia Infectious diseases Encephalitis Meningitis Syphilis (Treponema pallidum) Head traumas Brain tumours Nutritional deficiencies Especially of B- complex vitamins Kidney or liver failure Endocrine-gland problems Hyperthyroidism Exposure to toxins Lead or mercury Chronic drug and alcohol use

15. Treatment of Dementias Biological Treatments of Alzheimer’s Disease Involves death of brain cells that secrete acetylcholine thus try to  levels Blocking creation of amyloid from its precursor protein Antioxidants (vitamin E) may be useful in slowing progression

16. Treatment of Dementias (cont.) Psychosocial Treatments for Patients Supportive psychotherapy aiming at minimizing the disruption caused by the person’s behavioural changes Many individuals with dementias are supported by family members Ratio of individuals with dementia living with family in the community versus in institutions 2:1

17. Treatment of Dementias (cont.) Caregiver burden – four kinds identified: Emotional Physical Financial Employment Caregivers more likely to experience chronic health problems Resources available to caregivers On-line forum Support groups Respite from caregiving (health care workers take over from family for periods)

18. Delirium Delirium— “a clouded state of consciousness” Trouble concentrating and focusing attention Cannot maintain coherent thought Early stages— person frequently restless especially at night Perceptual disturbances Memory impairment Paranoid delusions in 40 to 70% severe delirium Speech is rambling and incoherent Person is bewildered and confused Difference between delirium and other conditions People with delirium have lucid intervals, show fluctuations in mental state over the course of the day

19. Dementia vs. Delirium

20. Causes and Treatment of Delirium Causes Drug intoxications Drug-withdrawal reactions Metabolic and nutritional imbalances Uncontrolled diabetes and thyroid dysfunction Infections or fevers Neurological disorders Stress Treatment If syndrome identified correctly and underlying cause promptly treated 1-4 weeks for condition to clear If underlying cause not treated Permanent brain damage Death Intervention addresses risk factors Sleep deprivation, Immobility Dehydration Visual and hearing impairment Cognitive impairment

21. Old Age and Psychological Disorders Rates of mental disorders are lowest in age 65 and older, most are free from serious psychopathology Instead, cognitive impairments are more common 5.5% of older men and 4.7% of older women About 10 – 20% of older adults have psychological problems serious enough to need professional help

22. Depression Depression is less prevalent in older adults than younger people In Canada (2005): 2.6% with major depression 4.9% with minor depression (2-4 symptoms) Late onset depression (first episode in old age) Causes of depression: Less involvement in daily activity Depression maintained by self-critical thoughts Is related to medical illness Bereavement

23. Treatment of Depression Depression is under-treated in the elderly Cognitive, behavioural, interpersonal and brief psychodynamic approaches have been used Quality of client-therapist alliance is a key predictor of therapeutic response Reminiscence therapy can be effective ‘life review therapy’ reflect on past experiences re-examine events Example: perfectionists who are pre-occupied with past mistakes work on less self-critical interpretations of their experiences

24. Anxiety Disorders Anxiety more prevalent than depression Less prevalent in older people than younger adults; about 7% of people 65 and older Risk factors: e.g., being female, having several chronic medical conditions, not being married, low levels of education Can complicate other conditions Most prevalent: GAD and agoraphobia

25. Substance-Related Disorders Alcohol use and dependence In Canada: 8.9% had definite alcohol abuse; 3.7% had questionable alcohol abuse In US: 10.8% of elderly men; 2.9% in elderly women In England: 28.6% in elderly men; 10.3% in women Heavy drinking is linked to depression, anxiety, health problems Medication misuse Much greater problem than drug and alcohol abuse Elderly are 13% of population but they consume 33% of all prescribed meds Problem: Obtain prescriptions from several doctors

26. Sleep Disorders Insomnia: Common problem: 1 in 5 older adults (65-79) More frequent, less severe than in younger populations with more complications Less night-time sleep, more daytime naps, more night- time interruptions, less time in REM sleep More sleep disturbance in older men than in older women Causes of sleep disorders: Medication, anxiety, depression, lack of activity, poor sleep habits, sleep apnea Treatment of sleep disorders Pharmacotherapy, possible over-use in nursing homes

27. Suicide Prevalence: 3x higher than in younger adults Peak ages for suicide: 80-84 in white US men Older adults are less likely to communicate their intention than younger adults Ratio between attempted and completed suicide are much higher in older adults (4:1) compared with 8:1 in overall population Causes of suicide: loneliness, poor cognitive functioning, general and interpersonal hopelessness Link between health problems, depression and suicide Alcohol use associated with more violent methods

28. Treatment & Care of Older Adults Nursing Homes Alternative Living Settings Community-Based Home Care Considerations in Therapy: Social context Loneliness Physical frailty Death and dying

29. Treatment and Care of Older Adults APA Practice Guidelines

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