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Chapter 15
Late Life and Psychological Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Aging: Issues and Methods

In US, many people dread aging
» Elderly not revered as in other cultures

When are we old?
» Society arbitrarily sets old as over 65

2001 census
» 12.4% or 35 million individuals were 65 or
older
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Figure 15.1 Number of Old and OldOld
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Myths About Late Life

Aging involves inexorable cognitive decline
» 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
– More brain activation in key areas when viewing positive images

Late life is a lonely time
» Some less likely to develop new friendships
» 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
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Late Life Problems

Ageism
» Discrimination against a person, young or old, based on
chronological age

Sleep disturbances increase with age
» Insomnia
» Sleep apnea

Medical treatment
» Chronic problems instead of curable disorders
» Polypharmacy
– Practice of prescribing multiple drugs to patients
– Side effects and toxicity of medications
» Psychoactive drugs usually tested on younger
participants
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Table 15.1 Age, Cohort, & Time-ofMeasurement Effects
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Research Designs

Cross-sectional studies
» Researcher tests different age groups at one point
in 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
– May extend over several years or decades
» Attrition a potential problem
– Selective mortality can lead to biased sample
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Cognitive Disorders in Late Life

Most elderly do not have cognitive
disorders
» Prevalence has decreased over last 15
years

Dementia
» A deterioration of cognitive function

Delirium
» A state of mental confusion
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Dementia

Deterioration of cognitive function
» Interferes with social and occupational functioning
» Progresses over time
– Begins with difficulty remembering recent events



Deficits can be detected before impairment
becomes obvious
Mild cognitive impairment increases risk of
developing dementia
Prevalence worldwide
» .4% of world population
» Prevalence increases with advancing age
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Alzheimer’s Disease


Described by Alois Alzheimer in 1906
Irreversible brain tissue deterioration
» Death usually occurs within 12 years

Usually begins with
» Difficulty remembering recent events
» Learning new material
» Irritability

As disease progresses
» Language problems intensify including word-finding
» Disorientation
– Time, place, and identity confusion
» Agitation
» Depression
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Brain Changes in Alzheimer’s
Disease

Plaques
» β-amyloid protein deposits
» Primarily found in frontal cortex

Neurofibrillary tangles
» Protein filaments composed of tau in cell bodies of neurons
» Primarily found in hippocampus




Measured using PET scans
Loss of synapses for Acetylcholinergic (Ach) and
glutaminergic neurons
As neurons die, atrophy of cerebral & entorhinal
cortices and hippocampus
Enlargement of ventricles
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Alzheimer’s Disease

Genetic factors
» Heritability 79%
» Early onset (before age 60)
– Dominant genes on chromosomes 21, 1, and 14 may cause
some cases
» Later onset
– Gene on chromosome 19


APOE-4 allele
Environmental factors
» Head trauma
» Depression


Strong baseline linguistic ability reduces risk
Frequent cognitive activity reduces risk
» e.g. crossword puzzles
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Frontal-Temporal Dementia



Begins in mid to late 50s
Memory not severely disrupted
Impairment of executive functions
» Planning
» Problem solving
» Goal directed behavior


Difficulty recognizing & regulating emotion
Neuronal deterioration in several areas
involving serotonergic neurons
» Amygdala, anterior temporal lobes, prefrontal
cortex, and other regions
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Vascular Dementia

Involves neurological impairment
» Weakness in limb
» Abnormal reflexes

Typically results from stroke
» Clot forms and impairs circulation
» Cells die

Risk factors
» Smoking, high LDL cholesterol, high BP

Affects African Americans more often than
whites
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Dementia with Lewy Bodies
(DLB)

Two subtypes
» With Parkinson’s
» No Parkinson’s

Symptoms similar to Parkinson’s and Alzheimer’s diseases
» Shuffling gait
» Loss of memory

Symptoms differ in that DLB patients have:
» Fluctuating cognitive symptoms
» Prominent visual hallucinations
» Intense dreams involving movement and vocalizing

Disorder involves unusual patterns of dopamine activity in
the basal ganglia
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Treatment of Dementia

Medications
» No drug reverses Alzheimer’s disease
» Some drugs produce slightly less decline
– Acetylcholinesterase inhibitors



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
Drugs that prevent breakdown of acetylcholine
» Donepezil (Aricept)
» Galantamine (Reminyl)
Vitamin E, statins, and nonsteroidal antiinflammatory 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
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Treatment of Dementia

Psychological treatments
» Supportive psychotherapy for family and
patient
» Education about disease and care
» Cognitive interventions when disease is in
early stages
– Labeling drawers, appliances
– Calendars, clocks, and strategically placed notes
» Exercise has been associated with cognitive
benefits
» Music appears to reduce agitation and
disruptive behavior
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Delirium

