1. Disorders of Aging and Cognition
chapter fifteen
Disorders of Aging and Cognition

2. Disorders of Aging and Cognition
Old age brings special pressures, unique upsets, and major biological changes
Variety of psychological disorders are tied closely to later life
Pressures related to aging
Unique traumatic experiences and biological abnormalities
Neurocognitive disorders are the most publicized and feared psychological problems among the elderly.

3. On the Rise
The population of people aged 65 and older in the United States has increased 11-fold since the beginning of the twentieth century
The percentage of elderly people in the population is expected to be more than 20 percent in 2030 (U.S. Census Bureau, 2011; Cummings & Coffey, 2011; Edelstein et al., 2008)
Old age is usually defined in our society as the years past age 65.
Around 36 million people in the United States are “old” – 12 percent of the population and growing.
Older women outnumber older men by 3 to 2.
Like childhood, old age brings special pressures, unique upsets, and major biological changes.

4. Old Age and Stress
GEROPSYCHOLOGY is the field of psychology dedicated to the mental health of elderly people
As many as 50 percent of elderly people would benefit from mental health services
Fewer than 20 percent actually receive them
The stresses of elderly people need not result in psychological disorders; however, studies indicate that as many as 50 percent of elderly people would benefit from mental health services.

5. The Oldest Old
There are currently around 65,000 centenarians in the United States—people whose age is 100 years or older
On average, they are more healthy, clear-headed, and agile than those in their 80s
Many are employed, sexually active, and enjoy outdoors and the arts
What is their secret?
Longevity gene
Engaged lifestyle
Robust personalities
So…do you think you will live to be 100?

6. 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
Disorders of cognition that result from brain abnormalities
Disorders that may be common in people of all ages but are connected to the process of aging
Depressive, anxiety, and substance-related disorders
Disorders of cognition that result from brain abnormalities
Delirium, mild neurocognitive disorders, and major neurocognitive disorders

7. Depression in Later Life
DEPRESSION is one of the most common mental health problems of older adults
As many as 20 percent of people experience this disorder at some point during old age; highest in older women
Depression among older people raises risk of developing significant medical problems and committing suicide
Same features of depression are the same for elderly and younger people.
Elderly persons are also more likely to commit suicide than younger ones, and often their suicides are related to depression.

8. Depression in Later Life
Therapy
Behavioral therapy
Interpersonal therapy
Antidepressant medications
Combination of these approaches
Impact
Depression improvement with over 50 percent of older patients
Antidepressant drugs side effects
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 body’s metabolism works differently in later life.
Moreover, among elderly people, antidepressant drugs have a higher risk of causing some cognitive impairment.

9. Anxiety Disorders in Later Life
ANXIETY is common among the elderly
At any given time, around 6 percent of elderly men and 11 percent of elderly women in the United States experience at least one of the anxiety disorders
Causes
Treatment
The prevalence of anxiety increases throughout old age.
GAD is particularly common, experienced by up to 7 percent of all elderly persons.
Causes
Declining health
Researchers have not, however, systematically tied anxiety disorders among the elderly to specific events or losses.
Treatment
Psychotherapy of various kinds, particularly cognitive-behavior therapy
Antianxiety medications

10. Substance Abuse in Later Life
Alcohol-related disorders
3 to 7 percent of older people, particularly men, have alcohol-related disorders in a given year
Differences between new and long-term older problem drinkers
Alcohol use disorder in elderly people is treated much the same as in younger adults
Approaches include detoxification, Antabuse, Alcoholics Anonymous (AA), and cognitive-behavioral therapy
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.
Surveys find that 3 to 7 percent of older people, particularly men, have alcohol-related disorders in a given year.
Researchers often distinguish between older problem drinkers who have experienced significant alcohol-related problems 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.
Rate of substance abuse not easily obtained.

