chapter 32-end Flashcards
robert butler- middle adulthood (40-65)
aging
taking stock of accomplishment and setting goals for future.
reassessing commitments to family, work, and marriage.
dealig with parental illness and death
attending to all developmental tasks withou losing capacity to experiene pleasure
george valliant- factors correlating with emotional well being in middle adulthood
physical health
psychosocial adjustment during college years
stable parental home
close sibling relationship durng college years
capacity to work during chilhood
climacterium
during middle adulthd- decreased biological and hysiological functioning-womes menopause (40-55),
male’s hormones stay constant at 40-50, and then begin to decline, a derease in healthy sperm and seminal flid
Paul Bhannan- types of separation at divorce
psychic divorce- recovery takes 2 years legal divoce- 75%(W) and 80%(M) marry within 3 years economic divorce community divorce coparental divorce
life expectancy
M= 77.4, F= 82.2
predictors for longevity
heriditary- 50% of fathers to people over 80 also lived past 80
other predictors- regular checkup, minimal caffeine and alcohol, work gratification and perceived sense of self as being useful, eating healthy, exercise
changes in causes of death -CVA, MI
60% decline in mortality fromm CVA, 30% in coronary
leading causes of death among older people
heart disease, cancer, stroke
also accidents are prevalent- e.g. falls- most commonly resulting from hypotension or arrythimia
M:F ratio with age(per 100 females)
55-64: 92
65-74- 83
75-84- 67
85< - 46
alcohol , salt, statins and longevity
1 oz =30 ml of alcohol a day reduce HDL and correlate with longevity
salt less than 3 gr- reduce hypertension
statins reduce CV disease in diet and exercise resistant hyperlipidemia
aging changes- neurons
degenaeration mainly in superior temoral ,precentral and inferior temporal gyri.
no loss in brainstem nuclei
aging- cellular changes
increased collagen and elastin
altered receptor sites and sensitivity
deacreased anabolism and catabolism of cellular transmitter substances
immune changes in aging
increased autoimmune,
leukocytes unchanged but reduced T lymphocytes and their response
increased ESR
usculoskeletal changes in aging
2 inch loss of height from second to 7th decade
slongation of nose and ears
deepening of thoracic cage
risk of hip fractue at age 90- 10-25%
weight changes - aging
men gain till 60, then lose
women gain till 70, then lose
crainal sutures closure- aging
parietomastoid suture does not attain complete closure until age 80
grey hair- aging
by age 50, 50% of people are 50% grey/
caused b loss of melanin
vision- aging
thickening and yellowing of optic lens
reduced peripheral visio and accomodation (presbyopia)
decreased light-dark adaptation
reduced acuity of all senses
hearing loss- aging
high frequency hearing loss (presbyacusis): age 60- 25% 65- 30% 75- 50% by age 80- 65%
neuropsychiatric- aging
slowed learning new material, but still complete learning
IQ stable till 80
verbal ability maintained
decreased psychomotor speed
memory- aging
difficult to shift attention
encoding and simple recall diminish
recognition remains intact
neurotransmitters -aging
decreased NE and increased MAO and serotonin
brain changes - aging
17% decrease of brain weight by 80
wide sulci, smaller convolutions, gyral atrophy
enlarged ventricle
increased transport in BBB
decreased cerebral blood flow and oxygenation
cardiovascular- aging
increased in size and weight- lipofuscin
decreased valvulaar elasticity
cardiac output maintained in absence of coronary heart disease
GI- aging
risk for atrophic gastritis, hiatal hernia, diverticulosis
diminished saliva flow, constipation, reduced gi absorption
endrocrine changes- aging
reduced androgens and estrogen
increased LHm FSH inpostmenopause
T4, TSH normal, decreased T3
glucose tolerance test results decrease
respiratory functions- aging
decreased VC , cough reflex and bronchial ciliary action
stable personality traits
agreableness ,conscientiousness, openness to experience, neuroticism, extroversion,
A CONE
may increase agreeblenss and decreased extroversion(first letter, last letter)
aging- erik erikson
integrity(sastisfaction of past life) vs despair
contenment comes with getting beyond narcissism and into intimacy and generativity
George Vaillant - correlates of emotional health at 65
having close brothers and sister during college and developing traits of pragmatism and dependabilityin young adulthood predict well being
deression between 21-59 -emotional problems
early traumatic experiences did not crrelate with oor adaptation
