Late Life and Neurocognitive

Disorders
• As we age physiological changes are inevitable, and there may be
emotional and mental changes as well. Many of these changes wil
influence social interactions.
• The social problems of aging may be especially severe for women.
• The elderly are usually defined as people over age of 65, an arbitrary point
set largely by social policies rather than any physiological process.
• At the time of the last census in 2010, population, people 65 or older
comprised 12.5 percent (35 million) of the U.S population.
• The speed of population aging is more rapid in other parts of the World,
including Europe and particularly Asia, than it is in the U.S.
• Countries with a sharper rise in numbers of elderly hold more negative
attitudes towards the elderly.
Myths About Late Life
• Severe cognitive problems do not ocur for most people in late life.
• After a dip in middle age, happiness increases into late life in countries
around the world.
• Lab studies verify that older individuals are actually more skilled at regulating their
emotions.
• Another myth, that older people are lonely, has received considerable
attention.
• Social selectivity or social isolation
• Many stereotypes we hold about the elderly are false, but considerable
research suggest that the negative attitudes about the elderly learned early
in life persist and become negative self-perceptions as people move into
their later years.
The Problems Experienced in Late Life
• Physical decline and disabilities, sensory acuity deficits, loss of loved
ones, the social stress of stigmatizing attitudes towards the elderly,
and the cumulative effects of a lifetime of unfortunate experiences.
• By age 60, more than half of the people have one medical condition
that causes severe disability.
• Polypharmacy, the prescribing of multiple drugs to a person
• Increases the risk of adverse drug interactions such as side effects and
toxicity. Oftern, physicians prescribe more medications to combat the side
effects, thus amplifying the initial problem.
Research Methods in the Study of Aging
• Age effects are the consequences of being a certain chronological
age.
• Cohort effects are the consequences of growing up during a
particular time period with its characteristic challenges and
opportunities.
• Time-of-measurement effects are confounds that arise because
events at a particular point in time can have a specific effect on a
variable that is being studied.
Psychological Disorders in Late Life
• The DSM criteria are the same for the older and younger adults.
• Because medical conditions are more common in the elderly, it is
particularly important to rule out such explanations.
• Medical problems such as thyroid problems, Addison’s disease,
Cushing’s disease, Parkinson’s disease, Alzheirmer’s disease,
hypoglycemia, anemia, testosterone deficits and vitamin deficiencies
can produce symptoms that mimic schizophrenia, depression, or
anxiety.
• Medication may result in anxiety and depression.
Prevalence Estimates of Psychological Disorders in Late Life
• Every single disorder was less common in the elderly than in young
adults.
• Most people who have an episode of psychological disorder late life
are experiencing a recurrence of a disorder that started earlier in life
rather than an initial onset.
• For example, 97 percent of older adults with generalized ansiety
disorder report that their symptoms began before the age of 65.
• Late onset is also extremely rare for schizophrenia.
• In contrast, late onset is more common for driniking problems.
Methodological Issues in Estimating the Prevalence of
Psychopathology
• Methodologically, older adults may be more unconfortable
acknowledging and discussing mental health or drug use problems
than younger people are.
• In one study, researchers interviewed elderly people about depressive
symptoms and then interviewed a family member about whether that
elderly person was experiencing depressive symptoms.
• Among those elderly whom family members described as meeting the
criteria for majör depressive disorder, about one-quarter did not
disclose depressive symptoms to the interviewer.
• Discomfort discussing symptoms may minimize prevalence estimates.
• In addition to reporting bias, there may be cohort effects.
• Beyond these explanations, people with psychological disorders are at
risk for dying earlier- before age 65- for several different reasons.
(selective mortality)
• Cardiovascular disease and diabetes are more common among
people with a history of anxiety disorders, depressive disorders,
bipolar disorders and alcohol use disorders.
Treatment
• Many of the pharmacolgical and psychological treatments that work
in earlier life are efficacious for the elderly.
• Nonetheless, several issues require careful consideration. Many
psychiatric medications, including benzodiazepins, antipsychotic
medications, and some antidepressants can cause serious side
effects.
• Therapists may need to adapt psychotherapies to adjust for vision or
hearing loss, ot to offer telephone sessions for elderly clients with
limited mobility.
Dementia
• Dementia is a descriptive term for the deterioration of cognitive
abilities to the point that functioning becomes impaired.
• The diagnosis of dementia is based on declines in cognitive abilities,
including attention, executive function, learning, memory, language,
perceptual-motor ability, abstract thinking, and social cognition.
• Of these, diminished memory is the most common symptom.
• As dementia progresses, most people tend to develop
neuropsychiatric symptoms- psychiatric symptoms that appear to be
secondary to the neurological disease.
• The most common neuropsychiateric syndrome is depression, which
affects about 50 percent of those with dementia, but other affective and
motivational symptoms, such as apathy, anxiety and irritability can
develop.
• Sleep disturbances are common.
• Delusions and hallucinations can ocur.
• Most dementias develop very slowly over a period of years; subtle
cognitive and behavioural deficits often emerge well before the person
shows any noticeable impairment.
• The early signs of decline before functional impairment is present are
labelled as «mild cognitive impairment»
DSM 5 Criteria for Mild Neurocognitive Disorder

