Download - Normal aging Cognitive disorders associated with aging Aging and trauma

Aging: Special Considerations

Cheryl L. Shigaki, PhD, ABPPUniversity of MissouriDepartment of Health PsychologyJuly, 2011

Objectives

Normal aging Cognitive disorders associated with

aging Aging and trauma

Normal AgingCognition & personality

Normal Aging

Productivity and decline: both characterize late life. Nearly half of older

Americans consider themselves to be middle aged or young.3

Only 15 percent of those 75 + consider themselves “very old.”3Migrant fruit worker from Arkansas,

Berrien County, Michigan

Cognitive Change in Normal Aging

In aging, we experience increasing limits on intellectual and physical performance.

However, changes may not interfere much with functioning in every day life activities.

Age-related limitations become more apparent under stressful or demanding conditionsConversely limitations are less apparent when the environment is familiar and sufficient time is provided.


Cross-sectional studies show peaks between 20-30 years old.4

Longitudinal studies show increases into 30s to 40s, stability in mid 50s or 60s, and gradual decline thereafter.5,6

Though many participants showed stable abilities in later life. Physical changes in the aging brain

include loss of brain volume7


What doesn’t change5

Vocabulary – the meanings of words and their pronunciation

Fund of information – facts we learn through education and experience.

Implicit/incidental learning – Ability to remember things that were heard or read but have not been told to memorize.

Stable man at the Eastern States Fair,

Springfield, Massachusetts


What does change?4,5

Speed of mental processing Abstraction ability – using concepts to

make and understand generalizations (e.g. shared properties or patterns).

Mental flexibility – tasks that require the individual to respond in novel ways; task-switching.

Efficiency – ‘encoding’ new information in a way that it can be easily retrieved later on.


Addressing changes Restoration Compensation Environmental

supports

Residents of St. Paul, Minnesota


Compensation: Maintaining performance by drawing on other cognitive resources or abilities that are not affected by the aging process.5

Example: Expert (older) typists were able to perform as rapidly and accurately as younger typists, despite experiencing slowing in reaction time. They compensated by anticipating upcoming words in the text better than less experienced typists.8


Environmental supports Recognition memory changes less

than recall Assist the older person in organizing

information to be learned Prevent distractions Provide more time for learning and

recalling new material

Personality and Aging

Basic personality traits remain relatively consistent throughout adult life.5

Extroversion Openness to new experiences Anxious/depressed personality style

"Fiddlin'" Bill Henseley. Asheville, North Carolina. Photographer: Ben Shahn


Mr. and Mrs. Andrew Lyman. Windsor Locks, Connecticut. Photographer: Jack Delano

Older people are more cautious When tested – older

individuals were less likely to guess than younger ones when uncertain about the correct answer.9

Implication: May make more errors of omission.

May be less willing to take risks, even if the probability of success is high.10,11


Common changes in personality May demonstrate less interest in the outside world. Both positive and negative feelings may be less

intense12

People perceive themselves as changing in meaningful ways, more self-confident, better adjusted, etc., even if tests cannot objectively confirm these changes.5

Social and historical context (e.g. war, economic circumstances) shapes personality development.5

Implication: We may attribute characteristics to “aging” when

they are really more related to shared experiences.

Small groups:

Review: Help each other to understand the material presented

Discuss: How has the Genocide of 1994 affected the older people of Rwanda?

Think: Think of older people you know personally or from your work, who have experienced changes in their thinking.

Cognitive Disorders Associated with Aging

Washstand in the dog run...Hale County, Alabama. 1935 or 1936. Photographer: Walker Evans

Cognitive Impairment in Older Adults Categories of cognitive impairment:

Mild Cognitive Impairment Dementia of the Alzheimer’s Type (DAT) Stroke Traumatic Brain Injury (TBI) Depression

Risk for certain conditions increases with age Risk for stroke more than doubles for each

decade after 5513

50% of adults over 85 years have DAT14

Criteria for Dementia (DSM-IV-TR)

Impaired memory Affects new learning or recall of previously learned

information One or more of the following:

Aphasia – disturbance of language Apraxia – impaired ability to carry out motor activities

despite intact motor function Agnosia – failure to recognize or identify objects, despite

intact sensory functioning Disturbance in executive functioning – i.e. planning,

organizing, sequencing, abstracting. Causes impaired social or occupational functioning

and represents a decline from previous level of functioning

Mild Cognitive Impairment

Problems with thinking and memory that do not meet full criteria for dementia.

