Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale & John M. Neale 1 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Chapter 14: Late Life and Neurocognitive Disorders I. Aging: Issues and Methods II. Psychological Disorders in Late Life 2 Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.

 In U.S., many people dread aging Elderly not revered as in other cultures Elderly not revered as in other cultures  When are we old? Society arbitrarily sets old as over 65 Society arbitrarily sets old as over 65 Young-old: years, old-old: 75-84, oldest-old: 85+ Young-old: years, old-old: 75-84, oldest-old: 85+  2001 census 12.4% or 35 million individuals were 65 or older 12.4% or 35 million individuals were 65 or older 3 © 2012 John Wiley & Sons, Inc. All rights reserved.

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 Aging involves inexorable cognitive decline Severe cognitive problems do not occur for most Severe cognitive problems do not occur for most  Mild declines are common  Late life is a sad time and most elderly are depressed Older individuals report less negative emotion than younger people Older individuals report less negative emotion than younger people  More brain activation in key areas when viewing positive images  Late life is a lonely time Some less likely to develop new friendships Some less likely to develop new friendships Social selectivity Social selectivity  As we age, we focus on the interpersonal relationships that matter most to us  Older people lose interest in sex Sexual activity does not decrease from mid-to late life for most people Sexual activity does not decrease from mid-to late life for most people 5 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Problems multiply with age physical decline and disabilities physical decline and disabilities sensory and neurological deficits sensory and neurological deficits loss of loved ones loss of loved ones social stresses such as stigmatizing attitudes towards elderly social stresses such as stigmatizing attitudes towards elderly Eighty percent of elderly people have at least one major medical condition Eighty percent of elderly people have at least one major medical condition  Sleep disturbances increase with age Insomnia Insomnia Sleep apnea Sleep apnea  Medical treatment Chronic problems instead of curable disorders Chronic problems instead of curable disorders Polypharmacy: Practice of prescribing multiple drugs to patients Polypharmacy: Practice of prescribing multiple drugs to patients Psychoactive drugs usually tested on younger participants Psychoactive drugs usually tested on younger participants 6 © 2012 John Wiley & Sons, Inc. All rights reserved.

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 Cross-sectional studies Researcher tests different age groups at one point in time Researcher tests different age groups at one point in time Fails to provide information about how people change over time Fails to provide information about how people change over time  Longitudinal studies Researcher retests the same group of people with the same measures at different points in time Researcher retests the same group of people with the same measures at different points in time  May extend over several years or decades Attrition a potential problem Attrition a potential problem  Selective mortality can lead to biased sample 8 © 2012 John Wiley & Sons, Inc. All rights reserved.

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 Most elderly do not have cognitive disorders Prevalence has decreased over last 15 years Prevalence has decreased over last 15 years  Dementia A deterioration of cognitive function A deterioration of cognitive function  Delirium A state of mental confusion A state of mental confusion 10 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Deterioration of cognitive function Impaired social and occupational functioning Impaired social and occupational functioning Progresses over time Progresses over time  Begins with difficulty remembering recent events  Deficits can be detected before impairment becomes obvious  Mild cognitive impairment develop slowly  DSM-5 proposes two categories, differentiated by ability to live independently: Mild neurocognitive disorder (mild cognitive impairment) Mild neurocognitive disorder (mild cognitive impairment) Major neurocognitive disorder (dementia) Major neurocognitive disorder (dementia) 11 © 2012 John Wiley & Sons, Inc. All rights reserved.

12 © 2012 John Wiley & Sons, Inc. All rights reserved.

13  Minor cognitive decline from previous levels in one or more domains based on both of the following: o Concerns of the patient, a close other, or a clinician o Neurocognitive performance below appropriate norms (i.e., between the 3rd and 16th percentile) on formal testing, or equivalent clinical evaluation.  The cognitive deficits do not interfere with independence (i.e., tasks such as paying bills or managing medications), even though greater effort, compensatory strategies, or accommodation may be required to maintain independence.  The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another psychological disorder © 2012 John Wiley & Sons, Inc. All rights reserved.

14  Evidence of significant cognitive decline from previous levels in one or more domains based on both of the following: o Concerns of the patient, a close other, or a clinician o Neurocognitive performance below the 3rd percentile on formal testing, or equivalent clinical evaluation.  The cognitive deficits interfere with independence  The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another psychological disorder © 2012 John Wiley & Sons, Inc. All rights reserved.

