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«WHAT PRACTITIONERS SHOULD KNOW ABOUT WORKING WITH OLDER ADULTS NORMAN ABELES, PHD President, American Psychological Association APA Working Group on ...»

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Despite common physical difficulties, three-fourths of community dwelling people aged 65 to 74 report their health to be good, very good, or excellent compared with others their age, as do two-thirds of noninstitutionalized persons 75 years and over.

The top five causes of death among older adults are heart disease, cancer, cerebrovascular disease, pneumonia and influenza, and chronic obstructive pulmonary disease.

MANY OLDER ADULTS PROVIDE ASSISTANCE TO YOUNGER FAMILY

MEMBERS, INCLUDING GIVING EMOTIONAL SUPPORT, CARING FOR

GRANDCHILDREN OR DISABLED CHILDREN, PROVIDING A PLACE TO

LIVE, OR MAKING MONETARY GIFTS OR LOANS.

WHAT ARE THE COGNITIVE CHANGES ASSOCIATED WITH NORMAL AGING?

Some cognitive abilities decline with age, some may improve, and some show little change. Such changes are highly variable from one person to another, and even vary within a given person for different aspects of cognition. For example, creativity can continue into the ninth decade of life. For those functions that do decline, the change is not severe enough to cause significant impairment in daily occupational or social

functioning, as occurs with a dementing disorder such as Alzheimer’s disease. Some general findings include:

Information processing speed declines with age, which may result in a slower learning rate and greater need for repetition of new information.

Divided attention between two simultaneous tasks shows age-related decline, as does ability to switch attention rapidly between multiple auditory inputs, although ability to switch attention between visual inputs does not change much with age. Overall levels of performance in sustained attention or vigilance tasks appear to reduce with age. Filtering out irrelevant information through selective attention also appears to decline with age.

Short-term, or primary, memory shows relatively less age-related decline.

Long-term, or secondary, memory shows more substantial age changes, although the decline is greater for recall than for recognition, and performance generally benefits from cueing.

Most aspects of language ability are well-preserved, such as the use of language sounds, meaningful combination of words, and verbal comprehension; and some aspects may continue to improve with age, such as vocabulary. However, word-finding, or naming, ability and rapid word list generation show declines with age.

A variety of tasks shows age-related visuospatial decline, including three-dimensional construction and drawing.

Abstraction and mental flexibility also show some decline with age.

An accumulation of practical expertise, or wisdom, may continue toward the very end of life.

WHAT ABOUT THE MENTAL HEALTH OF OLDER ADULTS?

Older people evidence fewer diagnosable psychiatric disorders than younger persons, excluding cognitive impairments. A major population-based survey found that the overall prevalence of mental disorders for older adults was lower than for any other age group. Only cognitive impairment shows a definite age-associated increase in incidence.

General life satisfaction among older adults is as good as, if not better than, any other age group. Life satisfaction is associated with good health, an adequate income, adequate social relationships, and a sense of control over one’s life.

Older adults often have a positive outlook and seek challenges and activities that maintain their well-being.

They may take classes, participate in elder hostels, exercise, study new subjects, travel, and have satisfying sexual relationships.

HOW IS PERSONALITY AFFECTED BY AGE?

A variety of studies shows considerable stability of key personality traits, such as neuroticism, extraversion, and locus of control, over time.

Stability across the second half of the adult lifespan may be stronger than across the first half.

HOW DO OLDER ADULTS COPE WITH NORMAL AGE-ASSOCIATED CHANGES?

Despite physical or cognitive declines, many older adults develop effective coping mechanisms, either

spontaneously or through outside instruction:

“Use it or lose it”—Practicing memory and other cognitive strategies by doing crossword puzzles, playing bridge, engaging in other challenging mental activities.

–  –  –

Modifying tasks or modifying the environment to accommodate physical changes.

Drawing strength from personal spirituality and cultivating creativity, optimism, and hope.

–  –  –

IV. PSYCHOLOGICAL PROBLEMS SOME OLDER ADULTS EXPERIENCE

Older adults may evidence a broad array of psychological issues and disorders, including almost all the problems that affect younger adults. Older adults may suffer recurrences of psychological disorders they experienced when younger, or they may have new problems due either to the developmental stresses of late life or neuropathology. Older adults often have multiple problems. For example, an individual may have a mental disorder such as major depression and a substance abuse or personality disorder. Medical problems are more common in older adults, and psychological symptoms and syndromes are often comorbid with physical illness.





In addition, the classic presentation of disease is sometimes not evident, but rather the symptoms present in a nonspecific manner (e.g., refusal to eat, falling). Further, older adults often receive one or more medications for medical problems, and difficulties may arise due to drug-drug interactions or side effects of medications.

Understanding comorbidity of mental and medical disorders is a central task in assessing and treating psychological problems in older adults. The psychological disorders listed are in alphabetical order.

ANXIETY DISORDERS

Population-based surveys have found that about 6 percent of older people have anxiety disorders. Because anxiety disorders often coexist with affective disorders, medical disorders, and dementia, this rate may actually be higher.

The most common anxiety diagnosis among older adults is generalized anxiety disorder.

A number of medical conditions are often mistaken for generalized anxiety disorder because anxiety and shortness of breath may be prominent early symptoms.

Obsessive-compulsive symptoms wax and wane throughout the life course and can present as a primary problem or secondary to depression.

Panic disorder rarely has a later-life onset, and, among those who developed it earlier, the symptoms usually recede by late adulthood. Some older adults report episodes of panic, but these are usually less severe and may coexist with physical illness or symptoms of depression.

Phobic disorders affect some older adults but are more common earlier in life.