• Modest cognitive decline from previous levels in one or more

domains based on the following:
• Concers of the patient, a close other, or clinician
• Modest neurocognitive decline on formal desting or equivalent clinical
evaluation
• These cognitive deficits do not interfere with independence in
everyday activities (e.g. paying bills or managing medications) even
though greater effort, compensatory strategies, or accomodation may
be required to maintain independence.
• The cognitive deficits do not ocur exclusively in the context of
delirium and are not due to another psychological disorder.
DSM 5 Criteria for Major Neurocognitive Disorder

• Significant cognitive decline fro previous levels in one or more

domains based on both of the following:
• Concerns of the patient, a close other, or clinician
• Subtantial neurocognitive impairment or equivalent clinical evaluation
• The cognitive deficits interfere with independence in everyday
activities
• The cognitive deficits do not ocur exclusivley in the context of
delirium and not due to another psychological disorder.
Alzheimer’s Disease
• The most prominent symptom of Alzheimer’s disease is memory loss.
• The illness may beging with absentmindedness and gaps in memory
for new material.
• The person may leave tasks unfinished and forgotten if interrupted.
• It may be hard to find words.
• These shortcomings may be overlooked for several years but
eventually interfere with daily living.
• Apathy is common even before the cognitive symtoms become
noticeable and about a third of people develop full-blown depression
as the illness worsens.
• Worldwide prevalence estimates of dementia in 2010 were over 35
million.
• Although less than 2% of people develop dementia before age 65, the
prevalence increases dramatically as people age, to more than a third
of people in their 90s.
• By far, the most common form of dementia is Alzheimer’s disease,
which accounts for more than half of dementias.
• As the disease develops, problems with language skills and Word
finding intensify.
• Visual spatial abilities decline, which can manifest in disorientation
(confusion with respect to time, place or identity).
• The person may easily become lost, even in familiar surroundings.
• People with the disorder are typically unaware of threir cognitive
problems initially, and they blame others for lost objects even to the
point of developing delusions of being persecuted.
• Memory continues to deteriorate and the person becomes
increasingly disoriented and agitated.
• Beyond genetic and medical risk factors, lifestyle variables play a role
in Alzheimer’s.
• Across large-scale representative samples, social isolation and
insomnia are related to a greater risk of Alzheirmer’s disease,
• While fish consumption, a Mediaterranean diet, exercise, education
and engagement in cognitive activities are related to a lower risk.
• Many large scale longitudinal studies suggest that exercise may
prevent memory problems.
• Regular exercise predicts less decline in cognitive functions and
decreased risk of developing Alzheimer’s disease over time.
• Engagement in intellectual activities also appears helpful.
• For example, regular reading of a newspaper is related to lower risk.
• Frequent cognitive activity (for example, reading and puzzle solving) is
related to 46 percent decrease in risk of Alzheimer’s disease
compared to infrequent cognitive activity.
• We know that biological changes in the brain begin 20 years before
the symptoms of Alzheimer’s disease first emerge; it is plausible that
those brain changes influence motivation to take part in exercise or
cognitive activities.
• The complexity of trying to identify the direction of effects is illustrated by
the relationship of depression and Alzheimer’s disease.
• Depression can be a consequence of dementia. Vice versa, a lifetime
history of depression predicts greater risk for Alzheimer’s disease and
other forms of dementia.
• Cognitive scores declines significantly 12 years before diagnosis, and their
cognitive decline escalated in the years before diagnosis- that is after
cognitive declines had already begun.
• Depressive symptoms earlier in life were unrelated to the risk of dementia.
• The findings indicate that the depressive symptoms observed before
dementia onset may a manifestation of the neurological decline.
Frontotemporal Dementia
• Frontotemporal dementia is caused by a loss of neurons in frontal and
temporal regions of the brain.
• FTD typically occurs predominantly anterior temporal lobes and
prefrontal cortex.
• Typically begins in the late 50s and it progresses rapidly, death usually
occurs within 5 years of the diagnosis.
• Unlike Alzheimer’s disease, memory is not severely impaired.
• There are multiple subtypes of FTD
• The diagnostic criteria for behavioural variant, the most common
form, include deterioration in at least three of the following areas:
• Empathy
• Executive functions (capacity to plan and organize)
• Ability to inhibit behaviour