Clouded state of consciousness
»
»
»
»
»
»

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Extreme trouble focusing attention
Disturbances in the sleep/wake cycle
Fragmented thinking
Speech is rambling and incoherent
Disorientation
Memory impairments
Secondary to underlying medical condition
Detection of delirium important but often missed
» Untreated, further cognitive decline and mortality
may occur

Beyond treating the underlying medical
conditions, the most common treatment is
atypical antipsychotic medication
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Table 15.2 Comparative Features of
Dementia and Delirium
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Table 15.3 One-Year Prevalence Rates of
Mental Illness in Older and Younger
Generations
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Incidence Rates of Psychological
Disorders in Late Life

Psychological disorders in late life, are usually recurrences
of earlier disorder
» Most episodes of depression and anxiety are recurrences
» Schizophrenia rarely appears for the first time in late life

Rates for psychological disorders lower than in younger
populations
» May be due to:
– Cohort effects
– Reporting bias
– Selective mortality

Aging also appears to be genuinely related to better
mental health
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Medical Issues in Diagnosing
Psychological Disorders

No diagnosis if symptoms are accounted for
by medical condition or medication side
effects
»
»
»
»
»
»
»
Thyroid dysfunction
Addison’s disease
Cushing’s disease
Parkinson’s disease
Alzheimer’s disease
Hypoglycemia
Anemia and vitamin deficiencies
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Major Depressive Disorder
Low prevalence but ½ of psychiatric
admissions are for depression
 Comorbid with alcohol abuse
 Cognitive deficits more likely when
depression first appears in late life

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Etiology of Depression in Late Life

Strokes and other vascular disease
» Over 20% develop depression after myocardial infarction
» White matter hyperintensities (WMH) often present in brain and
associated with late-onset depression

Poor physical health
» Especially disabilities, such as inability to walk

Life events expected to trigger depression in late life
» Death of spouse
– Most people recover from loss
» Social isolation
– Not as much of a problem in late life as it is in mid-life
» Retirement
– Presents the greatest problem for those in ill health and with low
income
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Treatment of Depression


Depression underdiagnosed in late life
Successful treatments include:
» SSRIs
» CBT
» IPT no more successful than placebo in preventing relapse

Older adults more sensitive to side effects of medications
» Postural hypotension upon rising which may lead to fall


Drugs increase risk of heart attack and toxic reactions
Electroconvulsive therapy (ECT)
» May carry more cardiovascular and cognitive risks


Psychotherapy in the home for patients with mobility
problems
Treatment helps but difficult to restore all aspects of quality
life
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Suicide

Older adults 3x as likely to take their own lives
than younger adults
» Men
– Suicide rates increase with age from adolescence
– Older white men most likely to commit suicide

Peak age from 80 to 84
» Women
– Suicide rates peaks in 50s, then declines gradually


Major risk factor is depression
Medical screening allows for detection and
treatment even when the individual does not
present with psychological problems
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Anxiety Disorders




More prevalent than depression
GAD most common disorder
PTSD sometimes found in older war veterans
Causes of anxiety often related to life
circumstances
» Poverty
» Medical difficulties
» Social isolation

Treatments
» CBT
» Benzodiazepenes
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Delusional (Paranoid) Disorders

Paranoid symptoms present in many elderly
psychiatric patients
» Most common cause is brain disease
– Delirium or dementia
» Paranoid ideation also linked to hearing loss and
social isolation

Treatment
» Supportive and cognitive therapies
» Antipsychotic medications
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Substance Abuse and Dependence

Physiological consequences of alcohol more
intense in late life
» Tolerance for alcohol diminishes with age
– Higher blood alcohol concentration
» Older people metabolize alcohol more slowly
» Cognitive deficits caused by alcohol more pronounced
in elderly


Problems may go unnoticed because of isolation
Misuse of prescription and OTC drugs a greater
problem in the elderly
» Consume 1/3 of all prescribed medications
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Adjusting Treatment for Older Adults

Barriers to treatment
» More negative beliefs about mental illness and
treatment
» Less likely to seek treatment
– Clinicians less likely to expect successful outcome
» Less likely to be assessed and referred for treatment
» Financial barriers may prevent access

Innovative treatments
» Behavioral gerontology
» Teaching older adults to use computer
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Figure 15.2 Geriatric InterdisciplinaryTeam Role Map
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COPYRIGHT
Copyright 2009 by John Wiley & Sons, New
York, NY. 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.
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