May represent the onset of a progressive process.

Imaging studies have shown that the brain may be able to recruit areas outside the usual structures that mediate memory, in order to maintain performance.15

Health and Behavioral Risk Factors for Cognitive Impairment

Breathing disorders: (COPD, emphysema, sleep apnea)

Chronic health conditions:

(heart disease, diabetes, high blood cholesterol)

Surgical procedures Smoking Heavy alcohol use

Dementia of the Alzheimer’s Type (DAT)

Degenerative & terminal disease Slow, gradual onset (“the long good-

bye”). Changes at the cellular level of the

brain lead to changes in cognition, mood and behavior.

No medical test available. Diagnosed by cognitive and behavior changes

Medications are not very effective against the disease process.

Dementia of the Alzheimer’s Type (DAT)

Memory impairment is the cardinal feature, Though, depression may be the first

apparent symptom Later in the course decreased use of

language, confusion, inability to recognize familiar things.

In mid- to late stages, mood and personality can change and behavior can be disruptive Suspiciousness, delusions, repeated questions,

combativeness, restlessness, utilization behavior Associated with high levels of caregiver

stress

Street scene, Washington, D.C.

Stroke

Ischemic or non-bleeding stroke (88%) Blockage or of blood vessels in the brain Prevents oxygen from reaching brain cells

Hemorrhagic strokes (12%) Blood vessel in the brain burst Causes increase in pressure in skull Blood/oxygen is not transported to brain cells.

Transient Ischemic Attacks (mini-strokes) Cannot be seen with imaging techniques Symptoms resolve

Unilateral Effects of Stroke

LEFT BRAIN STROKES Right-sided paralysis Impaired vision on

right Dysarthria – speech Aphasia – language Apraxia – planned

movement Slow / cautious

behavior Impaired memory

(verbal)

RIGHT BRAIN STROKES Left-sided paralysis Left spatial neglect

inattention Inability to recognize or

appreciate body parts Visual-spatial skills Impaired vision on left Impulsive behavior Impaired awareness Impaired memory

(activities)

Aging and Traumatic Brain Injury (TBI)

Adults 75+ years have highest rates of TBI related hospitalizations and deaths.16

Some symptoms may be evident immediately, while others may not surface until several days or weeks.

Common Cognitive Effects of TBI

Impairments in: Memory Attention Visual-spatial skills Processing speed Expressive language Problem-solving Organization/planning Comprehension/receptive

language Self-monitoring / personality

changeOutside water supply, Washington, D.C. Only source of water supply winter and summer for many houses in slum areas. In some places drainage is so poor that surplus water backs up in huge puddles

Behavioral Considerations

ERRORS OF COMMISSION:

ApathyDifficulty with

initiationRisk for self-neglectInability to mobilize if

help is neededRisk for self-

neglect

ERRORS OF OMISSION:

DisinhibitionImpulsivityConfabulationPerseverationIntrusion errorsStimulus-

boundednessRisk for falls, other

injury, injury to others.

Falls in Older Adults

In the U.S., falls are the leading cause of TBI (30%), followed by motor vehicle accidents (17%)

61% of TBI in persons 65+ years are due to falls 17

Elders may not report falls or injury: May feel fine even though they are behaving differently May attribute problems to an issue they are already

aware of (e.g. nausea due to having a cold). Embarrassment Impaired memory/confusion

Risk factors for Falls in Older Adults

Sleep changes/difficulty Diabetes Dehydration Decreased vision Vestibular/hearing changes Slowed reaction time Gait or balance problems Taking multiple medications Variable blood pressure (orthostatic hypotension) Cognitive impairments/confusion

Risk Factors for Falls in Older Adults

Hazards in the everyday environment: Poor lighting Clutter Uneven surfaces Small rugs Foot / shoe problems

Marketplace in the French quarters of New Orleans, market for

Resettlement Administration's rehabilitation clients

Fall Prevention

Smooth out uneven surfaces Eliminate area rugs Maintain proper lighting Keep frequently used items in easy-

to-reach places Try to maintain good sleep and

nutrition Exercise to stay strong

Small groups

Review: Help each other to understand the material presented

Identify: Any questions that your small group still has about aging and changes in cognition.

