Transcript PS277-Lecture_16_mental_health_in_later_life

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
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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
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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