Mental Health Issues in Later Life

PS277 - Lecture 16 – Chapter 4

Outline

Types of disorders

Depression and its causes

Suicide issues

Dementias and Alzheimer’s disease: Symptoms, causes

Experiencing Alzheimer’s

I. Broad Typology of Disorders

Externalizing Behavior Problems – e.g., conduct disorders, substance abuse?

Internalizing Behavior Problems – e.g., anxiety, phobias, mood disorders and depression

Severe Cognitive Impairments – dementias, schizophrenia

Some General Points

These different types can co-occur (e.g., dementia and depression)

Likely both genetic and environmental triggers for many of these disorders in complex relation

There is great variability in how these various problems and diagnoses manifest themselves – many of these are best thought of as a family of disorders, not one single condition

Externalizing Disorders

Individuals create problems for others, frequently not distressed themselves

Under-controlled in terms of impulses

Higher for males over the life course

Largely absent by later adulthood – “burned out”…but substance abuse can increase

Patterns of Antisocial Disorders

Internalizing Disorders

Anxiety disorders

Cause trouble for self, not for others

Over-controlled patterns

Generally less severe, but can be chronic, persist over time

Types of Internalizing Disorders Anxiety disorders – physical symptoms such

as sweating, nausea, dizziness, hyperventilation, chest pains, are common

Older adults may have various physical symptoms and problems associated with medications that make diagnosis of anxiety disorders difficult

Phobias, obsessive-compulsive disorder, Post Traumatic Stress Disorder, etc.

Darwin and Anxiety Disorder

From the time he was 30 to age 60 or so, Darwin suffered extensively from many of the symptoms noted for anxiety disorders – nausea, heart palpitations, dizziness, etc.

Consulted many doctors, most prescribed physical cures which didn’t much help

Current consensus is that these were largely psychosomatic symptoms, produced and/or worsened by anxiety over his theory and its social and personal implications, as well as his fears of being an invalid

Seemed to get better in later life, perhaps due to fact that theory got out and world didn’t end

II. Depression and Depressive Mood

Most common types: Major depressive disorder, dysthymic disorder, bipolar disorder

Variable across adult lifespan, severe disorders tend to be lower in later life, while dysthymia tends to be higher, bi-polar disorders less common overall

Somewhat hard to untangle these results from cohort differences, as depression is on rise over generations

Common Symptoms of Depression CES-D:

I did not feel like eating, my appetite was poor

My sleep was restless

I talked less than usual

I felt that people dislike me

I had crying spells

I felt that I could not shake off the blues

Prevalence of Depression Across Adulthood

Common Risk Factors for Depression Lack of social support

Poverty

Emotional and relational losses

Physical health problems

Gender – ratio is about 2:1

Examples of folks at your placements?

III. Suicide Prevalence

Responding to Suicide Concerns

What to do if you suspect someone is thinking about suicide: Ask questions in calm manner – “Are you thinking about hurting

yourself?” Try to assess seriousness of intent in terms of planning, etc. Be a good listener and supportive without being falsely

reassuring Try to persuade person to get help and assist him or her to find

it What not to do: Do not ignore warning signs. Do not refuse to talk about suicide if someone wants to. Do not react with humour, disapproval, repulsion. Do not give false reassurances like “everything will be fine.” Do not abandon the person after the crisis has passed or after

they begin professional help.

IV. Cognitive Impairment: Alzheimer’s and Dementias - Ronald Reagan

Ronald Reagan’s 1994 Letter

“My fellow Americans, I have recently been told that I am one of the millions of Americans who will be afflicted with Alzheimer's disease…

At the moment I feel just fine. I intend to live the remainder of the years God gives me on this Earth doing the things I have always done… Unfortunately, as Alzheimer's disease progresses, the family often bears a heavy burden. I only wish there was some way I could spare Nancy from this painful experience. When the time comes, I am confident that with your help she will face it with faith and courage.

In closing, let me thank you, the American people, for giving me the great honor of allowing me to serve as your president. When the Lord calls me home, whenever that day may be, I will leave with the greatest love for this country of ours and eternal optimism for its future. I now begin the journey that will lead me into the sunset of my life. I know that for America there will always be a bright dawn ahead. “

Alzheimer’s – Symptoms and Course of the Disease Reagan’s letter to death – 10 year sequence

Stages: early, middle, late – many different patterns suggested

Progressive symptoms – memory loss, confusion, impaired judgment, loss of language, agitation, wandering, difficulty with routine self-care, coma, death

Diagnosis – only made with autopsy of brain, plaques and tangles, but try to rule out other causes which might be treatable first

Treatments: can slow the course, no cure so far

Genetic Bases of Alzheimer’s

Early-onset: before age 60 – 5% of cases, clearly runs in families – autosomal dominant pattern – seems linked to Chromosome 21 as many Down Syndrome adults experience this

Late-onset: after 60, linked to Chromosome 19, APOE gene, Apoe4 variant from both parents = 80% risk, some linkage to fatty diets, perhaps to diabetes

Defining Dementia

Disorders of thinking, memory, language, behavioral function that result from damage to brain

Prevalence: 5-8% of people over 65, increases with age

75-84 = 12%, 85+ = about 25-30% of people experience moderate to severe degree of dementia

Some people distinguish cortical and sub-cortical types of dementias, based on brain locale of problem

Types of Cortical Dementias and Prevalence Alzheimer’s – memory and language function, 65% of all

dementias, high prevalence among Down syndrome adults, has different forms

Vascular dementia – sudden onset, multiple strokes – 15-20%?

Lewy-Body disease – 15% of all dementias, combines both cognitive and motor problems, can be present with Alzheimer’s

AIDS dementia complex: small percentage of AIDs cases experience this, protein kills neurons

Pick’s disease – rare fronto-temporal disorder, mostly personality and speech disruptions, earlier onset

Creutzfeldt-Jakob disease – very rare, prion folding disorder, associated with BSE and some other disorders, 40 cases last year in Canada – devastating outcomes

Some Types of Subcortical Dementias Huntington’s – begins with motoric problems,

cognitive impairments come much later

Parkinson’s – similar pattern, due to dopamine lack in neurotransmitters, tremors, slowness, stiffness, etc. – Michael J. Fox

Any examples of people working with at placements with dementias?

Mini-Mental State Diagnostic Exam

Experiencing Dementia

Still Alice – Novel, Lisa Genova (2007)

Living in the Labyrinth – McGowin (1993)

Woman in her late 40’s who was diagnosed with AD

Book is a diary of her experiences during the earlier phases of disease

Getting Lost

McGowin, describing her efforts to get directions from a local guard at a park: “I appear to be lost,” I began, making a great effort to keep my voice level despite my emotional state. “Where do you need to go?”, asked the guard. A cold chill enveloped me as I realized I did not remember the name of my street. Tears began to flow down my cheeks…Suddenly, I remembered bringing my grandchildren to this park. That must mean that I lived relatively nearby. “What is the closest subdivision?” I quavered. The guard scratched his head thoughtfully. “The closest subdivision would be Pine Hills, maybe.” “That’s right,” I exclaimed gratefully. The name of my subdivision had rung a bell…Once home a wave of relief brought more tears…”

V. Schizophrenia

Impairment of thinking, distorted perception (e.g., hallucinations), loss of contact with reality

Most common onset is in early adulthood: about 1% of people worldwide experience this in all cultures; less common in later adulthood

Symptoms change somewhat in later life and in later onset, less thought disorder, less restriction of affect in older adults

Prevalence of Schizophrenia