Aging, Mental Health and Cognition

Cognition, mood and health are interrelated.

Symptoms and effects can be overlapping

MoodCognition

Health

Depression & Cognition

Older adults may present with predominant cognitive symptoms: Loss of memory Vagueness Slowing of movement and speech Attention and concentration appear

adequate

Depression & Cognition

Clinical observations: When being tested for memory,

depressed older adults may say “I don’t know” frequently and be distressed with incorrect answers.

In contrast: individuals with dementia will often give wrong answers, have poor attention and concentration and appear indifferent or unconcerned.

Co-morbid Depression

Rate of depression following stroke is 30-50%

Rate of depression following TBI is ~50%18

Increased risk following non-neurologic events.

For example: depression is common following heart attacks and hip fractures.

Trauma History & Cognition

VETERANS WITH PTSD19

Differences seen in tested memory among older veterans with and without PTSD (CVLT; Korean War and WWII Korean War).

These differences were not observed in a middle-aged veterans with PTSD (Viet Nam).

IMPLICATION: Are there differential effects as aging occurs for veterans with PTSD?


NAZI HOLOCAUST SURVIVORS19

Those with PTSD had poorer memory than survivors without PTSD and the non-exposed group.

36% of the PTSD group would be considered to have “impaired” memory.

Trauma survivors without PTSD did not differ from non-exposed group.

IMPLICATIONS:

The deficits appear to be associated with PTSD, not trauma exposure. Difficulty is with

encoding and retrieval. Retention is not impaired

This is different from typical DAT profile

*Cross-sectional study


Imaging studies have found that certain brain structures are diminished in size and activity in individuals with PTSD.

These patients also were frequently found to have impaired memory.

Treatment with antidepressant mediation led to small increase in size, and moderate increase in memory function.20

Two one-legged men outside churchon Sunday morning, St. Louis, Missouri


HOLOCAUST SURVIVORS WITH PTSD 19

In survivors with PTSD, older age was associated with lower scores on tests of memory.

Lower memory was not found in older survivors who did not have PTSD, or Jewish adults who were not exposed to the Holocaust.

Similar tests with veterans yielded less clear results.

IMPLICATION:

A hypothesis that PTSD may somehow cause “premature aging” continues to be investigated.

Other factors could be at play.

Trauma History & Cognition Findings that link PTSD with cognitive

changes come from studies that look at data averages.

Results from various studies aren’t consistent

In the clinic, we must be careful in making predictions for individuals.

Even massive trauma exposure is not invariably associated with subsequent enduring cognitive change.19

Trauma History & Dementia “Executive functions” - ability to think about,

organize and control one’s thinking and subsequent behavior.

Impaired executive functioning: sometimes occurs with dementia; may decrease ability to manage traumatic memories: Misidentifications – sounds, movements, shadows Misinterpretations – meanings of sounds, others’

behaviors Impaired orientation to time Suspiciousness, frank hallucinations and delusions Interaction with sensory impairments.

Mental Health Services and Older Adults Treatment with medication or psychotherapy or some

combination of these has been shown to be effective in about 80% of individuals with depression.

Many individuals who are treated for depression experience improvement in cognitive concerns.

Questions:

How do you think you can best help older Rwandans who have depression?

What approaches may be most helpful?

Mental Health Services and Older Adults

Older patients in the US: May be less aware of the purpose and

effectiveness of mental health services than younger patients.

May prefer to seek counseling assistance from medical professionals or clergy.

May benefit from education regarding the relationships between emotions, thoughts and more general physical health.

Assessing Depression in Older Adults

Clinical Interview (DSM-IV-TR) Geriatric Depression scale (GDS)

Yes / No format Cut scores Comes in many languages Has short forms available

Cornell Scale for Depression in Dementia Observer rated Scoring is relative

Revised Memory and Behavior Problems Checklist*

Caregiver report measure for dementia (DAT) Frequency of the problem (past week) How much this has bothered or upset you?

