Morteza Ansarinia Institute for Cognitive Science Studies November 2016 Cognitive Disorders in the Elderly 

Outline ✦ Introduction ✦ Comorbidity ✦ Potential Triggers & Symptoms ✦ Neurobiology ✦ Elderly in DSM-5 ✦ Depression, Anxiety, Psychosis, Substance Abuse, and
 Dementia ✦ Alzheimer’s Disease, Delirium, and Parkinson’s ✦ Sex Differences ✦ Rehabilitation Methods ✦ Caregivers ✦ Reverse Aging 2 

2 3 4 1 Old age refers to ages nearing or surpassing the life expectancy of human beings, and is thus the end of the human life cycle. Zimmer (2016) and Xiao et al. (2016) identified the maximum human lifespan at an average age of 115, with an absolute upper limit of 125 years. old age is a social construct rather than a definite biological stage. Most developed countries accepted 65 yo as old age, UN suggested 60, and WHO set 50. The definitions of old age continue to change. Mental marks of old age include adaptability, caution, depressed mood, fear of crime, mental disorders, reduced mental and cognitive ability, and preference for the routine. 3 Facts Wikipedia (Retrieved October 2016) 

4 UN (2013) Facts Depression 0-18 19-40 41-60 60+ 0% 20% 40% 60% 80% Population Change (2010-50) Anxiety 0% 20% 40% 60% 80% OCD 0% 20% 40% 60% 80% Psychosis 0% 20% 40% 60% 80% Social Phobia 0% 20% 40% 60% 80% … 

5 Aging and the Brain ✦ The brain shrinks and there are changes at all levels from molecules to morphology. ✦ Brain volume declines with age (~5% per decade after age 40).
 Different areas affected in men and women.
 Decrease in dendritic synapses or loss of synaptic plasticity.
 WM declines(the myelin sheath deteriorates even in normal aging).
 The late myelinating regions of the frontal lobe are most affected by WML. ✦ Episodic memory decline, a characteristic of the memory loss seen in Alzheimer's disease (AD). ✦ Semantic memory increases gradually from middle age to the young elderly but then declines in the very elderly. ✦ Slower reaction times, lower attentional levels, slower processing speeds, and a lesser ability to use strategies. ✦ HAROLD: hemispheric asymmetry reduction in older adults. Peters (2006) 

6 Aging and Neurotransmitters ✦ Dopamine levels decline (~10% per decade) and have been associated with declines in cognitive and motor performance. - Dopaminergic pathways between the FC and the striatum decline - levels of dopamine itself decline, - synapses/receptors are reduced or binding to receptors is reduced. ✦ Serotonin falls with increasing age and may be implicated in the regulation of synaptic plasticity and neurogenesis in the adult brain. ✦ Sex hormones can affect cognitive processes in adulthood and that changes occur in aging particularly in women. ✦ Growth hormone levels also decline with age and may be associated with cognitive performance although the evidence is far from clear. ✦ Reduction in glucose may partly be attributable to atrophy rather than any change in glucose metabolism. Nyberg and Bäckman (2004) Nair et al. (2014) 

Introduction ✦ The Elderly, seniors, older adults, old patients, geriatrics, elders, gerontology, senile diseases, etc. ✦ Mental disorders are common in old age but frequently remain undetected and undiagnosed. ✦ They impair life quality, promote further disability, disturb rehabilitation, are strongly interrelated with somatic diseases, burden the health system both for old patients and their relatives, respond to treatment, and of multi-morbid fashion. ✦ One in two older adults had experienced a mental disorder in their lifetime, one in three within the past year and nearly one in four currently had a mental disorder. The most prevalent disorders were anxiety disorders, followed by affective and substance-related disorders. 7 Hilger & Fischer (2001) Andreas et al. (2016) 

Comorbidity ✦ Late-life mental disorders rarely occurs in isolation.
 Comorbidity (or multimobidity) refers to the coexistence
 of two or more chronic conditions. ✦ Two types of very high comorbidity among elderly: between depression and anxiety disorders, as well as between different anxiety disorders (reported comorbidity of 50-90%). ✦ 91% of the elderly with GAD also had depression. ✦ 95% of those with depression had symptoms of anxiety. ✦ All the measures of multimorbidity and individual diseases is associated with the social activity limitations (Jones et al., 2016). 8 Skoog (2011) Gum and Cheavens (2008) Jones et al. (2016) Lindesay et al. (1989) Antidepressants and/or CBT for comorbid anxiety. Antidepressants and dialectical behavior therapy for comorbid personality disorders. Antidepressants and counseling for alcohol abuse that incorporates specific coping skills training for mood management, based on CBT. Salive (2013) 

