UNDERSTANDING PSYCHOPATHOLOGY

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UNDERSTANDING PSYCHOPATHOLOGY

• Cognitive Disorders

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OVERVIEW

• Assessment
• Definition of Cognitive Disorders
• Alzheimers Disease

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AGING AND MENTAL DISORDERS ECA DATA ON 1-YEAR
PREVALENCE, IN PEOPLE AGES 55YEARS

• Any anxiety disorder 11.4
• Severe cognitive impairment 6.6
• Any mood disorder 4.4
• Any mental disorder 19.8

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ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES

• Clinical presentation may differ from that of
  younger individuals
• e.g., more somatic symptoms
• Detection is complicated by comorbidity with
  medical disorders
• somatic disorders may mimic symptoms of mental
  disorders

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ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES

• Physicians feel ill equipped to detect mental
  disorders in the elderly
• e.g., in one study, only 55 of internists felt
  confident diagnosing depression, and only 35
  felt confident in prescribing anti-depressants to
  their elderly patients (Callahan et al., 1992).
• Based on the ECA, it is estimated that up to 63
  of adults 65 years experience an unmet need for
  mental health services (Rabins, 1996).

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ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES

• Stereotypes about the elderly result in incorrect
  or delayed diagnosis
• e.g., some believe that depression is an
  unavoidable consequence of bereavement and
  therefore does not warrant clinical attention
• Cognitive decline makes assessment and diagnosis
  difficult
• e.g., cognitive deficits may make it difficult to
  obtain an accurate history

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COGNITIVE DISORDERS IN THE DSM IV

• A. Clinically significant deficit in
  cognition
• Intelligence
• Information processing
• Problem solving
• Language
• Learning
• Memory
• B. Represents a change from previous levels of
  functioning

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AGING AND MENTAL HEALTH

• With increasing age, cognitive disorders become
  more prevalent. E.g., rates of cognitive
  disorders among the elderly
• 65 or older 5
• 80 or older 20
• Over 80 (50) of the elderly have one (two or
  more) chronic health condition(s)
• But beware of myths about aging

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DSM IV COGNITIVE DISORDERS

• Dementia
• Delirium
• Amnesia

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DSM IV COGNITIVE DISORDERS

• 1. Dementia Permanent loss of basic cognitive
  functions
• Memory deficit (required for diagnosis)
• Language deficit Aphasia
• Apraxia (impaired ability to execute motor
  behavior)
• Agnosia (failure to recognize objects or people)
• Impairment in executive functioning (planning,
  abstract thinking)

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DSM IV COGNITIVE DISORDERS

• 2. Delirium
• A. Disturbance of consciousness reduced
  ability to focus, sustain, or shift attention
• B. Change in cognition (e.g., memory deficits)
  or development of perceptual disturbances
• C. Rapid onset fluctuating course

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DSM IV COGNITIVE DISORDERS

• 3. Amnestic Disorder
• A. Memory impairment
• impaired ability to learn new information
• impaired ability to recall previously learned
  information
• B. The memory disturbance causes significant
  impairment and represents a decline from a
  previous level of functioning.
• C. The memory disturbance does not occur
  exclusively during the course of delirium or
  dementia.

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DIFFERENTIAL DIAGNOSIS
Feature Delirium Dementia
Clinical course rapid onset insidious
onset short duration long duration fluctuat
ing relatively stable
Cognitive Disturbances Awareness impaired
usually normal Alertness reduced usually
normal Orientation impaired may be
intact Memory recent --impaired recent
remote impaired Thinking slow or
accelerated/ poor abstraction/ dreamlike imp
overished
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DIFFERENTIAL DIAGNOSIS
Feature Delirium Dementia
Perception often misperceptions typically absent
Sleep-wake cycle always disrupted/ fragmented
sleep often drowsiness during the
day/insomnia at night
Physical illness or drug toxicity usually
present often absent
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Multiple causes of cognitive disorders in the
elderly
Medical Illness
Medications
COGNITIVE DISORDER
Brain disease
Psychiatric illness
Behavioral Alterations
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MYTHS ABOUT THE ELDERLY

• Uniformity (all old people are the same)
• within group differences increase with age
• health varies widely
• lifestyles vary widely
• due to rapid social change, each generation of
  elderly likely will differ from the next

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ALZHEIMERS DISEASE

• Diagnosis is based on cognitive symptoms
• Behavioral symptoms, however, are common and
  often very disruptive (often prompting
  institutionalization)
• e.g., 30-50 of Alzheimers patients experience
  delusions
• Many experience insomnia, incontinence, emotional
  and physical outbursts

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ALZHEIMERS DISEASE

• Estimated to affect 8-15 of people over 65
• Clinical picture involves gradual memory loss,
  deficits in language, planning ability, abstract
  thinking, behavioral symptoms such as agitation,
  and may include depressive and psychotic
  symptoms.
• Diagnosis is difficult due to lack of biological
  markers, insidious onset, and similarity to
  dementias due to other causes

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ALZHEIMERS DISEASE

• Diagnosis depends on clinical features
• Diagnosis can be confirmed with pathological
  evidence (biopsy or autopsy) characteristic
  malformation of neurons (neuritic plaques and
  neurofibrillary tangles), especially in the
  hippocampus, and loss of brain cells.

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ALZHEIMERS DISEASE

• Clinical course involves a gradual decline
• Memory deficits typically are the first symptoms
• Depression is common in the early stages
• Agitation is more common in the later stage
• Duration of illness averages 8 to 10 years

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ETIOLOGY OF ALZHEIMERS DISEASE

• Familial form (accounts for 5 of cases)
  --genetic factors mutations in chromosomes 21,
  14, and 1
• These mutations appear to result in
  overproduction of the protein found in neuritic
  plaques, beta-amyloid.
• Onset of the familial form is early, but course
  and nature appear to be influenced by
  environmental factors

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ETIOLOGY OF ALZHEIMERS DISEASE

• Approximately 50 of individuals with a family
  history of Alzheimers, if followed into their
  80s and 90s, develop the disorder.
• Non-familial form--genetic influences possibly
  related to chromosome 19 other genes are under
  study.

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ETIOLOGY OF ALZHEIMERS DISEASE

• Biological changes due to aging (these changes
  have led some to speculate that most individuals
  will eventually develop Alzheimers if the human
  life span was extended)
• neuron and synaptic loss
• decreased dendritic span
• lower cortical acetylcholine levels
  (neurotransmitter)

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ALZHEIMERS DISEASE PROTECTIVE FACTORS

• Genetic endowment with the ApoE-e2 allele
  (mechanism is not understood)
• Higher education
• Use of nonsteroidal anti-inflammatory drugs
  (possibly slow plaque formation)
• Estrogen replacement therapy
• Vitamin E and the drug selegiline (deprenyl)
  appear to slow progression

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MYTHS ABOUT THE ELDERLY

• Loss of productivity or creativity
• older workers have fewer avoidable absences form
  work, fewer work accidents
• Goethe wrote Faust at age 80 years
• George Bernard Shaw wrote Farfetched Fables at
  age 93
• A. Rubinstein played at Carnegie Hall at age 90

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MYTHS ABOUT THE ELDERLY

• Loss of productivity or creativity
• older workers have fewer avoidable absences form
  work, fewer work accidents
• Goethe wrote Faust at age 80 years
• George Bernard Shaw wrote Farfetched Fables at
  age 93
• A. Rubinstein played at Carnegie Hall at age 90

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SUCCESSFUL AGING depends on...

• Avoiding disease and disability
• Sustaining high cognitive and physical
  functioning
• Engaging with life (i.e., maintaining
  relationships and productive activities)