Chapter 14 - Late Life and Neurocognitive Disorders Flashcards
1
Q
social selectivity
A
interests shift from seeking new social interactions to cultivating a few social relationships that matter to us
2
Q
polypharmacy
A
prescribing of multiple drugs to a person
3
Q
age effects
A
consequences of being a certain chronological age
4
Q
cohort effects
A
consequences of growing up during a particular time period with unique challenges and opportunities
5
Q
time of measurement effects
A
confounds that arise because events at a particular point in time can have a specific effect on a variable that is being studied
6
Q
selective mortality
A
when people are no longer available for follow up due to death
7
Q
angina
A
congestive heart failure
8
Q
vestibular system
A
inner ear control of one’s sense of balance
9
Q
dementia
A
descriptive term for the deterioration of cognitive abilities to the point that functioning becomes impaired
10
Q
disorientation
A
confusion with respect to time, place or identity
11
Q
Alzheimer’s disease
A
brain tissue irreversibly deteriorates, death within 12 years
12
Q
plaques
A
small, round, beta-amyloid protein deposits outside neurons
13
Q
neurofibrillary tangles
A
twisted protein filaments composed largely of the protein tau in the axons of neurons
14
Q
smoking single depressed low social support
A
lifestyle variables of alzheimer’s
15
Q
cognitive reserve
A
the idea that some people may be able to compensate for the disease by using alternative brain networks or cognitive strategies such that cognitive symptoms are less pronounced
16
Q
frontotemporal dementia
A
caused by a loss of neurons in frontal and temporal regions of the brain impairment in empathy, executive function, inhibition, compulsion, hyperorality and apathy
17
Q
executive function
A
cognitive capacity to plan and organize
18
Q
hyperorality
A
tendencies to put nonfood objects in the mouth
19
Q
pick’s disease
A
characterized by the presence of spherical inclusions within neurons
20
Q
tau
A
protein filaments that contribute to the neurofibrillary tangles observed in Alzheimer’s disease
21
Q
vascular demenia
A
dementia is a consequence of cerebrovascular disease
22
Q
Dementia w/ Lewy bodies
A
include prominent visual hallucinations and fluctuating cognitive symptoms
23
Q
cholinesterase inhibitors
A
drugs that interfere wit hthe breakdown of acetylcholine
24
Q
delirium
A
being off track or deviating from the usual state extreme trouble focusing attention profound disturbances in the sleep/wake cycle
25
delusions
beliefs contrary to reality
26
What are the 3 groupings of ageing, defined by gerontologists?
\*65-74 years = the young-old \*75-84 years = the old-old 85 and above = the oldest-old
27
When considering social attitudes to ageing, what is the main difference between Eastern & Western Cultures?
In Eastern Cultures older people are held in high esteem whereas, in Western Cultures, growing old tends to be feared, or even abhorred by many. This is especially true for women in Western Cultures.
28
Name some of the common myths about ageing.
\*we will become doddering and befuddled \*We will become unhappy, cope poorly with our troubles, and become focused on our poor health \*We will become lonely and our sex lives will become unsatisfying
29
What are some of the findings specific to cognitive functioning from research into ageing that might suggest a more positive future?
Severe cognitive problems do not occur for most people, though a mild decline in cognitive functioning is common
30
What are some of the findings specific to emotional regulation from research into ageing that might suggest a more positive future?
\*Elderly (60 years +) experience less negative emotion than do young people \*The Elderly are more skilled at regulating their emotion
31
What are some of the findings specific to pain from research into ageing that might suggest a more positive future?
Many older people under report somatic symptoms, perhaps because of beliefs that aches & pains are an inevitable part of late life
32
What are some of the findings specific to sexual activity from research into ageing that might suggest a more positive future?
Older people have considerable sexual interest & capacity Among those with a partner, most who are in good physical health remain sexually active
33
Which myth does the phenomenon of Social Selectivity challenge?
Social Selectivity challenges the myth that older people are lonely and socially isolated \*The number of social activities engaged with is unrelated to psychological well-being among older people
34
What is the reality of social selectivity?
\*When we have less time ahead of us, we tend to place a higher value on emotional intimacy than on exploring the world. \*the tendency to preference time with closest ties rather than acquaintances
35
What could social selectivity be mistaken for?
To those unfamiliar with the age-related changes, social selectivity could be mistaken for harmful social withdrawl
36
What is a common prejudice about the elderly held by many people?