Manifestations ✦ Manifestations of mental disorders may be different in the elderly, compared with younger age groups. ✦ Elderly people may present with a smaller number of symptoms or one dominating symptom. ✦ Low recovery rate for depression, and high rate for social phobia at
 5-year follow-up. ✦ Criteria for mental disorders are often validated in younger age groups, and their use in the elderly has therefore been questioned. ✦ Examples of different manifestations for the elderly: - Anxiety disorders may have different manifestations, with fewer symptoms, less somatic and autonomic symptoms, less avoidance, more agitation, irritability, talkatively, tension, and with more somatization. - Elderly people with late-onset psychosis have better preserved personality compared to the younger adults, less affective blunting, less formal thought disorder, more insight, and less excess of focal structural brain abnormalities and cognitive dysfunction, compared with age-matched control subjects. 9 Skoog (2011) 

Elderly in DSM-5: Overview ✦ Major Depressive Disorders ✦ Anxiety Disorders ✦ Body Dysmorphic Disorder ✦ Hoarding Disorder ✦ Caffeine Intoxication ✦ Sedative, Hypnotic, or Anxiolytic Use Disorder ✦ Neurocognitive Disorders (disentangling symptoms of delirium, dementia, and Alzheimer’s disease) and Neurocognitive Disorder with Lewy Bodies (NCDLB) ✦ Dependent Personality Disorder ✦ Sleep-Wake Disorders (Obstructive Sleep Apnea
 Hypopnea) 10 APA (2013) 

Elderly in DSM-5 ✦ Schizoaffective disorder (depressive type) may be more common in older adults. ✦ The presence of specific phobia in older adults is associated with decreased quality of life and may serve as a risk factor for major neurocognitive disorder. ✦ Specific phobia is frequently associated with a range of other disorders, especially depression in older adults. ✦ In older adults, impairment may be seen in caregiving duties and volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and reduced physical and social functioning, and may lead to receiving formal or informal home support. 11 APA (2013) 

Elderly in DSM-5: Social Anxiety ✦ Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. ✦ Older adults express social anxiety at lower levels but across a broader range of situations. In older adults, social anxiety may concern disability due to declining sensory functioning (hearing, vision) or embarrassment about one's appearance (e.g., tremor as a symptom of Parkinson's disease) or functioning due to medical conditions, incontinence, or cognitive impairment (e.g., forgetting people's names). ✦ Detection of social anxiety disorder may be challenging because of several factors, including a focus on somatic symptoms, comorbidity, limited insight, changes to social environment or roles that may obscure impairment in social functioning, or reticence about describing psychological distress. ✦ Social anxiety disorder also interferes with leisure activities. 12 APA (2013) 

Elderly in DSM-5: Panic Disorders ✦ Lower prevalence of panic disorder in older adults appears to be attributable to age-related dampening of the autonomic nervous system response. ✦ Many older individuals with panicky feelings are observed to have a hybrid of limited-symptom panic attacks and generalized anxiety. ✦ Older adults tends to to attribute their panic attacks to certain stressful situations, such as a medical procedure or social setting. Older individuals may retrospectively endorse explanations for the panic attack, which would preclude the diagnosis of panic disorder, even if an attack might actually have been unexpected in the moment (and thus qualify as the basis for a panic disorder diagnosis). This may result in under-endorsement of unexpected panic attacks in older individuals. ✦ Careful questioning of older adults is required to assess
 whether panic attacks were expected before entering the
 situation, so that unexpected panic attacks and the
 diagnosis of panic disorder are not overlooked. 13 APA (2013) 