top 10 chronic conditions in 65+
arthritis hypertension hearing loss heart disease cataract orthopedic deformities and problems chronic sinusitis diabetes visual loss varicose veins
depression in the elderly
less depression and dysthymia than youner
suicide rate in the elderly
high- 40/100,000
women perceived as mentally adn men as physically ill
alzheimer heredity
autosomal dominant in 10-30%
among the elderly who consider suicide- what is the most common reason
loneliness
mental morbidity among patients who commit suicide
75% had depression and/or alcohol
methodist episcopelian
tests broca aphasia
cant demnstrate use of simle objects(key, match ets)
ideomotor apraxia
test wernickes aphasia
naming objects
visuospatial functioning in the elderly
some decline
loss of abstract thinking
ma be an early sign of dementia
immediate retention and recall
6 digits forwards, 5-6 digits backwards in normal people
but can be impaired also in anxiety
effects of age and education on MMSE
can affect results (pg 1344)
effects of depression on psychomotor performance
impaired visuospatial and timed motor performance
tests for visuospatial functions
Bender Gestalt test
Halstead-Reitan Battery(covers entire spectrum of information processing and cognition)
most common psychiatric disorders in the elderly
depression, cognitive disability,alchol, phobia,
DeCAP
prevalence of dementia
5% above 65 -severe dementia, 15%- mild dementia
20% above 80 have severe dementai
delusions and hallucinations in dementias
75% of patients
treatable dementias
10-15%
subcortical dementias
NPH, wilson, huntington, parkinson, casculat
characteristics of subcortical dementia
movement dis,gait apraxia, psychomotor retardation, akinetic mutism, apathy
characteristics of cortical dementias
aphasia, agnosia, apraxia
prion disease- mutation
prion protein gene- PRNP- can be inherited, acquired, sporadic
types of prion diseases
autosomal dominant: CJB, gertsmann- straussler- scheinker, fatal familial insomnia
kuru- cannibalism and implantations(cornea, GH, gonadotropin)
CJD- 85% sporadic. 1/milion/year, mean age of onset- 65
depression among the elderly
15%
risk factors for depression in the elderly
not age!
widow, chronic illness.
recurrence in late onset depression
commn
common features in geriatric depression
melancholic features, somatic, hypochondriasis, sleep problems- early awakening and multiple awakenings. low self esteem, self accusations (especially about sex and sinfullness), paranoid and suiciadal ideation
pseudodemntia among depressive elderly
depression among dementia patients
15% pseudodementia among depressives
25-50% depression among dementia patients
schizophrenia in the elderly
among early onset schizohprenics- 20% show no active symptoms by age 65. the rest- varying impairments.
30% of all schizophrenics are residual- need chronic care.
late onset- usually paranoid type, more woman.
delusional disorder in the elderly
age of onset- usually 40-55. most comon-perseutory
in one study of 65 yo and older- 4% had persecutory ideation
paraphrenia
lateonset delusional disorder, typically persecutory. not associated with dementia
prevalence of anxiety among the elderly
5.5% in 1 month.
4-8% most common-phobia.
panic- 1%
rect more severly to PTSD
percentage of chronic disorders among persons over 60
80%(usually arthritis and CV disease)
alcohol dependence in nursing homes
20%
percentage of alcohol and substance dis of emotional problems among the elderly
10%
OTC among the elderly
35%-70%, and 30% use laxatives. rule out when examining symptomotoligy
the single most importat factor associated with increased prevalence of sleep diso
advanced age
most common sleep dis. among the elderly
dyssmonias, especially: primary insomnia, nocturnal myoclonus, restless leg syndrome, sleep apnea.
parasomnias that almost exclusively iccur among the elderly
REM sleep behavior disorder
effects of alcohol on sleep
fragmantation, early awakening, aggrevate apnea
sleep changes in people over 65
REM: redistribution throughout the night: more REM period, but shorter and less total REM sleep
NREM: decreased delta amplitude, lower stage 3 and 4, higher 1 and 2
low amplitude of circadian rhythm, 12 hour sleep propensity ryth, shorter cycles. ,
suicide among the elderly
the highest than any population. rate for white men over 65- time 5 than general population,
1/3 report loneliness as a reason for considering suicide
10 of those with suicidal ideation report financial problems, poor mecial health, depression for reason.
suicide victims vs suicide attempts
60% of those who commit suicide- men.