That all old people are the same \*Each older person brings to late life a developmental history that make his or her reactions to common problems unique
37
"Late life would qualify as the Olympics of coping" - why is this?
\*Physical decline & disabilities \*Sensory & neurological deficits \*Loss of loved ones \*The cumulative effects of a lifetime of many unfortunate experiences \*Social Stresses such as stigmatising attitudes towards the elderly
38
As people age they experience problems with sleep. What are the main issues?
\*quality & depth of sleep declines \*by the age of 65, 25% of people report insomnia \*Rates of sleep apnoea also increase with age \*Insomnia is often caused by medication side effects \*Untreated chronic sleep deficits can worsen physical, psychological, & cognitive problems, even increasing the risk of mortality \*However, psychological treatments have been shown to reduce insomnia successfully among the elderly.
39
Several problems are evident in the medical treatment available during latest life. What are some of the general issues older people face?
\*Chronic health problems generally continue \*Doctors often get frustrated when there is no cure \*There is added time pressure on the health system
40
What are some of the issues specific to medication faced by older people?
\*Polypharmacy: the prescribing of multiple drugs - approximately 1/3 of elderly people have 5 or more prescription medications \*Multiple drugs increase the risk of side effects, toxicity, & allergic reactions \*people may then be prescribed side effects meds \*Most psychoactive drugs are tested on younger people - older people have slower metabolic rate, requiring a different dose \*1/5 of elderly people have filled prescriptions deemed inappropriate for their age range due to side effects
41
What should GP's ensure they do when treating older patients?
\*It is essential to have regular medication reviews, discontinue non-essential drugs and prescribe only minimum required dose
42
What are 3 key factors that must be taken into account when designing research for elderly clients?
\*Age effects \*Cohort effects \*Time of Measurement effects
43
What are age effects?
Age effects are the consequences of being a certain chronological age
44
What are cohort effects?
Cohort effects are the consequences of growing up during a particular time period with it's unique challenges and opportunities. e.g. the Great Depression, WWI or WWII, 9/11 each shape experiences and attitudes \*Similarly, the expectations for marriage have changes drastically in the past century in Western societies from a focus on stability to a focus on happiness & personal fulfilment
45
What are time-of-measurement effects?
Time of Measurement effects are the confounds that arise because events at a particular point in time can have a special effect on a variable that is being studied. e.g. people tested right after Hurricane Katrina in New Orleans might demonstrate evalated levels of anxiety
46
What are the 2 major research designs used to assess developmental change?
\*Cross-sectional \*Longitudinal
47
What are the key characteristics and disadvantages in Cross-sectional research designs?
Characteristics: The investigator compares different age groups at the same moment in time on the variable of interest Disadvantages: \*these studies do not examine the same people over time; consequently, they do not provide clear information about how people change as they age
48
What are the key characteristics, advantages and disadvantages in Longitudinal research designs?
Characteristics: The researcher periodically retests one group of people using the same measure over a number of years or decades Advantages: \*allow us to trace individual patterns of consistency or change over time Disadvantages: \*Results can be biased by attrition where participants drop out due to death, illness, lack of interest \*People with the most problems are likely to drop out of studies
49
What are the learnings from the Baltimore Longitudinal Study of Ageing which has followed 1,400 people since 1958?
\*Much has been learned about mental health and ageing \*people who are happy at 30, tend to be happy as they move to late life
50
In the context of research design, what is selective mortality?
Selective mortality is the tendency for less healthy individuals to die more quickly leading to sample bias in the long term follow up studies \*Results obtained with the remaining sample are more relevant to drawing conclusions about relatively healthy people than about unhealthy people.
51
Why is it especially important to be careful before diagnosing an older person with a psychological disorder from the DSM5?
DSM5 states that a psychological disorder should not be diagnosed if the symptoms can be accounted for by a medical condition or medication side effect \*medical conditions are more common in the elderly, so it is particularly important to rule out such explanations.
52
What are some of the medical conditions that can produce symptoms that mimic schizophrenia, depression, or anxiety?
\*Thyroid problems \*Addison's Disease \*Cushing's Disease \*Parkinson's Disease \*Alzheimer's Disease \*Hypoglycaemia \*Anaemia \*Vitamin deficencies
53
What are some of the medical conditions that can produce symptoms that mimic anxiety specifically?
\*Angina \*Congestive Heart Failure \*Excessive Caffeine Consumption
54
What are some of the medications that can contribute to symptoms of depression and anxiety?