Elderly in DSM-5: Sleep Disorders ✦ Sleep continuity is often interrupted in healthy older adults who nevertheless identify themselves as good sleepers. ✦ Insomnia complaints are more prevalent among older adults. The type of insomnia symptom changes as a function of age … with problems maintaining sleep occurring more frequently among older individuals. ✦ The increased prevalence of insomnia in older adults is partly explained by the higher incidence of physical health problems with aging.
 Changes in sleep patterns associated with the normal developmental process must be differentiated from those exceeding age-related changes. Polysomnography may be useful in the differential diagnosis among older adults because the etiologies of insomnia (e.g., sleep apnea) are more often identifiable in older individuals. ✦ As many as 50% of individuals with sleep apnea may also report insomnia symptoms, a feature that is more common among older adults. 14 APA (2013) 

Elderly in DSM-5: Sleep Disorders ✦ Narcolepsy onset is typically in children and adolescents/young adults but rarely in older adults. ✦ Behavioral factors such as irregular sleep schedules, voluntary early awakening, and exposure to light in the early morning should be considered in older adults. ✦ Age at circadian rhythm sleep-wake disorders onset is variable, but the disorder is more common in older adults. 15 APA (2013) 

Elderly in DSM-5 ✦ Incapacitating or embarrassing symptoms include a fear of falling in older adults. ✦ Agoraphobia: Older adults are likely to over-attribute their fears to age- related constraints and are less likely to judge their fears as being out of proportion to the actual risk. ✦ Anxiety Disorders: in older adults, being in shops, standing in line, and being in open spaces are most often feared. Also, cognitions often pertain to falling in older adults. ✦ Older adults report greater concern about the well-being of family or their own physical heath. ✦ Hoarding symptoms appear to be almost three times more prevalent in older adults (55-94 yo) compared with younger adults (34-44 yo). 16 APA (2013) 

Elderly in DSM-5 ✦ Cannabis Use Disorder: Social acceptance and availability of medical marijuana may increase the rate of onset of this disorder among elderly. ✦ Gambling Disorder is more common among younger and middle-age persons than among older adults.
 Younger individuals prefer different forms of gambling (e.g., sports betting), while older adults develop problems with slot machine and bingo gambling. ✦ Full-threshold PTSD also appears to be lower among older adults; there is evidence that subthreshold presentations are more common in later life and these symptoms are associated with substantial clinical impairment. ✦ Somatic Symptom Disorder: may be under-diagnosed in older adults either because certain somatic symptoms (e.g., pain, fatigue) are considered part of normal aging or because illness worry is considered understandable in older adults who have more general medical illnesses and medications. Concurrent depressive disorder is common in older people who present with numerous somatic symptoms. 17 APA (2013) 

Elderly in DSM-5 ✦ Avoidant/Restrictive Food Intake Disorder: reduced intake in older adults. ✦ The Hypoactive State of Delirium may be more frequent in older adults. 18 APA (2013) 

Potential Triggers ✦ Physical disability. ✦ Long-term illness (e.g., heart disease or cancer). ✦ Dementia-causing illness (e.g. Alzheimer’s disease). ✦ Physical illnesses that can affect thought, memory, and emotion (e.g. thyroid or adrenal disease). ✦ Change of environment, like moving into assisted living. ✦ Illness or loss of a loved one. ✦ Medication interactions. ✦ Alcohol or substance abuse. ✦ Poor diet or malnutrition. 19 Geriatric Mental Health Foundation Female sex, adverse life events, physical health, disability, institutionalization, medical drugs, decreased social network and support, and cerebral organic factors, such as brain atrophy and cerebrovascular disease, previous psychiatric history, family history of depression, low education, personality factors, smoking, alcohol consumption, being unmarried, being divorced, low social functioning, sensory impairments, especially deafness, vascular disease, and more dependence in community care, and somatic disorders. 

Symptoms ✦ Sad or depressed mood lasting longer than two weeks. ✦ Social withdrawal; loss of interest in things that used to be enjoyable. ✦ Unexplained fatigue, energy loss, or sleep changes. ✦ Confusion, disorientation, problems with concentration or decision-making. ✦ Increase or decrease in appetite; changes in weight. ✦ Memory loss, especially recent or short-term memory problems. ✦ Feelings of worthlessness, inappropriate guilt, helplessness; thoughts of suicide (suicide ideation). ✦ Physical problems that can’t otherwise be explained: aches, constipation, etc. ✦ Changes in appearance or dress, or problems maintaining the home or yard. ✦ Trouble handling finances or working with numbers. 20 