75% of those who attempt- woman
among those who succeed- usually guns or hanging
among attemters- 70% -drug OD, 20%- cut,
precipitants for suicide
most common preciitants are physical illness and loss.
most who commited suicide had a mental dis, especially depression
more of them are widowed, and few re single/divorced/separated(as opposed to younger adults)
most common suicide precipitants among oung adults
problems with employment, finances and family relationships
do the elderly communicate about their suicidal ideation
most ofsuicide victims communicate their thought with family or friends before commiting the act
elder abuse
10%
study of psychotherapy in an old age home
less urinary incontinence, improved gait, greater mental alertness, improved memory, better hearing
Bernice Neugarten major conflict of old age
giving up position of authority , evaluating achievements. reconciliation with others. resolution of grief over the death of others and approaching death
Daniel levinson
between 50-55 transition with developmental crisism person feels incapable of changins intolerable life structure
“late adult transition”- ages 60-65, narcissists and those too invested with body appearenceare liable to become more reoccupied with death.
creative mental activity is a normal substitute for reduced physical activity
second and third individuation
second individuation- when adolescents leave their parents
third- continues through adulthood
cavin colarusso and robert nemiroff
adult developmental process same as child, but child develops psychic structure, and adult continues evolution of existing structure.
trailmaking part A
information processing speed; rapid graphomotor tracking
WAIS digit symbol
information processing speed-rapid graphomotor tracking
stroop A, B
information processing speed- rapid word reading and color naming
finger tapping
motor dexterity:right and left finger dexterity
boston naming test
word retrieval
WAIS picture completion
visual perception
WAIS block design
construction ability
Rey-Osterieth Complex Figure
visuospatial- paper and pencil copy og complex design
Beery developmental test of visual motor integration
paper and pencil copy of simple to complex designs
logical memory subtest
immediate and delayed recall of visual designs
Rey-Osterieth Complex Figure 3 minute delyed recall
delayed recall of complex design
trailmaking part B
executive functions- rapid alterations between tasks
stroop C
exectuive functions- inhibition of an overlearned response
wisconsin card sorting test
executive functions- categorization and mental flexibility
design fluency
executive functions- rapid generation of novel designs
verbal fluency
executive functions- FAS and category- rapid word generation
brain death evaluations
0-2 months- 48hr interval, two cofirmatory tests
2-12 months- 24 hr interval, one confirmatory test
1-18 yrs- 12 hr interval , confirmatory test- optional
above 18- optional ,confirmatory test- optional
examples of brain death clinical criteria
absence of pupilary response to light, uils at midposition with respect to dilatation (4-6 mm)
absence of respiratory drive at paCO2 60 mm HG or higherm or 20 mm HG above normal baseline
coma
and more
causes of death amng the young
half of 1-14, and 75% of late adolescence and early adlthood- from accidents, homicides and suicides
preschool attitude to death
preoperational.
death is seen as a temporary absence, incomplete and reversible , like departure or sleep.
the main fear is seperation from care taker. - a fear that surfaces iin nightmaresm aggressive play, concern about death of others.
terminally ill preschoolers- may assume responsibility for their illness, as a unishment, and family seperation as rejection
school age attitude to death
concrete operational. recognize death as a final reality, but think it happens to old people only
between ages 6-12- active phantasies of violence, aggression, often dominated by themes of death and killing.
grief
צער
subjective feeling precipitated by the death of a loved one
Mourning
אבל
the process by which grief is resolvedm a societal expression of post bereavemtn behavior
bereavement
שכול
the state of being deprived of someone by death and refers to being in the state of mourning
normal stages of response to loss
shock and denial- minutes-weeks- disbelief, numbness, protest, and then searching behaviors, yearning
acute anguish- weeks-months- somatic distress, withdrawal, preoccupation, anger, guilt
lost patterns of conduct- restless and agitated, aimless and amotivational, identification with the bereaved
resolution- months, years- returns to work, old rules, reexperience pleasure, seek companionships.