\*Anti-hypertensive medication \*Hormones \*Corticosteroids \*Anti-Parkinson medications
55
What are the findings of prevalence estimates of psychological disorders in late life?
People over 65 years of age have the lowest overall prevalence of mental disorders of all the age groups \*every single disorder was less common in the elderly than the young \*Most people over the age of 65 are free from serious psychopathology
56
When considering the incidence rate for psychological disorders in late life, what are the main conclusions?
\*Most people who have an episode of a psychological disorder late in life are experiencing a recurrence of a disorder that started earlier in life rather than an initial onset. \*On exception is late life onset is more common for alcohol dependence among older adults with drinking problems.
57
What are the theories to explain why the rates of psychopathology is so low in late life?
\*Some argue that methodological issues might be leading us to underestimate the prevalence of psychological disorders (response bias, cohort effects, & selective mortality) \*There may also be some processes related to ageing that promote better mental health
58
What are the 3 methodological explanations that might skew our belief that the rates of psychopathology is so low in late life?
\*response bias: Older adults may be uncomfortable discussing mental health or drug use \*cohort effects: People who were adults in the drug-using 1960's might continue to use drugs as they age \*selective mortality: People with mental health issues are at risk of dying before the age of 65 years
59
What accounts for most hospital admissions and inpatient days than any other geriatric condition?
Although most elderly people do not have cognitive disorders, cognitive disorders account for more hospital admissions and inpatient days than any other geriatric condition
60
What is Dementia?
Dementia is a descriptive term for the deterioration of cognitive abilities to the point that functioning becomes impaired.
61
What are the main symptoms of Dementia?
\*Difficulty remembering things, even recent events \*inability to recognise their own children \*Hygiene may become poor \*May get lost \*Judgement becomes faulty \*Dis-inhibition: course language, inappropriate jokes, shoplift, sexual advances to strangers \*Loose ability to deal with abstract concepts \*Emotional disturbances become regular \*Delusions and hallucinations can occur \*Language disturbances \*Trouble recognising familiar things \*Delirium (mental confusion) may occur
62
How does dementia progress?
The course of dementia may be progressive, static, or remitting, depending on the cause \*Most dementias develop very slowly over a period of years, subtle cognitive & behavioural deficits can be detected well before the person shows any noticeable impairment.
63
What are the early signs of dementia known as?
The early signs of decline noted before functional impairment is present have been labelled as mild cognitive impairment.
64
Why is it important to be cautious about diagnosing these early signs of decline?
\*Not all people with mild cognitive symptoms go on to develop dementia. \*10% of adults with a mild cognitive impairment will develop dementia; whereas 1% of adults without mild cognitive impairment will develop dementia \*Do not assume all symptoms will progress
65
What is the world wide prevalence of dementia?
\*overall about 0.4% in the year 2000. \*in people aged 60-69 years = 1-2% \*in those over 85 years = 20%
66
Name 4 types of dementia
\*Alzheimer's disease (most researched) \*Frontaltemporal dementia (frontaltemporal areas of brain are most effected) \*Vascular Dementia (caused by cerebrovascular disease) \*Dementia with Lewy bodies (abnormal deposits on neurons)
67
What happens to the brain in Alzheimer's disease?
The brain tissue irreversibly deteriorates and death usually occurs within 12 years after the onset of symptoms
68
What are the main symptoms at the onset and through the progression of Alzheimer's disease?
\*Begins with absent-mindedness & difficulties concentrating \*Problems with language skills & word finding \*Spatial ability declines leading to disorientation NB: Sufferers are usually unaware of their problems initially \*Memory deteriorates further with increased disorientation & agitation. \*Sufferers tend not to recognise people in their family and become wholly dependent on others for care. \*about 1/3 of people develop full blown depression as the illness worsens.
69
What are some of the brain changes for people with Alzheimer's disease?
People with Alzheimer's disease have more: \*Plaques - small round beta-amyloid protein deposits that are outside the neurons \*Neurofibrillary tangles - twisted protein filaments composed largely of the protein tau in the axons of neurons. Some people also have either excessive amounts or deficiencies of beta-amyloid from the brain
70
For people with Alzheimer's disease, the plaques & tangles appear to be related to a host of brain changes over time. What are some of the early stages experienced in the neurons of the brain?
\*There seems to be a loss of synapses for acetylecholinergic (ACh) & glutamatergic neurons \*Neurons begin to die
71
For people with Alzheimer's disease, the plaques & tangles appear to be related to a host of brain changes over time. What are the 3 areas of shrinkage in the brain?