11. Substance Abuse in Later Life
Prescription drug misuse
Leading kind of substance problem in the elderly
Most often unintentional
Nursing home medication misuse

12. Psychotic Disorders in Later Life
Elderly people have a higher rate of psychotic symptoms than younger people
Causes
Among aged people, these symptoms are usually due to underlying medical conditions such as the disorders of cognition

13. Psychotic Disorders in Later Life
SCHIZOPHRENIA is less common in older persons than in younger ones
Symptoms lessen in later life
Emergence of new cases uncommon
DELUSIONAL DISORDER develops in a few elderly people
Some elderly persons suffer from schizophrenia or delusional disorder.
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.
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.

14. Disorders of Cognition
With age, memory difficulties and lapses of attention increase, and they may occur regularly by age 60 or 70
Most cognitive problems have organic roots, particularly when they appear in later life
The leading cognitive disorders among elderly persons are DELIRIUM, NEUROCOGNITIVE DISORDER, and MILD NEUROCOGNITIVE DISORDER
Cognitive “mishaps” (e.g., leaving without keys, forgetting someone’s 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.
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.

15. Delirium
DELIRIUM is characterized by a major disturbance in attention and orientation to the environment
Awareness of the environment becomes less clear and often accompanies great difficulty concentrating and thinking in an organized way
This leads to misinterpretations, illusions, and, on occasion, hallucinations
Prevalence and duration
Causes
Dx Checklist
Delirium
Over the course of hours or a few days, the individual experiences fast-moving and fluctuating disturbances in attention and orientation to the environment.
Individual also displays a significant cognitive disturbance.
Table 15-1
Prevalence and duration
Affects fewer than 0.5 percent of the nonelderly population, 1 percent of people over 55, and 14 percent of those over 85 years of age.
Typically develops over a short period of time, usually hours or days, most commonly in elderly persons.
It may occur in any age group, including children, but it is most common in elderly persons.
Causes
Fever, certain diseases and infections, poor nutrition, head injuries, strokes, stress (including the trauma of surgery), and intoxication by certain substances

16. Alzheimer’s Disease and Other Neurocognitive Disorders
NEUROCOGNITIVE DISORDER is characterized by significant decline in at least one area of cognitive functioning
Memory and learning
Attention
Visual perception
Planning and decision making
Language ability
Social awareness
Personality and behavior changes
Neurocognitive disorder A disorder marked by a significant decline in at least one area of cognitive functioning
Major neurocognitive disorder A neurocognitive disorder in which the decline in cognitive functioning is substantial and interferes with a person’s ability to be independent
Mild neurocognitive disorder A neurocognitive disorder in which the decline in cognitive functioning is modest and does not interfere with a person’s ability to be independent

17. Neurocognitive Disorders
Dx Checklist
Major Neurocognitive Disorder
Individual displays substantial decline in at least one of the following areas of cognitive function: • Memory and learning • Attention • Perceptual-motor skills • Planning and decision-making • Language ability • Social awareness.
Cognitive deficits interfere with the individual’s everyday independence.
Mild Neurocognitive Disorder
Individual displays modest decline in at least one of the following areas of cognitive function: • Memory and learning • Attention • Perceptual-motor skills • Planning and decision-making • Language ability • Social awareness.
Cognitive deficits do not interfere with the individual’s everyday independence.
Table 15-2

18. Have you friended your grandmother on Facebook yet?
Remember to Tweet; Tweet to Remember
Elderly people increasingly are going online and joining social networking sites
Potential benefits
Maintain and improve cognitive skills, coping skills, social pleasures, and emotions
Have you friended your grandmother on Facebook yet?
Some 45 percent of all elderly people online now use Facebook; 9 percent use Pinterest; 5 percent tweet, and 1 percent use Instagram—all sizable increases from previous years.

19. Alzheimer’s Disease and Other Neurocognitive Disorders
The occurrence of substantial cognitive decline is closely related to age. Fewer than 1 percent of all 60-year-olds have major neurocognitive disorders, compared with as many as 50 percent of those who are 85. (Information from: ASHA, 2015; Advokat et al., 2014.)
Figure 15-2 The occurrence of substantial cognitive decline is closely related to age. Fewer than 1 percent of all 60-year-olds have major neurocognitive disorders, compared with as many as 50 percent of those who are 85. (Information from: ASHA, 2015; Advokat et al., 2014.)