Cognition is the ability to think, understand, and reason. Cognitive functions include memory, orientation, language (verbal fluency, receptive, and expressive communication), praxis (doing things), recognition, visuospatial ability, abstract thought, executive function (decision-making, planning, judgement), and insight. Alzheimer’s Disease and Other Dementia 21 Fong (2009) ✦ A progressive disease that destroys memory and other
 important mental functions. Brain cell connections and
 the cells themselves degenerate and die. ✦ 3 millions per year (only in US); can’t be cured, but
 treatment may help; and it’s chronic. ✦ narrowing of gyri and widened sulci,
 and hippocampal atrophy with enlargement
 of lateral ventricles, especially temporal horn. 0-18 19-40 41-60 60+ 

✦ Most studies on risk factors for mental disorders are concerned with depression. ✦ Risk factors for late-life depression tend to be more biological. ✦ Major depression has been associated with ventricular enlargement, changes in the caudate nuclei, putamen, and with atrophy in the frontal, temporal, and parietal lobes. ✦ Postmortem studies have reported on cellular alterations such as neuronal death, neuronal shrinkage, decrease in dendritic and glial density, and cell death in the frontal cortex and hippocampus in the elderly with major depression. Depression Dementia ✦ Largely replaced by major NCD in DSM-5. ✦ The prevalence of dementia and milder forms of cognitive decline increases with age. ✦ Decline with age for depression and anxiety disorders disappear if people with dementia are excluded. ✦ Depression has repeatedly been suggested to be a risk factor for dementia. ✦ Anxiety and psychotic symptoms may also increase risk for subsequent dementia (within 5 years). ✦ 35% of patients with late paraphrenia had dementia within 3 years of diagnosis. 22 Foley and Heck (2014) Skoog (2011) 

✦ Seniors have among the highest rates of suicide, nearly 50% higher than the average. ✦ Perceived burdensomeness, physical disorders, and loneliness account for significant variance in suicide ideation, even after predictors such as depressive symptoms, hopelessness, and functional impairment are controlled. Sucide Ideation Hypochondria (Health Anxiety Disorders) 23 Delirium ✦ Characterized by inattention and acute cognitive dysfunction. ✦ Predictors: structural changes including cortical atrophy, ventricular dilatation, white matter lesions, acute stress, and disruptions of neurotransmission. ✦ Hypoactive delirium frequently occurs in older patients; frequently misdiagnosed as depression or a form of dementia. ✦ Confusion Assessment Method (CAM) provides diagnostic algorithm. ✦ Nonpharmacological treatment strategies: reorientation and behavioral intervention (e.g., clear instructions and frequent eye contact). ✦ Pharmacological treatments: Antipsychotics (Haloperidol), atypical antipsychotics (Risperidone), Benzodiazepines (Lorazepam), and Cholinesterase inhibitors (Donepezil). Fong (2009) Cukrowicz (2011) Erlangsen (2015) Parkinson's Disease 

✦ Motor Screening Task (MOT) ✦ Reaction Time (RTI) ✦ Paired Associates Learning (PAL) ✦ Pattern Recognition Memory (PRM) ✦ Delayed Matching to Sample (DMS) ✦ Spatial Working Memory (SWM) ✦ Rapid Visual Information Processing (RVP) Alzheimer’s Battery Parkinson’s ✦ MOT ✦ PAL ✦ RTI ✦ PRM ✦ OTS ✦ SWM 24 Cambridge Cognition CANTAB 

Sex Differences ✦ Women live longer than men; at the age of 95 years, the female-to-male ratio is 4 to 1. ✦ Female sex is the most consistent risk factor for depression and some anxiety disorders. ✦ However, the female preponderance of depression is most accentuated in middle life, and the sex difference may diminish with increasing age. ✦ Social and specific phobias are more common in older woman. But first, some fears (e.g., spiders and heights) may be innate in humans.
 And as part of gender socialization, boys may be, to a greater extent than girls, encouraged to expose themselves and habituate toward these stimuli. Second, fears may develop more often in girls owing to gender differences in role modeling or in information regarding the danger of different exposures. ✦ Burdensomeness exerted a greater influence on suicide ideation in males. Cukrowicz et al. (2011) found no support for this hypothesis. 25 