\*the cerebral cortex \*the entorhinal cortex \*the hippocampus all shrink initially
72
For people with Alzheimer's disease, the cerebral cortex, entorhinal cortex & hippocampus all shrink initially. What are the next 3 areas of shrinkage in the brain?
Later the \*Frontal \*Temporal \*Parietal lobes shrink
73
After the 6 areas of brain shrinkage, what is the area that become enlarged?
\*The Ventricles become enlarged
74
For people with Alzheimer's disease, there are some areas of the brain that remain largely unaffected, which is why people do not appear to have anything physically wrong with them until later in the disease. What are these areas?
\*The Cerebellum, \*spinal cord, and \*motor & sensory areas of the cortex remain largely unaffected
75
Based on the largest Alzheimer's twin study, what is the heritability estimate for Alzheimer's?
approximately 79% so, about 79% of the variance in onset of Alzheimer's appears related to genes, and about 21% of the variance appears to be related to the environment.
76
Some genes on chromosome 19 has been found to display particular properties for some cases of Alzheimer's. What are the genes, and what are the increased risk of Alzheimer's associated with the presence of the allele?
\*Apolipoprotien ε4 or ApoE-4 allele \*Having 1 allele increases the risk to 20% \*Having 2 alleles brings the risk substantially higher \*people with 2 alleles show overproduction of beta-amyloid plaques, loss of neurons in the hypocampus, & low glucose metabolism in several regions of the cerebral cortex before they develop symptoms of Alzheimer's disease. \*GAB2 is another gene that seems to effect risk of Alzheimer's but less is known about it.
77
Lifestyle factors are also thought to influence the development of Alzheimer's disease. What are some of the factors that increase the risk and some factors which decrease the risk of developing Alzheimer's disease?
Factors that increase the risk: \*smoking, being single, depression, low social support Factors that decrease the risk: \*Mediterranean diet, exercise, education, cognitive engagement
78
What two key factors are thought to be most protective in terms of guarding against the development of Alzheimer's?
\*Exercise is thought to ward off memory problems \*Engagement in intellectual activities: "use it or lose it" attitude. NB a comparison of people with similar levels of plaques & tangles found those with higher cognitive activity showing fewer negative cognitive symptoms.
79
What are the key properties of Frontotemporal Dementia (FTD)?
\*FTD is caused by a loss of neurons in frontal and temporal regions of the brain. \*The neuronal deterioration of FTD occurs mainly in the anterior temporal lobes & prefrontal cortex \*FTD typically begins in the mid-late 50's \*It's progress is rapid, death usually occurs within 5-10 years of diagnosis
80
What is the diagnostic criteria for Frontotemporal Dementia (FTD)?
Deterioration in at least 3 of the following areas at a level that leads to functional impairment: \*empathy \*executive functioning (ability to plan & organise) \*ability to inhibit behaviour \*compulsive behaviour \*hyperorality (put non-food stuffs in mouth) \*apathy
81
What are the key differences between Frontotemporal Dementia (FTD) & Alzheimer's disease?
\*Unlike with Alzheimer's Memory is not severely impaired in FTD \*Emotional processes are more profoundly effected in FTD than with Alzheimer's disease \*People with FTD have more strained interpersonal relationships as a result of changes in emotional processing: social relationships & marriages can be damaged e.g. those with FTD fail to show embarrassment facially or in their psychophysiology
82
What is thought to cause Frontotemporal Dementia (FTD)?
It is increasingly clear that FTD can be caused by many different molecular processes. e.g. Pick's disease which is characterised by the presence of Pick bodies (spherical inclusions) within neurons. \*There is a strong genetic component for FTD, though there maybe multiple genetic pathways involved \*Some people with FTD show high levels of Tau (the protein filaments that contribute to the neurofibrillary tangles observed in Alzheimer's \*Other diseases or pathological processes can result in FTD
83
What is Vascular Dementia the main consequence of?
\*Cerebrovascular disease \*Most commonly the individual has a series of strokes, in which a clot is formed, impairing circulation, & causing cell death.
84
What percentage of people will develop Vascular Dementia in the year after the first stroke?
About 7%, with the risk increasing with recurrent strokes
85
What are the risk factors for Vascular Dementia?
The risk factors are the same for cardiovascular disease i.e. high levels of bad/LDL cholesterol, elevated blood pressure & smoking \*Strokes are more common in African-Americans than Caucasians
86
How does Vascular Dementia manifest?
