Late Life and Neurocognitive Disorder

• Elderly


  Over the age of 65
• In less than 200 years, life expectancy has almost doubled in the Western world
• 40% of practicing psychologists regularly conduct clinical work with older adults
• Myths about late life

  • Aging involves inexorable cognitive decline
  • Severe cognitive problems do not occur for most
  • Mild declines are common
  • Older adults are unhappy
  • Older adults are more skilled at emotion regulation; Attend more to positive; Display less psychophysiological response to negative emotion
  • Late life is a lonely time
• Problems experienced in late life

  • Physical decline and disabilities
  • Sensory acuity deficits
  • Loss of loved ones
  • Social stress of stigmatizing attitudes towards elderly
  • Cumulative effects of a lifetime of stressors
  • Decline in quality and depth of sleep
  • Polypharmacy: Prescribing multiple drugs to a person; 40% of elderly persons are prescribed at least 5 medications; Increases the risk of adverse drug reactions
• Cross-sectional studies


  • Researcher compares different age groups at the same point in time on a variable of interest; Fails to provide information about how people change over time
• Longitudinal studies


  • Researcher retests the same group of people with the same measures at different points in time; May extend over several years or decades; Attrition can lead to biased sample; Selective mortality – no longer available for follow-up because of death; People with the most problems are likely to drop out from a study
• DSM criteria are the same for older and younger adults
• Disentangling medical and psychological concerns is complex!
• Psychological disorders are less common in the elderly than in younger adults
• Reasons for lower prevalence of psychological disorders in the elderly

  • More positive emotionality
  • More close-knit social circles
  • May grow out of those symptoms
  • Methodological issues lead to underestimation of prevalence
  • Most people with psychological disorders in late life are experiencing a continuation of symptoms that began earlier
• Methodological issues leading to underestimation of prevalence

  • Response bias: Discomfort discussing symptoms may minimize prevalence estimates
  • Cohort effects: E.g., many people who reached adulthood during the drug-oriented era of the 1960s continue to use drugs as they age
  • Selective mortality: Psychological disorders are associated with premature mortality
• Treatment for psychological disorders in the elderly

  • Similar to treatments that work in earlier life
  • Many medications can cause serious side effects in elderly
  • Psychotherapy is the first line approach for anxiety
  • Adapt to adjust for vision and hearing loss
  • Telemental health for people with limited mobility
  • May include a caregiver in therapy sessions
  • Use of memory aids (e.g., worksheets on session content)
• Dementia


  Deterioration of cognitive abilities causing impairment
• Most common symptoms of dementia

  • Diminished memory, especially for recent events
  • Depression
  • Sleep disturbances
  • Delusions and hallucinations
  • Difficulty with impulse control
• Most dementias develop slowly over a period of years
• Mild Cognitive Impairment (MCI)


  Early signs of decline before functional impairment
• Problems with DSM-5 criteria requiring a low score on only one cognitive test
• Some cognitive tests are more reliable and relevant than others; Using more than one test improves reliability
• 10% of the time, cognitive declines are tied to other problems: Infection, sleep loss, thyroid disease, vitamin deficiencies
• Current MCI criteria may not be very reliable; Could lead to over-diagnosis
• Not all people with MCI develop dementia
• Mild Neurocognitive Disorder (Mild Cognitive Impairment)


  Modest cognitive decline from previous levels in one or more domains
• Major Neurocognitive Disorder (Dementia)


  Significant cognitive decline from previous levels in one or more domains
• Less than 2% of dementia occurs before the age of 65
• Prevalence of dementia increases dramatically as people age, with more than 1/3 of people in their 90s having dementia
• Prevalence of dementia appears lower in sub-Saharan Africa and higher in Latin America
• Age of onset of dementia is becoming later over time in the US and Europe
• The number of dementia cases is expected to double by 2030 as the number of elderly grow
• Types of dementia discussed

  • Alzheimer's disease
  • Frontotemporal dementia
  • Vascular dementia
  • Lewy body dementia
• Alzheimer's disease is the most common form of dementia, accounting for more than half of all dementias
• Alzheimer's disease


  Irreversible brain tissue deterioration; Death usually occurs within 12 years
• Early symptoms of Alzheimer's disease


  • Absentmindedness and gaps in memory for new material
  • Leaving tasks unfinished or forgotten
  • Difficulty finding words
• Other symptoms of Alzheimer's disease


  • Apathy, depression, disorientation
  • As brain deterioration progresses, the severity of symptoms increase
  • At first, people are often unaware of their cognitive problems
  • Progresses to oblivious awareness of surroundings
• Plaques


  β-amyloid protein deposits, primarily found in frontal cortex
• Neurofibrillary tangles


  Protein filaments composed of tau, primarily found in hippocampus
• Immune responses to plaques lead to inflammation and loss of synapses and neuronal death
• The ApoE-4 gene increases deposition of beta-amyloid plaques
• Late onset Alzheimer's disease has a heritability between 60-80%
• 19 specific genetic loci have been identified for Alzheimer's disease, but most of the genes explain a very small amount of risk