Download Aging: Change and Adaptation Aging and Mental Health

Aging: Change and Adaptation
Aging and Mental Health
Andrea S. Schreiner PhD
The University of Vermont
February 15,2005
PSYCHOLOGY OF AGING
Cognition—attention, memory, problem-solving
Self & Personality---this includes moods and emotions—
who you are---what you value---temperament, character
Social Relationships —how you relate to others, social
support groups, networks
Mental Health-- focuses on differentiating normal
changes that occur with aging as opposed to
pathological changes in each of the above areas.
Review of Changes to the Brain and
Nervous System with aging
I. The Central Nervous System
Brain
Spinal cord
Nervous System
• II. The Peripheral Nervous System
Nerves –afferent & efferent
• III. Synapses & Neurotransmitters
norepinephrine, serotonin,
dopamine, and the enzyme
acetylcholine
Normal Structural Changes To the Brain and
Nervous System Related to Aging
Anatomical Changes:
•
Increase in the size of the ventricals and
a widening of sulci resulting in some
cortical atrophy and an increase in
cerebral spinal fluid
Normal Structural Changes To the Brain and
Nervous System Related to Aging
• Decrease in cerebral
blood flow, especially
in the frontal lobes
Normal Structural Changes To the Brain and
Nervous System Related to Aging
• Decrease in number of
synaptic connections between
neurons
HOWEVER, functional changes
such as cognitive performance
among older adults have not
demonstrated similar
consistent changes.
***High Degree of Plasticity***
IN GENERAL,
• older adults experience a general
loss of neurons, slowed conduction of
nerve impulses, and loss of peripheral
nerve function that makes
maintenance of homeostasis,
recovery from stress and adaptation
to heat and cold and exercise less
quick and less complete
FIVE Functional Changes and Health Risks That Occur with Normal Aging
1. Thermoregulation
Increased risk for hypothermia and hyperthermia.
Reasons for this include changes in thyroid functioning,
loss of body fat, malnutrition, decreased activity,
certain drugs (tranquilizers, pain killers and so on).
Hypothermia--- 35°C or lower
person appears confused---all body systems slow down, heart
.
rate, respiration, muscle response
Hyperthermia --- 40°C or higher
Dizziness, weakness, nausea and vomiting, diarrhea and
headache-- As the temperature rises, the classic
symptoms of psychosis, delirium, loss of consciousness, and hot,
dry skin appear. The cardiac output decreases and circulatory failure
and death occur
2. Motor function—
• Reaction time slows down---the time between a stimulus
and the person’s response--response is slower but it is
more accurate--an example of Selective Optimization with Compensation
• We should follow the**Rule of 5-second-wait**
• Reflexes also slow down and there may be a slight
tremor of the limbs with aging
3. Memory/Cognition"Universal-Decrementalist Perspective" is false
•
•
•
•
•
TYPES OF MEMORY
"Working Memory“---declines in the ability to store and
process--- but could be related to testing time.
"Epidsodic Memory" ---declines in ability to remember past events.
“Semantic Memory“—may have improvements and there are cohort
effects
Crystallized intelligence –increases
Procedural Memory---few declines in ability to remember how to
perform motor
Again, Selective Optimization with Compensation
Cognitive Training leads to lasting improvements
Differential Diagnosis
• Physiological conditions such as brain tumors, or
metabolic, endocrine , or electrolyte disturbances, as
well as dietary insufficiencies, certain medications, and
alcoholism can effect the memory. Therefore, extensive
testing is necessary to determine the nature of any
memory deficit.
4. Sleep--the older we get the longer it
takes us to fall asleep and the
less deeply we sleep. Older persons
Have more awakenings and
less REM sleep.
• Medications such as beta blockers,
alcohol, and caffeine can inhibit sleep,
having to wake often to urinate also
reduces sleep. Establishing a regular
cycle of sleep and waking is important
as you age.
• 5. Proprioception
• Balance becomes less stable with aging, especially if the person
has visual loss. The sensation of dizziness increases with aging.