 Described by Alois Alzheimer in 1906  Irreversible brain tissue deterioration Death usually occurs within 12 years Death usually occurs within 12 years  Usually begins with Difficulty remembering recent events Difficulty remembering recent events Learning new material Learning new material Irritability Irritability  As disease progresses Language problems intensify, including word-finding Language problems intensify, including word-finding Disorientation Disorientation  Time, place, and identity confusion Agitation Agitation Depression Depression 15 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Plaques β -amyloid protein deposits β -amyloid protein deposits Primarily found in frontal cortex Primarily found in frontal cortex  Neurofibrillary tangles Protein filaments composed of tau in axons of neurons Protein filaments composed of tau in axons of neurons Primarily found in hippocampus Primarily found in hippocampus  Measured using PET scans  Plaques most dense in frontal cortex; tangles most dense in hippocampus  Loss of synapses for acetylcholinergic (Ach) and glutaminergic neurons As neurons die, atrophy of cerebral and entorhinal cortices and hippocampus As neurons die, atrophy of cerebral and entorhinal cortices and hippocampus Enlargement of ventricles Enlargement of ventricles 16 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Genetic factors Heritability 79% Heritability 79% ApoE4 allele: Gene on chromosome 19 ApoE4 allele: Gene on chromosome 19  Having one E4 allele increases risk by 20%  Having two E4 alleles increases risk substantially more  Related to over-production of beta-amyloid plaques, loss of neurons in the hippocampus, and low glucose metabolism in cerebral cortex  Environmental factors Smoking, being single, low social support, and depression related to greater risk of developing Alzheimer’s Smoking, being single, low social support, and depression related to greater risk of developing Alzheimer’s Mediterranean diet, exercise, education, and cognitive engagement predict a lower risk Mediterranean diet, exercise, education, and cognitive engagement predict a lower risk  e.g. solving crossword puzzles, reading the newspaper daily Cognitive reserve Cognitive reserve  Use alternative brain networks to compensate for disease 17 © 2012 John Wiley & Sons, Inc. All rights reserved.

18 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Loss of neurons in frontal and temporal lobes Memory not severely disrupted Memory not severely disrupted  Impairment of executive functions Planning Planning Problem solving Problem solving Goal-directed behavior Goal-directed behavior  Difficulty recognizing and regulating emotion Much more profound impact than Alzheimer’s Much more profound impact than Alzheimer’s  Caused by multiple genetic pathways Pick’s Disease Pick’s Disease High levels of tau proteins High levels of tau proteins 19 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Typically results from stroke (cardiovascular) Clot forms and impairs circulation Clot forms and impairs circulation Cells die Cells die  Risk factors Smoking, high LDL cholesterol, high BP Smoking, high LDL cholesterol, high BP  Symptoms can vary greatly, depending upon location of strokes 20 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Two subtypes With Parkinson’s With Parkinson’s No Parkinson’s No Parkinson’s  Symptoms similar to Parkinson’s and Alzheimer’s diseases Shuffling gait Shuffling gait Loss of memory Loss of memory  Symptoms differ in that DLB patients have: Fluctuating cognitive symptoms Fluctuating cognitive symptoms Prominent visual hallucinations Prominent visual hallucinations Intense dreams involving movement and vocalizing Intense dreams involving movement and vocalizing 21 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Other medical issues Encephalitis (inflammation of brain tissue by viruses) Encephalitis (inflammation of brain tissue by viruses) Meningitis (inflammation of covering membranes by bacteria) Meningitis (inflammation of covering membranes by bacteria) HIV HIV Head traumas Head traumas Brain tumors Brain tumors Nutritional deficits (B-complex vitamins) Nutritional deficits (B-complex vitamins) 22 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Medications No drug reverses Alzheimer’s disease No drug reverses Alzheimer’s disease Some drugs produce slightly less decline Some drugs produce slightly less decline  Cholinesterase inhibitors (drugs that prevent breakdown of acetylcholine)  Donepezil (Aricept)  Galantamine (Reminyl)  Vitamin E, statins, and nonsteroidal anti- inflammatory drugs have failed to find support  Preventive work focuses on processes involved in the creation of amyloid from its precursor protein  Antidepressants for depression  Antipsychotic medication for agitation 23 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Psychological treatments Supportive psychotherapy for family and patient Supportive psychotherapy for family and patient Education about disease and care Education about disease and care Cognitive interventions when disease is in early stages Cognitive interventions when disease is in early stages  Labeling drawers, appliances  Calendars, clocks, and strategically placed notes Exercise has been associated with cognitive benefits Exercise has been associated with cognitive benefits Music appears to reduce agitation and disruptive behavior Music appears to reduce agitation and disruptive behavior 24 © 2012 John Wiley & Sons, Inc. All rights reserved.

 Clouded state of consciousness Extreme trouble focusing attention Extreme trouble focusing attention Disturbances in the sleep/wake cycle Disturbances in the sleep/wake cycle Fragmented thinking Fragmented thinking Speech is rambling and incoherent Speech is rambling and incoherent Disorientation Disorientation Perceptual disturbances Perceptual disturbances Memory impairments Memory impairments Mood swings Mood swings  Secondary to underlying medical condition  Detection of delirium important but often missed Untreated, further cognitive decline and mortality may occur Untreated, further cognitive decline and mortality may occur  Beyond treating the underlying medical conditions, the most common treatment is atypical antipsychotic medication 25 © 2012 John Wiley & Sons, Inc. All rights reserved.

26 © 2012 John Wiley & Sons, Inc. All rights reserved.

Copyright 2012 by John Wiley & Sons, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. 27 © 2012 John Wiley & Sons, Inc. All rights reserved.