Total score and subscales: Memory-related problems (e.g. asking same

question) affective distress (e.g. crying) disruptive behaviors (e.g. verbal aggression)

*Teri, Truax, Logsdon, Umomot, Sarit & Vitaloano (1992)Psychology & Aging, 7, 4,622-31,

Assessment/Treatment Considerations for Older Adults

FACTORS WHICH MAY LEAD TO MISDIAGNOSIS:

Acute medical issues (e.g. infection) Uncontrolled pain Fatigue Effects of medications Sensory impairments

(e.g. low vision, hard of hearing)

Low educational attainment

Loafers' wall, by courthouse, Batesville, Arkansas

Assessment/Treatment Considerations for Older Adults

Sleep problems difficulty falling asleep maintaining sleep,

frequent awakening to urinate, sleep apnea, drowsiness due to medications

Undertreated pain / positioning Subclinical illness/infection Metabolic issues: thyroid, testosterone Constipation Malnourishment / dehydration Elder maltreatment

Caregiver Concerns: Fact Sheets from the Family Caregiver Alliance*

Coping with Behavior Problems after Head Injury

Caring for Adults with Cognitive and Memory

Impairments

Caregiver’s Guide to Understanding Dementia Behaviors

Dementia Caregiving and Controlling Frustration

Caregiving and Depression

Taking Care of YOU: Self-Care for Family Caregivers

Caregiving and Ambiguous Loss

*Available at: www.caregiver.org

Questions?

Citations

1. Wikipedia: Farm Security Administration2. Library of Congress: http://www.loc.gov/pictures/resource/fsa.8a06937/?co=fsa3. NCOA (2002) American Perceptions of Aging in the 21st Century (

http://www.brown.edu/Courses/BI_278/projects/Aging/perceptions.pdf)4. Smith GE, Bondi MW. (2008) Normal aging, mild cognitive impairment, and

Alzheimer’s disease. In JE Morgan & JH Ricker (Eds) Textbook of Clinical Neuropsychology. NY: Taylor & Francis.

5. Zarit SH, Zarit JM (1998). Normal Processes of Aging. In Mental disorders in older adults. London: Guilford Press.

6. Schaie KW (1995) Intellectual development in adulthood . In JE Birren & KW Schaie (Eds) Handbook of the psychology of aging. (4th Ed)., pp 266-286). San Diego: Academic Press.

7. Good et al, A voxel-based morphometric study of aging in 465 normal adult human brains. Neuroimage, 14; 21-36. 2001

8. Salthouse (1984) Effects of age and skill in typing. J Exper Psych: General, 113, 345-71.

9. Botwinick 1984, Aging and behavior (3rd Ed). New York: Springer10. Botwinick 1966, Cautiousness in advanced age. J Gerontol, 21, 347-5311. Botwinick 1969, Disinclination to venture response versus cautiousness in

responding: Age differeneces. J Genetic Psychol, 115, 55-6212. Filip SH, 1996. Motivation and emotion. In JE Birren & KW Schaie (Eds), Handbook of

the psychology of aging (4th ed, pp. 281-235). San Diego: Academic Press.

http://www.loc.gov/pictures/resource/fsa.8a06937/?co=fsa

http://www.brown.edu/Courses/BI_278/projects/Aging/perceptions.pdf

Citations

13. CDC Stroke facts – available at: CDC.gov14. Estimate from the National Institute on Aging (2000)15. Desgranges, Baron & Eustache, 1998. The functional neuroanatomy of episodic

memory: The role of the frontal lobes, the hippocampal formation and other areas. Neurimage, 8, 198-213.

16. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010 see: CDC (2011): http://www.cdc.gov/TraumaticBrainInjury/statistics.html

17. CDC (2011): http://www.cdc.gov/TraumaticBrainInjury/statistics.html18. Bombardier C et al. JAMA 2010;303:1938-4519. Golier JA, Harvey PD, Legge J, Yehuda R. 2006. Memory performance in older trauma

survivors: Implications for the longitudinal course of PTSD. Ann NY Acad Sci. 1071:54-66.

20. Bremner JD 2006. The relationship between cognitive and brain changes in posttraumatic stress disorder. Ann NY Acad Sci. 1071: 80-86.

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