\*Because strokes & cardiovascular disease strike different regions of the brain, the symptoms can vary a great deal. \*The onset of symptoms is usually more rapid in Vascular Dementia than other forms of dementia \*Vascular Dementia can co-occur with Alzheimer's Disease
87
What are the main treatments for Dementia?
\*There is no cure for dementia \*Drug therapy can provide a modest protection against cognitive decline \*effects from vitamin E, statins, Nonsteroidal anti-inflammatory drugs have tiny benefits \*Research into the classification of biological markers of disease before symptom onset will facilitate the next generation: important markers included are signs of plaques, tangles, & neuronal death
88
How are medications currently treating the symptoms of Alzheimer's Disease?
\*Medications are used to treat the psychological symptoms: depression, apathy and agitation. \*Anti-psychotic medication can provide modest relief for aggressive agitation, but increases the risk of death. \*Medications can help slow it but they cannot restore cognitive decline \*Cholinesterase inhibitors interfere with the breakdown of acetylcholine and slow down memory decline. e.g.s donepezil (aricept) and rivastigmine (exelon) \*Memantine (Namenda) is a drug that affects glutamate receptors (thought to affect memory) has shown small benefits.
89
What other treatments are there for people and the families of people with Alzheimer's Disease or other types of dementia?
\*Supportive psychotherapy can help \*Exercise appears to have modest benefits \*Behavioural approaches to help compensate for memory loss and to reduce depression & disruptive behaviour (e.g. shopping lists, calendars, labels)
90
What is Delirium?
\*The term delirium literally means "out of track" \*The term implies being off-track or deviating from the usual state & is usually described as a clouded state of consciousness \*The 2 most common symptoms are extreme trouble focusing attention and profound disturbances in the sleep/wake cycle
91
What are the proposed DSM criteria for Delirium?
\*Disturbance in attention & awareness \*A change in cognition, e.g. language, orientation, memory, perception, planning, not better accounted for by a dementia \*Rapid onset (usually within hours or days) during the course of a day \*Symptoms are caused by a medical condition \*Fluctuation
92
Describe a typical presentation of delirium
\*people with delirium rather suddenly cannot maintain a coherent stream of thought as they cannot focus \*People become agitated at night and sleepy during the day as their sleep/wake cycle is disturbed \*They may be impossible to engage in conversation due to wandering attention, & fragmented thinking \*They may be unclear what day it is, where and even who they are \*Memory impairment is common People can have lucid intervals within the course of a delirium state Perceptual disturbance is common: they may think they are at home when they are in hospital \*Visual hallucinations are common as are delusions
93
How are mood and activity affected by delirium?
\*People with delirium can have swings in activity and mood. \*They can be erratic, sitting lethargically then suddenly ripping at their clothes \*Their emotions can shift swiftly: depression, anxiety, fear, anger, euphoria, and irritability can all be experienced in quick succession. \*Fever, flushed face, dilated pupils, tremors, rapid heartbeat, raised blood pressure and incontinence are all common
94
Who is prone to developing delirium?
\*People of any age are subject to delirium \*it is more common in children and older adults \*it is particularly common in nursing homes and hospitals \*Delirium is often misdiagnosed
95
We know delirium is caused by medical conditions. What is the etiology of delirium?
\*Drug intoxication & drug-withdrawal \*Metabolic & nutritional imbalances \*Infections or fevers \*Neurological disorders (head trauma / seizures) \*Stress from major surgery \*There is usually more than one cause
96
Why is Delirium more common in older people?
\*the physical declines of late life \*increased susceptibility to chronic diseases \*multiple medications \*greater sensitivity to medications \*Brain damage and dementia also greatly increase the risk of delirium
97
What is the most effective way to treat Delirium?
\*prompt treatment of the underlying cause(s) is the best method \*All possible reversible causes of the disorder need treating (such as drug intoxication, fever, infections, malnutrition). \*Atypical Anti-psychotic medication is also used to treat delirium \*Delirium is usually cleared up within 1-4 weeks, taking longer in older people
98
What are some of the preventative strategies for treating delirium?
Ensuring the following are treated on arrival to hospital/institution: \*sleep deprivation, immobility, dehydration, & visual/hearing impairments \*Medical rounds are scheduled for later in the morning to avoid waking patients \*Family members of those with delirium should be encouraged to learn the symptoms & understand it is reversible and not to be confused with dementia