20. Alzheimer’s Disease
ALZHEIMER’S DISEASE is the most common type of neurocognitive disorder and accounts for as many as two-thirds of all cases
This disease sometimes appears in middle age (early onset), but most often occurs after the age of 65 (late onset)
Dx Checklist
Neurocognitive Disorder Due to Alzheimer’s Disease
Individual displays the features of major or mild neurocognitive disorder.
Memory impairment is a prominent feature.
Genetic indications or family history of Alzheimer’s disease underscores diagnosis, but are not essential to diagnosis.
Symptoms are not due to other types of disorders or medical problems.
Around 5 million people in the United States currently have this disease.
Its prevalence increases markedly among people in their late 70s and early 80s.
Technically, sufferers receive a DSM-5 diagnosis of mild neurocognitive disorder due to Alzheimer’s disease during the early stages and major neurocognitive disorder due to Alzheimer’s disease during the later stages.

21. Alzheimer’s Disease Progression
Mild memory problems, lapses of attention, and difficulties in language and communication
Trouble completing complicated tasks and remembering important appointments
Difficulty with simple tasks, distant memories, and changes in personality often become very noticeable
Less and less awareness of limitations shown
Eventually fully dependent with no knowledge of past and failure to recognize familiar faces
Usually in good health until later stages of disease
Time between onset and death: 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.
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.
As 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.
Alzheimer’s victims usually remain in fairly good health until the later stages of the disease.

22. Alzheimer’s Disease
Diagnosis: Only after death with certainty, when structural changes in the brain can be fully examined
Senile plaques
Neurofibrillary tangles
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.
Scientists do not fully understand what role excessive numbers of plaques and tangles play in Alzheimer’s disease, but they suspect they are very important.
Today’s leading explanations for this disease center on these plaques and tangles and on factors that may contribute to their formation.
Biological culprits
Tissue from the brain of an individual with Alzheimer’s disease shows excessive amounts of plaque (large yellow-black sphere at lower right of photo) and neurofibrillary tangles (several smaller yellow blobs throughout photo).

23. What Are the Genetic Causes of Alzheimer’s Disease?
EARLY-ONSET
Researchers have found that this form of Alzheimer’s 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
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 late-onset Alzheimer’s disease is different from the ones involved in early-onset Alzheimer’s disease
Those with Apo-4 gene are more vulnerable to development of AD
It appears that Alzheimer’s disease often has a genetic basis
Early-onset (familial) Alzheimer’s disease
Late-onset (sporadic) Alzheimer’s disease

24. How Does Brain Structure Relate to Alzheimer’s Disease?
Biological factors
Certain brain structures seem to be critical to the proper functioning of memory
PREFRONTAL LOBES
TEMPORAL LOBES
DIENCEPHALON
Damage to or improper functioning of one or more of these brain structures is found
Researchers have identified a number of biological factors related to the brain abnormalities seen in Alzheimer’s disease.

25. What Biochemical Changes in the Brain Relate to Alzheimer’s Disease?
Certain biochemical activities seem to be especially important in memory
For new information to be acquired and stored, certain proteins must be produced in key brain cells
Several chemicals are responsible for the production of these memory-linked proteins
Some research suggests that abnormal activity by these various chemicals may contribute to the symptoms of Alzheimer’s disease
Acetylcholine, glutamate, RNA (ribonucleic acid), and calcium

26. Other Explanations of Alzheimer’s Disease
Zinc
Environmental toxin lead
Autoimmune theory
Viral theory
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 Alzheimer’s 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 Alzheimer’s disease resembles Creutzfeldt-Jakob disease (another type of neurocognitive disorder caused by a virus), some researchers propose that a similar virus may cause Alzheimer’s disease.
To date, no such virus has been detected in the brains of Alzheimer’s victims.
Slipping away

27. Assessing and Predicting Alzheimer’s Disease
Most cases of Alzheimer’s disease can be diagnosed with certainty only after death, when an autopsy is performed
Brain scans, which reveal structural abnormalities in the brain, now are commonly viewed as assessment tools
PET scans (Mosconi and colleagues)
Several research teams are currently trying to create tools that can identify persons likely to develop Alzheimer’s disease and other neurocognitive disorders.
Overall, the PET scans, administered years before the onset of symptoms, predicted mild neurocognitive impairment with an accuracy rate of 71 percent and major neurocognitive impairment with an accuracy rate of 83 percent.