• There are 4 types of dizziness and persons with sensory loss are
most at risk for this.
Syncope—is a condition in which consciousness is briefly lost. It can
relate to orthostatic hypotension.
To prevent problems, older persons with orthostatic hypertension
should get up from seated positions slowly and be careful.
Most Common Cognitive Problems Related
to Aging
3 main types of Age-Related Cognitive disorders—
(REMEMBER the brain is VERY sensitive to changes
in metabolism or oxygen supply)

1. Delirium—
Acute condition (which means it occurs suddenly in response to a
change and is self-limiting---i.e. NOT permanent) in which the person
experiences severe confusion and possibly hallucinations as well as poor
judgement, loss of reality, and restlessness or drowsiness. Delirium can
be a reaction to medications such as anesthesia. It is a very common
occurence in older adults after surgery
(occurs in 25% of older adults who have been hospitalized). It may
also be caused by fluid-electrolyte imbalance or acid-base imbalance,
fever or even infection. There are many possible causes.
Interventions for this include making sure the person has their eye
glasses or hearing aid, explaining to them what is happening, and
explaining to the family that this is a temporary condition. Hospital staff
may confuse this with dementia if the patient has no case history.
• 2. Dementia --There are eleven types of dementia but Alzheimer’s,
Cerebral Vascular Accident (CVA or Stroke) are the most
common. These are chronic conditions related to actual
tissue (cell) damage of the brain. The symptoms are
related to the area of damage but the main characteristic
is memory loss. However, in CVA dementia there may
be other losses including functional losses such as
problems with speech and paralysis.
PET
(Positron-Emission Tomography)
SCAN
3. Depression ---relatively uncommon in older
adults --should never be considered a normal
part of aging.
There is a distinct type of depression in late life
which may be reactive—such as after NH
admission.
In general, depressive symptoms may increase
overall but to a lesser degree of severity. Late
onset depression often has a cognitive
component, some memory impairment, which
may be related to decreased blood flows or TIAs.
Stroke is related to increased depressive symptoms
Depressive symptoms are very similar to dementia
so the person is often labeled
“demented”. Again, the correct diagnosis for
these cognitive problems will involve ruling out
the possibility of physiological problems that
could affect cognition.
Prevalence of Depression and
Medical Diagnosis
• 17.1%--Lifetime
prevalence
• 1-15%---Prevalence
among older adults
• Diagnostic and
Statistical Manual of
Mental Disorders (4th
edition, revised)
Diagnostic Criteria
• During a 2 week period or more:
• Four or more of the following including either depressed
mood (most of the day) or loss of interest/pleasure:
• wt loss or gain, insomnia or hypersomnia, fatigue,
feelings of worthlessness, diminished ability to think or
concentrate recurrent thoughts of death
• Concept of Late Life Depression—less severe symptoms
but includes presence of cognitive impairment
Differential Assessment
•
•
•
•
•
•
1. identifying presenting symptoms
2. obtaining a history
3. mental status testing
4. psychological and neuropsych testing
5. coordination with medical evaluation
6. when dementia is present, identifying
the probable cause
“Rule-Out” Medical tests
• Brain Scan—CT, MRI
• CBC Complete Blood Count
• BMP Basic Metabolic Profile—kidney fx,
liver fx, glucose
• Thyroid fx test
• Chest x-ray
• Tests for syphilis or HIV
• Urinalysis
Assessment Scales
• Geriatric Depression Scale—mood, affect
• Cornell Scale for Depression in
Dementia—mood, eating, sleeping,
thought processes, motor function
• Cognitive Testing
Neuropsych Testing
• WAIS III Test--Performance Tests like block
design or digit span---to test attention,
concentration, working memory
• Verbal tests—vocabulary, comprehension, and
memory fx like recall & recognition (naming)
• Wechsler Memory Scale (WMS-III)—tests
attention/concentration, general memory, verbal
memory, visual memory, delayed recall.
