Lecture 11- Mental Disorders Overview

1. Lecture 11- Mental DisordersOverview 1. Defining Psychopathology 2. Cognitive Disorders Dementia Delirium 3. Other Mental Disorders Depression Anxiety (see text)

2. Lecture 11- Mental DisordersOverview 4. Clinical Concerns Elder Abuse Suicide (see text) 5. Psychological Issues in Long-Term Care 6. Myth Busting: Facts on Aging Revisited

3. Psychological Disorders in Adulthood Psychopathology= Science of psychological disorders Lie outside range of ordinary human experience • Subjective distress • Impaired in everyday life • Cause risk to self or others • Engage in socially or culturally unacceptable behavior

4. Psychological Disorders in Adulthood: Diagnosis of Psychological Disorders Diagnostic and Statistical Manual of Mental Diseases (DSM-IV) • Based on field studies of specific disorders • Not developed specifically for older adults • Match symptoms to those in manual • Must meet specific criteria • Develop treatment plan Diagnostic process

5. Psychological Disorders in Adulthood: Diagnosis of Psychological Disorders DSM-IV Diagnostic Axes Axis I Clinical syndromes or disorders Personality disorders and mental retardation Axis II Axis III Medical conditions Axis IV Psychosocial stressors Axis V General level of functioning

6. Terminology Epidemiology • Lifetime prevalence- percentage of people who ever have had the disorder • Incidence- new cases within given period

7. Cognitive Disorders (DSM-IV) 1. Dementia 2. Delirium 3. Amnestic Disorder 4.Cognitive Disorder Not Otherwise Specified

8. Common signs Cognitive Disorders: Dementia Definition of Dementia • Clinical condition/syndrome • Loss of cognitive function • Interferes with normal activities • Interferes with social relationships Dementia 1. Impairment of memory 2. Multiple disturbances of cognition 3. Impairment of executive function. 4. Disorientation. 5. Behavioral changes.

9. Dementia: Causes 1. Reversible 2. Irreversible

10. Reversible Dementia (some causes) Dementia due to treatable condition: • infections • toxic effects of drugs (polypharmacy) • normal pressure hydrocephalus • head injury • nutritional deficiencies • Korsakoff’s syndrome (vitamin B1) Wernicke’s disease • metabolic problems (e.g., hypothyroidism) • mental and sensory deprivation • Depression (pseudodementia)* • Delirium* Important to treat early Can become irreversible

11. Irreversible: Neurological Diseases that Can Cause Dementia Disorder Cause Major symptoms Vascular dementia Transient ischemic attacks More rapid decline than AD, decline occurs in spurts Frontal lobe dementia Personality changes- apathy, lack of inhibition, obsessiveness, loss of judgment Damage to frontal lobes Parkinson’s disease Lack of dopamine in basal ganglia Tremors, shuffling gait, postural instability, speech problems Lewy Body dementia Accumulation of Lewy bodies Confusion, hallucinations, motor deficits Pick’s disease Accumulation of Pick bodies Frontal and temporal lobe deterioration, personality changes, loss of speech. Apathy, confusion, concentration problems, flattened emotions HIV dementia Final stages of AIDS

12. Irreversible: Neurological Diseases that Can Cause Dementia Disorder Cause Major symptoms Choreiform movements, loss of detailed memories, decreased higher order executive skills Huntington’s Hereditary (chromosome 4) Creutzfeld- Jakob rapid dementia and decline Slow virus Down’s Syndrome Extra chromosome 21 Mental retardation Alzheimer’s Disease Detailed notes Detailed notes

13. Canadian Study of Health and Aging (1991-1992) Prevalence Dementia Normal 8% of all Canadians aged 65+ meet the criteria for dementia.