28. Assessing and Predicting Alzheimer’s Disease
Most effective interventions
Prevention
Early intervention
The most effective interventions for Alzheimer’s disease and other neurocognitive disorders 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.

29. Other Types of Neurocognitive Disorders
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

30. Other Types of Neurocognitive Disorders
FRONTOTEMPROAL NEUROCOGNITIVE DISORDER (PICK’S DISEASE) is a rare disorder that affects the frontal and temporal lobes and is clinically similar to Alzheimer’s disease
NEUROCOGNITIVE DISORDER DUE TO PRION DISEASE (CREUTZFELDT-JAKOB DISEASE) has symptoms that include spasms of the body and is caused by a slow-acting virus

31. Other Types of Neurocognitive Disorders
NEUROCOGNITIVE DISORDER DUE TO HUNTINGTON’S DISEASE is an inherited progressive disease in which memory problems worsen over time, along with personality changes, mood difficulties, and movement problems
PARKINSON’S DISEASE is a slowly progressive neurological disorder marked by tremors, rigidity, and unsteadiness that can cause neurocognitive disorder

32. Other Types of Neurocognitive Disorders
Causes of other neurocognitive disorders
HIV infections
Traumatic brain injury
Substance abuse
Various medical conditions such as meningitis or advanced syphilis

33. What Treatments Are Currently Available?
Treatments and approaches
Drug therapy
Cognitive techniques
Behavioral interventions
Support for caregivers
Sociocultural approaches
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.

34. What Treatments Are Currently Available?
Drug therapy: Limited success
Affect acetylcholine and glutamate which are neurotransmitters known to play an important role in memory
Have limited benefits and sometimes high risk of harmful side effects
Have been approved by the FDA
Are administered after a person has developed Alzheimer’s disease
Drug therapy: Modest success
Certain substances now on the market for other problems (e.g., estrogen) may prevent or delay the onset of Alzheimer’s disease
Certain substances (e.g., ibuprofen) may reduce the risk of Alzheimer’s disease
Cognitive treatments have been tried with some temporary success
Behavioral interventions have been tried with modest success
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 Alzheimer’s disease.

35. What Treatments Are Currently Available?
Home care by relatives
Sociocultural approaches including day-care and assisted-living facilities
Home care by relatives
Caregiving can take a heavy toll on the close relatives of people with Alzheimer’s disease and other types of neurocognitive disorders.
Almost 90 percent of all people with Alzheimer’s disease are cared for by their relatives.
One of the most frequent reasons for the institutionalization of people suffering from Alzheimer’s is that overwhelmed caregivers can no longer cope with the difficulties of keeping them at home.
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 Alzheimer’s disease.
Studies suggest that such facilities often help slow the cognitive decline of residents and enhance their enjoyment of life.

36. Issues Affecting the Mental Health of the Elderly
Three issues have raised concern among clinicians
Problems faced by elderly members of racial and ethnic minority groups
Inadequacies of long-term care
Need for a health-maintenance approach to medical care in an aging world

37. Issues Affecting the Mental Health of the Elderly
Discrimination because of race and ethnicity has long been a problem in the United States, particularly for those who are old
Double jeopardy or triple jeopardy
Many older people require long-term care outside the family
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 minority groups to face barriers to medical and mental health care.
The quality of care residences varies widely.
Worry over these issues can greatly harm the mental health of older adults, perhaps leading to depression and anxiety, as well as family conflict.
“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.
Many worry about being “put away” and about the costs of long-term care.

38. 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