Mental Health Issues in Later Life

1. Mental Health Issues in Later Life PS277 - Lecture 16 – Chapter 4

2. Outline • Types of disorders • Depression and its causes • Suicide issues • Dementias and Alzheimer’s disease: Symptoms, causes • Experiencing Alzheimer’s

3. 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

4. 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

5. 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

6. Patterns of Antisocial Disorders

7. Internalizing Disorders • Anxiety disorders • Cause trouble for self, not for others • Over-controlled patterns • Generally less severe, but can be chronic, persist over time

8. 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.

9. 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

10. 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

11. 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

12. Prevalence of Depression Across Adulthood

13. 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?

14. III. Suicide Prevalence

15. 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.

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

17. 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. “

18. 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

19. 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

20. 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 ofdementias, based on brain locale of problem

21. 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

22. 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?

23. Mini-Mental State Diagnostic Exam

24. 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

25. 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…”

26. 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

27. Prevalence of Schizophrenia