14. Prevalence of dementia in Canada: Canadian Study of Health and Aging (1991-1992) • Female to male ratio is 2:1 • 2.4 % for 65-74 years • 34.5% for those aged 85+ • If prevalence estimates remain constant, 592,000 persons will have dementia by 2021

15. Prevalence of Alzheimer’s Disease and Vascular Dementia in Canada • Alzheimer’s 5.1% for 65+ • 1.0% for 65-74 years • 26% for 85+ years • Vascular dementia 1.5% for 65+ • 0.6 % for 65-74 years • 4.8 % for 85+ years

16. Dementia: Vascular Dementia Features • Associated with damage to the cerebral blood vessels • through arteriosclerosis • found in middle and later life (age of onset between 50-70) • accumulated effect of multiple cortical and subcortical infarcts • lead to clinical presentation • incidence higher in men • first sign delirium or small stroke

17. Dementia: Vascular Dementia Clinical Presentation • Abrupt onset • step-wise deterioration • somatic complaints • emotional incontinence • history of hypertension • history of cebrovascular accidents • focal neurological symptoms • focal neurological signs

18. Dementia:Alzheimer’s Disease History Alois Alzheimer (1864-1915) • Patient Auguste D. had dementia symptoms • Brain studies after her death revealed microscopic changes • Symptoms due to neuronal changes

19. Dementia and Related Neurological Disorders: Alzheimer’s Disease NINCDS/ADRDA Guidlines Criteria for probable Alzheimer’s diagnosis= • Dementia • Significant cognitive deficiencies • Progressive deterioration • No loss of consciousness • 40-90 years of age • No other diseases • Medical tests • Family history • Brain scans • Other symptoms Also includes

20. Alzheimer’s Disease: “Stages” of Progression Psychological Symptoms Early Memory loss for familiar objects and events Regular progression of loss Middle Personality changes Behavior changes Late Loss of ability to perform simple everyday functions People do not die of Alzheimer’s per se.

21. Clinical Presentation: • Memory loss • Aphasia • Apraxia • Agnosia • Disturbance in executive functioning Diagnosis done by exclusion Autopsy is only reliable method

22. Clinical Presentation

23. Amyloid plaque Alzheimer’s Disease Amyloid Plaques • Collection of waste products of dead neurons around a core of amyloid. • Formation occurs long before symptoms are evident • Amyloid-42 most common form found in plaques

24. Alzheimer’s Disease Formation of amyloid plaques • Proteases snip the APP into fragments. • If APP is snipped at wrong place, beta amyloid 42 is formed. • Beta amyloid fragments eventually clump together.

25. Alzheimer’s Disease Tangles http://www.ahaf.org/alzdis/about/AmyloidPlaques.htm

26. Alzheimer’s Disease Neurofibrillary Tangles Neurofibrillary tangle • Made up of tau protein • Tau maintains microtubules within axons • Tangles form when tau changes chemically and can no longer support the microtubules • Leads to collapse of transport system within neuron

27. Alzheimer’s Disease Neurofibrillary Tangles http://www.alzheimers.org/tangle.html

28. Gene Chromosome ApoE gene 19 APP gene 21 Presenilin 1 14 Presenilin 2 1 Alzheimer’s Disease Causes of Alzheimer’s Disease Familial Alzheimer’s Disease supports Genetic theory • Early onset • Late onset

29. Gene Chromosome ApoE gene 19 APP gene 21 Presenilin1 14 Presenilin 2 1 Alzheimer’s Disease Causes of Alzheimer’s Disease Familial Alzheimer’s Disease supports Genetic theory • Early onset • Late onset Majority of early-onset cases

30. Alzheimer’s Disease Causes of Alzheimer’s Disease Environmental Life style Head injury • Twin data • Japanese men who moved to Hawaii • Nun Study on mental activity • Severe injuries involving loss of consciousness • Causes damage to neurons

31. Treatment: Alzheimer’s Disease Category Action Name Increases available acetylcholine Anticholinesterase Tacrine Glutamate enhancers Facilitate glutamate Labazimide No trade name Stimulate neuron growth Nerve growth factors Stop free radicals Antioxidants Seligiline Anti-inflammatory Not known Advil Estrogen HRT Not known

32. Alzheimer’s Disease: Care for Person and Caregiver Psychosocial Treatments • Person • Prompts, cues, and guidance • Modeling • Positive reinforcement • Structure daily activities • modifications to environment Caregiver burden • caregiver • Respite care • Provide education • info on the disease progression • communication strategies • support groups

33. Lecture 11- Mental DisordersOverview 1. Defining Psychopathology 2. Cognitive Disorders Dementia Delirium 3. Other Mental Disorders Depression Anxiety (see text)

34. Delirium (confusional state) Definition • Fluctuating clinical state characterized by • disturbances of attention, cognition, arousal, • mood and self-awareness • common in the elderly • often undiagnosed