26 Heijer et al. (2004) Rehabilitation ✦ Reduce cardiovascular risk: - Regular exercise, - a healthy diet (energy restriction may prolong life), - and low to moderate alcohol intake may reduce cardiovascular risk and may stimulate the hippocampus. ✦ Increased cognitive effort in the form of education or occupational attainment. ✦ Healthy life both physically and mentally. Mukamal et al. (2003) Peters (2006) 

27 Nair et al. (2014) Rehabilitation: Exercise 

Caregivers ✦ One third of caregivers report no negative health effects. ✦ They report that caregiving makes them feel good about themselves and as if they are needed, gives meaning to their lives, enables them to learn new skills, and strengthens their relationships with others. ✦ Individuals in supportive social relationships are happier and
 healthier and live longer than those who are socially isolated. ✦ Recent findings suggest that supporting or helping others
 may be just as beneficial to health as receiving support. ✦ Studies show caregiving causes psychological distress,
 but virtually none have demonstrated that stress results
 in physiologic dysregulation, such as increased cortisol
 secretion or changes in immune function over time. ✦ Not yet demonstrated that such physiologic
 responses are directly linked to illness outcomes in
 caregivers. 28 Schulz and Sherwood (2008) 

Reverse the Aging ✦ Caloric Restriction: By reducing normal food intake by 30%, the life span of most animals can be extended by 30%. ✦ Antioxidants: Certain chemicals seems to reverse the damage caused by oxidation, which causes to age. ✦ Genetic & Bioinformatics: Genes such as SIR2, AGE-!, AGE-2,
 and other genes have been shown to influence the
 aging process. One might be able to isolate precisely
 where aging takes place in our cells. ✦ Mitochondria: Aging in the cell takes place in its “engine.” ✦ Parabiosis & GDF11: Growth Differentiation Factor 11
 appeared to be one of the key components of the
 young blood. 29 Sinha et al. (2014) 

References ✦ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. ✦ Borges, G., Acosta, I., & Sosa, A. L. (2015). Suicide ideation, dementia and mental disorders among a community sample of older people in Mexico. International journal of geriatric psychiatry, 30(3), 247-255. ✦ Cadieux, R. J. (1993). Psychiatric disorders in the elderly. Patient Care, 27(12), 111-126. ✦ Cukrowicz, K. C., Cheavens, J. S., Van Orden, K. A., Ragain, R. M., & Cook, R. L. (2011). Perceived burdensomeness and suicide ideation in older adults. Psychology and aging, 26(2), 331. ✦ Erlangsen, A., Stenager, E., & Conwell, Y. (2015). Physical diseases as predictors of suicide in older adults: a nationwide, register- based cohort study. Social psychiatry and psychiatric epidemiology, 50(9), 1427-1439. ✦ Gum, A. M., & Cheavens, J. S. (2008). Psychiatric comorbidity and depression in older adults. Current psychiatry reports, 10(1), 23-29. ✦ Hilger, E., & Fischer, P. (2001). Mental Disorders in Old Age. ✦ Jones, S. M., Amtmann, D., & Gell, N. M. (2016). A psychometric examination of multimorbidity and mental health in older adults. Aging & mental health, 20(3), 309-317. ✦ Petersson, S., Mathillas, J., Wallin, K., Olofsson, B., Allard, P., & Gustafson, Y. (2014). Risk factors for depressive disorders in very old age: a population-based cohort study with a 5-year follow-up. Social psychiatry and psychiatric epidemiology, 49(5), 831-839. ✦ Reynolds, K., Pietrzak, R. H., El-Gabalawy, R., Mackenzie, C. S., & Sareen, J. (2015). Prevalence of psychiatric disorders in US older adults: findings from a nationally representative survey. World Psychiatry, 14(1), 74-81. ✦ Salive, M. E. (2013). Multimorbidity in older adults. Epidemiologic reviews. ✦ Schulz, R., & Sherwood, P. R. (2008). Physical and mental health effects of family caregiving. The American journal of nursing, 108(9 Suppl), 23. ✦ Skoog, I. (2011). Psychiatric disorders in the elderly. The Canadian Journal of Psychiatry, 56(7), 387-397. ✦ Thakur, M. E. (Ed.). (2015). The American psychiatric publishing textbook of geriatric psychiatry. American Psychiatric Publishing. 30 

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