most lasting manifestation of grief, especially after spisal death
loneliness
grief process
length varies, usually 6 -12 months.
may have waves, can reemerge later with triggers
anniversary reaction
reemergance of grief at date of death, or when the bereaved reaches the age of the deceased when he died.
patterns of complicated bereavement
chronic, hypertrophic, delayed
chrnoic grief
most common of complicated bereavement.
.bitterness, idealization
occurs when dependant/very close/ambivalent relationship and when social supports lacking, no friends to share surrow
hypertrophc grief
usually after sudden death. bereavemt. reaction is intense, withdrawal. can disrupt family. frequently long term
delayed grief
prolonged denial, anger and guilt may complicate it’s course
traummatic grief
combined hypertrophic and chronic grief.
recurrent intense pangs of grief, persistent longing, intrusive images, avoidance and preoccupation with reminders of loss.
positiive memories often are blocked
a history of pschiatric illness is comon , as is a very close identity-defining relationship with the deceased.
(note- in DSM 5-it is s pecifier for complex bereavemtn regarding bereavement after violent death (e.g. suicie, homicie)
mortality assocaited with bereavement
highest after bereavement, especially from IHD.
greatest effect on mortality- men under 65
.
risk for death among widows
cirhosis and suicide increase
effect of bereavement on health behavior
increased alcohol consumption, smoking, use of OTC medications.
mental effects of bereavement
MDD, suicide, alchohol, smoking and drugs, prolonged anxiety,panic and PTSD like symptoms
biological effects of grief
impaired immune fuctions, decreased lymphocyte proliferation, impaired function of NK cells
grief therapy
one on one , group or self help.
30% of widows and widowers report becoming isolated after loss- grief therapy most useful for them
mourning in chldren
o-2 years: loss of sepach, diffuse distress
younger than 5- eating, aleeping and bowel and bladder dysfunction.
school aged- phobic, hypochondriac, withsrawan, pseudomature, reduced skill performance and peer relations
dolescents- behavioral problems, somatic symptoms, arratic mods, stoicis. boys- delinquent, girls- sexual
rates of depression in bereaved children and adolescents is as high as bereaved adults.
bereavement vs MDD
in bereavement- no guilt/worthlessesssuicidality/psychomotor retardation.
dysphoria triggered by reminders of deceased
onset within 2 months, and duration up to 2 months, only mild and transient functional impairment, no family or personal history of MSS
criterion A and B in persistent complex bereavement disorder
a. death of someone close
b. 1/4 for 12 months(adult( or 6 mnths(child):
1. persistent yearning .longing
2. intense surrow
3. preoccupation with the deceased
4. preoccupation with circumstances of the death
criterion C persistent complex bereavement disorder
6/12 for 12 months (adults), 6 mos(child)
1. difficulty accepting death
2. disbelief/emotional numbness
3.difficulty with positive reminisicne
4.bitterness or anger
5. maladaptive appraisals about death(e.g. self blame)
excessive aviodance of remininding.