35. Delirium (confusional state) Symptoms • Impairment in attention and disorientation • -distracted, slowed, disorganized thinking • Hallucinations may be present • -usually more visual than auditory • Fluctuating level of awareness • -mild confusion to stupor or active delirium • Speech may be incoherent • Confusion regarding day-to-day procedures or roles • Remote and recent memory impaired

36. Delirium (confusional state) Symptoms • Restlessness, aggressiveness, frightened • Delusions of persecution possible • Disturbance of sleep-wake cycle • Anxiety and lack of cooperativeness • Fluctuations throughout day • worse in the evening • can be lucid intervals

37. Delirium (confusional state) Causes • Infections or fever • strokes/cardiovascular disorders • drug intoxication (polypharmacy or abuse) or withdrawl • exacerbation of underlying medical illness • metabolic and nutritional disorders • postoperative stress* • or other factors related to hospitalization such as • sleep loss, excessive sensory input

38. Delirium (confusional state) Course and Treatment • Brief duration (usually less than a week) • some forms resolve on own • other forms, treatment depends on cause • while delirious • carefully-controlled environment (not too stimulating) • brief and continued reassurance • monitor nutritional and fluid status of person • help the caregivers understand what is going

39. Rapid onset marked attentional disturbance confusion prominent/clouding of consciousness fluctuating clinical course agitation and behavioral symptoms potentially reversible Usually insidious onset memory systems impaired consciousness intact slower, progressive course subtle behavioral symptoms can be irreversible Differential DiagnosisDelirium Dementia

40. Lecture 11- Mental DisordersOverview 1. Defining Psychopathology 2. Cognitive Disorders Dementia Delirium 3. Other Mental Disorders Depression Anxiety (see text)

41. Depression Mood Disorders and features • Depressive disorders- sad mood • Bipolar disorders- involve manic episode • Dysthymic Disorder-chronic but less severe • Mood disorders due to a general medical • condition

42. Depressed mood Loss of interest or pleasure Depressed mood for most of the day marked reduction in interest in daily activities 5% weight loss or significant change in appetite (increase or decrease) almost daily insomnia or hypersomnia almost daily physical agitation or retardation almost daily decreased energy or fatigue almost daily feelings of worthlessness or feelings of guilt almost daily decreased concentration or decreased decisiveness frequent thoughts of death or suicide Diagnostic Features of Major Depressive Episode (DSM-IV)Essential Features Associated Symptoms(1 of 2 required) (5 of 9 required)

43. Depression Prevalence of Depressive DIsorders Lifetime prevalence: NCS= 13% men 21% women Persons over 65: 1% major depressive disorder 2% dysthymia (chronic but less severe depression) However, 8-20% of older adults report symptoms

44. Depression Higher Prevalence of Mood Disorders in Medical Settings: • 12-20% in clinics and hospitals • 30% in long-term care settings Can lead to greater risk of more serious disorder and even fatal impairment

45. Depression Prevalence of Depressive DIsorders Myth: aging leads to depression- old age is depressing Reality: rates for major depression are lower in the elderly compared to younger adults

46. Depression Features of Mood Disorders in Older Adults • Less likely to report traditional symptoms involving negative feelings • More likely to seek treatment for bodily complaints • Seek treatment for disorders other than mood (anxiety, cognitive, bodily delusions)

47. Depression Features of Mood Disorders in Older Adults/causes • Lack of energy • Hopelessness • Loss of appetite Depletion syndrome • Mild or moderate • First appears after age 65 Late-onset depression

48. Depression Causes of Age Differences in Mood Disorders • Personality and emotional changes associated with aging • Cohort differences in experience of depression

49. Depression Problems in Diagnosis of Mood Disorders: • Older adults do not report symptoms accurately • Professionals not attuned to diagnosis of older adults • Not enough time spent with older adults • Wish to avoid stigmatization • Therapists unaware of benefits • cognitive difficulty can accompany depression • dementia and depression can both be present • “pseudodementia”

50. Depression Differentiating Dementia and Pseudodementia • Dementia has insidious onset (years) • history of psychiatric problems more common in • pseudodementia • dementia (mild) complains little about memory/concealment • depressive pseudodementia complains • dementia- behavior in line with clinical severity • depression- incongruities between behavior and • severity of cognitive deficit