• Compulsive or perseverative behaviour
• Tendecies to put nonfood objects in the mouth
• Apathy
• Particular deficits emerge in the ability to regulate emotions
• Socially inappropriate and impulsive behaviours
Vascular Dementia
• Vascular dementia is caused by cerebrovascular disease.
• Most commonly, strokes cause a blood clot, which then impairs
circulation and results in the death of neurons.
• About 7% of people will develop dementia in the year after a first
stroke, and the risk of dementia increases with recurrent strokes.
• Risk factors: older age, a high level of «bad» cholesterol, cigarette
smoking and elevated blood pleasure.
• Because a person affected by this dşsorder might suddenly start to
overeat, chain smoke, drink alcohol, or demonstrate other behavioral
symptoms , FTD often is misdiagnosed as a midlife crisis or as a
psychological disorder such as bipolar disorder or schizophrenia.
• The presence of apathy can result in misdiagnosis of depression.
Dementia with Lewy Bodies
• In dementia with Lewy bodies (DLB) , protein deposits called Lewy
bodies form in the brain and cause cognitive decline
• Lewy bodies are also iplicated in Parkinson’s disease.
• About 80 % of people with Parkinson’s will develop dementia, but
some people without Parkinson’s will develop DLB as well.
• The symptoms associated with this type of dementia are often hard
to distinguish from the symptoms of Parkinson’s and Alzheimer’s
disease.
• Prominent visual hallucinations and fluctating cognitive symptoms
Treatments for Dementia
• There is no cure for dementia.
• Some medications are used to delay symptom progression and to
address related symptoms.
• Much of the treatment research has focuses on Alzheimer’s disease
and on memory decline.
• Medications help slow decline, but they do not restore memory
function to previous levels.
• Although evidence is not entirely consistent, blood pressure
management for those with hypertension may have some benefits in
slowing down the progression
• Although antipsychotic medications may provide very modest relief
for aggressive agitation, they also increase the risk of death among
elderly people with dementia.
• Antidepressant medication have been shown to reduce agitation
among those with dementia , although there is a mixed evidence
about whether antidepressants reduce the depressive symptoms that
accompany dementia.
Psychological and Lifestyle Treatments
• Supportive psychotherapy can help families and patients deal with
the effects of disease.
• The therapist also provides accurate information about the illness,
helps family members care for the person in the home and
encourages a realistic attitude
• Behavioral approaches e.g. External memory aid visual reminders
• Music
• Psychotherapy for depression
• Exercise and cognitive training programs are used to prevent cognitive
declines before dementia has begun
Delirium
• The term delirium implies a deviation from the usual state – out of track
• Extreme trouble focusing attention so that they cannot maintain a
coherent stream of thought
• They may have trouble answering questions
• As the sleep/wake cycle becomes disturbed, patients become drowsy
during the day yet awake and agitated at night.
• Vivid dreams and nightmares are common
• In severe delirium speech is distrupted
• Bewildered and confused, some people with delirium may become so
disoriented that they are unclear about what day it is , where they are, and
even who they are.
• Perceptual disturbance are frequent in delirium
• Visual hallucinations are common- they are not always present
• Delusions have been noted in about 25% of older adults with
delirium.
• They may also shift rapidly from one emotion to another, fluctating
between depression, anxiety, fright, anger, euphoria and irritability.
• People of any age are subject to delirium, but it is more common
among children and older adults.
• Detecting and treating delirium is of fundemental importance.
• Multiple studies indicate that delirium is a predictor of death within
six months.
• Delirium laso predicts further cognitive decline.
• Several causes of delirium have been identified:
• Drug intoxications and drug withdrawal reactions
• Metabolic and nutritional imbalances (as in diabetes, thyroid dysfunction,
kidney or liver failure)
• Neurological disorder (like dementia, head trauma)
• Stress of majör surgery
Treatment of Delirium
• Complete recovery from delirium is possible if doctors are able to promptly
treat the underlying cause
• Physicians must consider all possible reversible causes of the disorder and
then treat any of the conditions identified.
• Beyond treating underlying medical conditions, the most common
treatment is atypical antipsychotic medications.
• Because of the high rates of delirium in hospitalized older adults,
preventive strategies are recommended to delirium from starting.
• The goal is to reduce common risk factors for delirium within the hospital
setting such as sleep deprivation, immobility, dehydration and visual and
hearing impairment