7. desire to die to join with the deceased
8, difficulty trusting others
9. feeling alone and detatched
10. life is meaningless,cannot function without him
11. confusion about role and identity
12.difficulty to pursue interests or plan future
endicott substitution criteria for depression:
changes in appetite/weight
tearfullness, depressed appearance
endicott substitution criteria for depression:
sleep disturbance
social withdrawal, decreased talkativeness
endicott substitution criteria for depression: loss of energy
brooding, self pity, pessimism
endicott substitution criteria for depression: memory and concentration deficits, indecisiveness
lack of reactivity
symptoms of persistent vegetative states
no evidence of awareness
no responsse
no receptive or expressive language
return of sleep-wake cycles,arousal, smiling, frowning, yawning
preserved brainstem ot hypothalamic autonomic functions
bowel and bladder incontinence
variably preserved cranial nerve and spinal reflexes
tarasoff 1 and 2
tarasoff 1- duty to warn in case a patient is dangerous
tarasoff 2- duty to protect in addition to warning
indications for seclusion and restraint
prevent imminant harm
prevent siginificant diruption to treatment program or physical surroindings
assist in treatment as part of an ongoing behavior therapy
decrease sensory ovestimulation(for seclusion)
patient’s voluntary reasonable request
contraindications for seclusion and restraint
unless under close supervivions: extremely unstable medical/mental condition
delirious ot demented who cnnot tolerate decreased stimulation
overly suicidal patientssevere drug reaction ot OD who require moitoring
M’Naghten rule
unguilty if crime due to mental disorder
Durham rule
an accused person is not criminally responsible if the act was a product of mental health
risk managemtn of recovered memories(pg 1390)
neutrality, do not suggest abuse
stay clinically focused
carefully document
closely monitor supervisory and collaborative therapy relationships
clarify nontreamten roles with family members
avoid hypnosis/amobarbitl unless indicated(with consultaion only)
dont take cases you cannot handle
obtain coonsultation
don’t suggest law suits
inform that more than brief therapy may be required
stop and refer if unconfortable
leading cases of disability -adjusted life year
HIV (12.1), MDD (5.7)
suicide - mental illness
a systematic review shoew that 98% had mental dis. 35,8%- mood dis 22.4%- substance 11.6%- personality 10.6%- schziophrenia
medications that can mimic dementia
anticholinergic antihypertensive antipsychotic steroids digitalis narcotics NSAIDS phenytoin polypharmacy sedative hypnotics
mental situation that mimic dementia
anxiety
depression
maina
delusional (paranoid) disorders
metabolic and endocrine disorders that may resemble dementia
addisn cushing hepatic faiure hypercarbia(COPD) hyper/hyonatremia hyer/hypothyroidism hyperparathyroidism hypoglycemia renal failure volue depletion
conditions that resemble dementia
fecal impaction
hospitalizaion
impaired hearing/vision
in WAIS R- what is and is not affected by age?
voacbulary and general knowledge may even improve with age (at least for first 7 decades)- chapter 54.2e in comprehensive text book
other test results- similarities ad digit symbol susbstitution- may change with age.
depression in depression in neuropsychiatric evaluation
impaired psychomotor performance, especially visuospatial functioning and timed motor performance
whcih part of WAIS-R is most sensitive indicator of brain damage?
performance more than verbal part.
delirium/confusion among the terminally ill
90%. reversible in 50%. may repond to antipsychotics or pain relievers
treatment of fatigue among terminally ill
stimulants
treatment for nausea and vomiting among terminally ill
THC.
oral- dronabinol (Marinol), 1-2 mg every 8 hours.
marijuana cigaretes more effective
depression or anxiety among terminally ill
use antianxiety/antidepressants. opoiods have strong antianxiety effect
dyspnea or cough among terminally ill
treat with: opiiids, oxygen, bronchodilaters
pשin for terminally ill
opiods are gold standard
among those considering euthenasia- what are the most common end of life concerns?
loss of autonomy-85%
decreased ability to participate in enjoyable life activities- 77%
losing control of body functions- 63%
4 elements of malpratice
4 Ds- duty, deviation, damage, direct causation:
1) a doctor -patient relationship existed that created a duty of care
2)a deviation from the standatd of care occured
3) patient was damaged
4) deviation directly caused the damage
giving advice on radio show- cannot be sued for malpractice
באלו מקרים לא חייבים הסכמת הורי לבדיקה וטיול במי שלא מלאו לו 18 שנים?
- החלטות הקשורות להריון
- מחלות מין
- תלות בסמים ואלכוהול
- מחלות מדבקות
policemant at the elbow law
criminal is not responsible if acted on an irresistible impulse- it could have been done even if the police were present.
M’Nagthen rule
persons are not guilty if crime performed under a mental illness, such that they were unaware of the naturem quality and consequences of their acts or if they were incapable of realizing that their act was wrong
to sbsolve from punshment- a delusio used in evidence must be one that, if true, would be an adequate defense. if the delusinal idea does not justify the crime- they are held resposible, guilty and punishable.
knwon as the “right-wrong” test.
