Aging: Change and Adaptation Aging and Mental Health

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Aging Change and AdaptationAging and Mental
Health

• Andrea S. Schreiner PhD
• The University of Vermont
• February 15,2005

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PSYCHOLOGY OF AGING

• Cognitionattention, memory, problem-solving
• Self Personality---this includes moods and
  emotionswho 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.

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Review of Changes to the Brain and Nervous System
with aging

• I.  The Central Nervous System
• Brain
• Spinal cord

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Nervous System

• II. The Peripheral Nervous System
• Nerves afferent efferent
• III. Synapses Neurotransmitters
• norepinephrine, serotonin,
• dopamine, and the enzyme
• acetylcholine

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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

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Normal Structural Changes To the Brain and
Nervous System Related to Aging

• Decrease in cerebral blood flow, especially
• in the frontal lobes

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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

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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

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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---
35C or lower person appears confused---all
body systems slow down, heart rate,
respiration, muscle response       Hyperthermia
--- 40C 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
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2.  Motor function

• Reaction time slows down---the time between a
  stimulus and the persons response--response is
  slower but it is more accurate---
• an example of Selective Optimization with
  Compensation
• We should follow theRule of 5-second-wait
• Reflexes also slow down and there may be a slight
  tremor of the limbs with aging

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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 Memorymay 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

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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.

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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.

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• 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.     
• Syncopeis 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.

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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)
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• 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.

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• 2. Dementia ---
• There are eleven types of dementia but
  Alzheimers, 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.

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PET (Positron-Emission Tomography) SCAN
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• 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 reactivesuch 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.

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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)

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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 Depressionless severe
  symptoms but includes presence of cognitive
  impairment

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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

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Rule-Out Medical tests

• Brain ScanCT, MRI
• CBC Complete Blood Count
• BMP Basic Metabolic Profilekidney fx, liver fx,
  glucose
• Thyroid fx test
• Chest x-ray
• Tests for syphilis or HIV
• Urinalysis

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Assessment Scales

• Geriatric Depression Scalemood, affect
• Cornell Scale for Depression in Dementiamood,
  eating, sleeping, thought processes, motor
  function
• Cognitive Testing

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Neuropsych Testing

• WAIS III Test--Performance Tests like block
  design or digit span---to test attention,
  concentration, working memory
• Verbal testsvocabulary, 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

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BIOCHEMISTRY OF DEPRESSION
Therefore both emotion and cognition
potentially have a biologic substratethe
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.

•  

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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

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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 over-activity) .
Point, circulating glucocorticoid levels provide
important hormonal control of affect.
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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

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• Psychotherapy---learned helplessness
• Behavioral and cognitive approaches have better
  outcomes with older adults
• Late onset depression may be more reactive than
  melancholic

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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.
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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

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Adult Personality Development

• Personality is one aspect of the SELF stable
  over age
• Erik Eriksons Developmental Tasks or Crises
• Generativity versus Stagnation
• Integrity versus Despairimportance of life
  reflection or reminiscence
• Older persons not more prone to
• depression and anxiety but LESS

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Life Events

• Older Adults have to cope with major life events
  including
• Familychanging relationships
• Love Marriagewidowhood
• Healthchronic illness
• Finances
• Work---retirement

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Personality Inventory Factors (NEO-PI-R) Costa et
al 1986

• Neuroticism--
• Extraversion--
• Openness to experience--
• Agreeablenessincreases with age
• Conscientiousnessincreases with age

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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..

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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 whats important to you to
maintainfor your sense of QOL Compensate for
losses so you can continue to have whats
important---focus on attaining the goal in
alternate ways.
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Theres much to forgive in what I have
written the rawness, the self-consciousness,
the vanity, the folly. Im older now, but am
I wiser--or merely not so young? Miss M in
Walter de La Mares Memoirs of Midget
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