Cohort effects, SES, influence outcomes
BIOCHEMISTRY OF
DEPRESSION
“Therefore both emotion and cognition potentially have a biologic substrate—the
transmission of information from one nerve cell to the another”
Neurotransmitters and neurohormones:
Serotonin (5-HT), Norepinephrine, Dopamine,
thyroid hormones as well as the
Hypothalamic-Pituitary-Adrenal Axis (HPA).
Serotonin system and the HPA --both respond to
chronic stress by changing secretion of various
neurotransmitters and hormones in the hippocampus
and hypothalamus--i.e.limbic system which is involved in sleep, appetite,
pleasure and mood control.
Stress
• Stress secretion of glucocorticoids &
cortisol from adrenal cortex these bind
to receptors in the hypothalamus where
they inhibit corticotrophin releasing
hormone and pituitary adrenocorticotropin
secretion.
• The hippocampus has an abundance of
glucocorticoid receptors which control
negative feedback
Biochemistry of Depression
IN DEPRESSION---this system changes from stress--- cortisol secretion
increases and is not controlled by normal feedback Findings in autopsy of
suicide victims show changes in the HPA system (referred to as overactivity) . Point, circulating glucocorticoid levels provide important
hormonal control of affect.
Treatments for Depression
•
Pharmacologic Therapy --Antidepressant Medications—
•
Tricyclics—
•
MonoAmineOxidase Inbitors
•
SSRIS—
Prozac (1987), Zoloft, Lexapro, Celexa, Paxil
•
It may be difficult to treat chronic depression in the older adults due to the
presence of other health problems.
•
Antidepressant medications often have many side effects such as
drowsiness, dizziness, blurred vision, dry mouth, urinary retention,
constipation, weight gain, hypotension and others.
•
ECT---Electric Convulsive Therapy
• Psychotherapy---learned helplessness
• Behavioral and cognitive approaches have
better outcomes with older adults—
• Late onset depression may be more
reactive than melancholic
Self-Mastery or Control
I have little control over the things that happen to me.
What happens to me in the future depends mostly on me." (reverse scored)
There is really no way I can solve some of the problems I have.
There is little I can do to change many of the important things in my life.
I can do just about anything I set my mind to." (reverse scored)
I often feel helpless in dealing with the problems in life."
Scoring scale: strongly agree (4) , agree (3), disagree (2), strongly disagree (1)
Mastery items from Pearlin, L.I. & Schooler, C., (1978). The structure of coping.
Journal of Health and Social Behavior. 19, 2-21.
Emotional Changes with Aging
• Mood or Affect:
• Positive mood is stable ---or may increase
• Duration of negative mood decreases
• Emotional Regulation or Control increases
with aging
Adult Personality Development
•
Personality is one aspect of the
SELF: stable over age
•
Erik Erikson’s Developmental
Tasks or Crises:
Generativity versus Stagnation
•
Integrity versus Despair—
importance of life reflection or
reminiscence
Older persons not more prone to
depression and anxiety but LESS
Life Events
• Older Adults have to cope
with major life events
including:
• Family—changing
relationships
• Love & Marriage—
widowhood
• Health—chronic illness
• Finances
• Work---retirement
Personality Inventory Factors
(NEO-PI-R) Costa et al 1986
•
•
•
•
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Neuroticism-Extraversion-Openness to experience-Agreeableness—increases with age
Conscientiousness—increases with age
Disengagement Theory
• Cumming & Henry, 1960
“Normal aging is a mutual withdrawal or
disengagement between the ageing
person and other in the social system to
which he belongs..”
The focus is really on SUCESSFUL AGING---the idea that we can do this
better and more positively “maximizing the positive, minimizing the impact
of age-related losses on QOL.”
Adaptive functioning in the face of declining resources
Baltes & Baltes (1990)
Selective Optimization with Compensation Model
Select what’s important to you to maintain—for your sense of QOL
Compensate for losses so you can continue to have what’s important--focus on attaining the goal in alternate ways.
“There’s much to
forgive in what I
have written—
the rawness, the
self-consciousness,
the vanity, the folly.
I’m older now, but
am I wiser--or merely
not so young?”
Miss M
in Walter de La Mare’s
Memoirs of Midget
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