Aging: Special Considerations

1. Cheryl L. Shigaki, PhD, ABPP University of Missouri Department of Health Psychology July, 2011 Aging: Special Considerations

2. Objectives • Normal aging • Cognitive disorders associated with aging • Aging and trauma

3. Normal Aging Cognition & personality

4. 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.”3 Migrant fruit worker from Arkansas, Berrien County, Michigan

5. 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 conditions Conversely limitations are less apparent when the environment is familiar and sufficient time is provided.

6. Cognitive Change in Normal Aging • 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

7. Cognitive Change in Normal Aging • 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

8. Cognitive Change in Normal Aging • 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.

9. Cognitive Change in Normal Aging • Addressing changes • Restoration • Compensation • Environmental supports Residents of St. Paul, Minnesota

10. Cognitive Change in Normal Aging • 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

11. Cognitive Change in Normal Aging • 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

12. 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

13. Personality and Aging • 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 Mr. and Mrs. Andrew Lyman. Windsor Locks, Connecticut. Photographer: Jack Delano

14. Personality and Aging • 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.

15. 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.

16. Cognitive Disorders Associated with Aging Washstand in the dog run...Hale County, Alabama. 1935 or 1936. Photographer: Walker Evans

17. 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

18. 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

19. 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

20. 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

21. 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.

22. 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

23. Street scene, Washington, D.C.

24. 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

25. Unilateral Effects of Stroke Left brain strokes 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) • Right-sided paralysis • Impaired vision on right • Dysarthria – speech • Aphasia – language • Apraxia – planned movement • Slow / cautious behavior • Impaired memory (verbal)

26. 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.

27. 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 change Outside 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

28. Behavioral Considerations Errors of COMMission: Errors of omission: Disinhibition Impulsivity Confabulation Perseveration Intrusion errors Stimulus-boundedness Risk for falls, other injury, injury to others. • Apathy • Difficulty with initiation • Risk for self-neglect • Inability to mobilize if help is needed • Risk for self-neglect

29. 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

30. 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

31. 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

32. 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

33. 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.

34. Aging, Mental Health and Cognition

35. Cognition, mood and health are interrelated. Symptoms and effects can be overlapping Mood Cognition Health

36. Depression & Cognition • Older adults may present with predominant cognitive symptoms: • Loss of memory • Vagueness • Slowing of movement and speech • Attention and concentration appear adequate

37. 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.

38. 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.

39. 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?

40. Trauma History & Cognition Nazi Holocaust survivors19 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 • 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. *Cross-sectional study

41. Trauma History & Cognition • 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 church on Sunday morning, St. Louis, Missouri

42. Trauma History & Cognition Holocaust survivors with PTSD 19 Implication: A hypothesis that PTSD may somehow cause “premature aging” continues to be investigated. Other factors could be at play. • 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.

43. 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

44. 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.

45. 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.

46. Questions: • How do you think you can best help older Rwandans who have depression? • What approaches may be most helpful?

47. 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.

48. 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

49. 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,

50. 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