Posttraumatic stress disorder can occur at any age and is a common symptom among older combat veterans and former prisoners of war.

THE MOST COMMON ANXIETY DIAGNOSIS AMONG OLDER ADULTS

IS GENERALIZED ANXIETY DISORDER.

CHRONIC PAIN

By far the most common painful condition found among older adults is osteoarthritis.

Assessment and diagnosis of pain are typically more complicated in older adults than in younger adults.

However, it is important that the condition be evaluated thoroughly, as pain complaints may mask a major depressive disorder.

Depression is often associated with chronic pain. This is especially true among older adults in which the two may coexist and interact. In addition, boredom, loneliness, and bereavement can influence the perception and report of pain.

Pain behavior may be reinforced inadvertently by well-meaning family members and others who pay more attention to the individual when he or she is complaining of pain than when there are no physical complaints.

DELIRIUM (ACUTE CONFUSIONAL STATE)

Rapid-onset, fluctuating mental status changes may represent a delirium or acute confusional state.

Delirium-related confusion and agitation are usually accentuated later in the day (so-called “sundowning”).

Predisposing factors to delirium include older age, metabolic disturbances, polypharmacy, infections, anesthesia, hip fracture, unfamiliar surroundings with loss of daily routine, sensory understimulation or overstimulation, disruption of sleep-wake cycle, a history of dementia or brain injury, and a number of other physical and psychological stressors.

Delirium generally remits when the precipitating factor is treated or removed.

DEMENTIA Population-based research has found that the prevalence of dementia increases dramatically with age, with estimates that 5 to 7 percent of those over age 65 and nearly 30 percent of those over age 85 suffer some form of this disorder. Up to 20 percent of patients have a partially or completely reversible form of dementia.

The most common types of age-associated dementia are those caused by Alzheimer’s disease and cerebrovascular pathology (most notably vascular dementia—formerly called multi-infarct dementia). Some older adults may have both Alzheimer’s disease and vascular dementia.

Unlike milder forms of cognitive decline associated with normal aging, the cognitive deficits associated with dementia cause significant impairment in social and occupational functioning.

People with progressive dementias often evidence coexistent psychological symptoms, which may include depression, anxiety, paranoia, and behavioral disturbances.

Along with the older adult’s need for individual attention, families and caregivers often need help in understanding and coping with the cognitive factors and behavioral problems that accompany dementia.

Dementia is a risk factor for delirium, and the two often coexist.

Depression may also be associated with memory complaints and cognitive impairment. Older adults with a major depressive disorder may perform more poorly on some measures of cognitive function than nondepressed older adults. This reversible cognitive impairment has sometimes been called pseudodementia.

MOOD DISORDERS

Major depressive disorder affects about 1 percent of older adults, and dysthymia, about 2 percent. Major depressive disorder is the most common late onset psychological problem.

Mania in late life does occur in the absence of acute medical precipitants. However, not enough is known about bipolar disorder in older adults, and it may be that it is underdiagnosed in adults over the age of 60.

Mood disorders may present differently in older than in younger adults. For example, compared to younger adults, depressed older adults are more likely to have anxiety, agitation, memory problems, and bodily complaints. They are less likely to complain of depression or feeling sad. Feeling hopeless is often an important indicator of depression among the elderly.

About 20 percent of older individuals living in the community report clinically significant depressive symptoms that do not reach criteria for a diagnosis of mood disorder. They fall into the diagnostic categories of dysthymic disorder or adjustment disorder with depressive features. Certain high-risk groups of older adults have a higher prevalence of depressive symptoms and syndromes, including medical outpatients, inpatients, and those in long-term care settings.

The highest suicide rate of any age group is found in older adults, primarily older Caucasian men who live alone, for whom suicide increases dramatically from age 65 to 85 and older.

PSYCHOTIC DISORDERS

Schizophrenia rarely occurs for the first time in older age. Only 10 percent of people suffering from schizophrenia experience the onset of the disorder after age 40. Consequently, older adults with schizophrenia often have a history of chronic psychotropic use and institutionalization. Older age appears to be related to reduction in frequency and severity of positive symptoms of the disorder, such as hallucinations and delusions. However, because of other aspects of schizophrenia, such as apathy and withdrawal, older people with schizophrenia are at high risk for social isolation and neglect by the mental health system.

The most common form of psychosis in later years is paranoia. Hearing loss may be one important risk factor for developing late-life paranoia. Other risk factors are social isolation, a long-standing personality disorder, dementia, and delirium. Paranoia in older adults tends to be characterized by beliefs that are less bizarre than those reported by younger adults. People may be able to function adequately and demonstrate normal cognitive functioning. Unfortunately, because older adults with paranoia often have delusions related to relatives, friends, and caregivers, the disorder is especially likely to result in increased social isolation.

SEXUAL DYSFUNCTION

Normal age-related changes in sexual functioning can be described as a generally slowed and slightly decreased response to stimulation at every stage of the sexual arousal cycle. However, these changes do not prevent arousal, sexual activities, or orgasm.

The incidence of sexual dysfunction increases with age for both men and women, mostly because of an increase in chronic health problems and increased medication use.

Medication can adversely affect sexual functioning. This is particularly the case with antihypertensive, antipsychotic, anxiolytic, antidepressant, and cardiac medications.

Health problems may also affect sexual functioning. Up to 50 percent of men with diabetes report erectile difficulties, and diabetic women often experience sexual dysfunctions as well. Older men often undergo a surgical procedure to reduce enlarged prostate, known as the transurethral resection of the prostate (TURP).

Older age is associated with a higher risk of sexual difficulties after this procedure.

Neurological disorders are sometimes tied to a decline in sexual functioning, including Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and stroke.

SLEEP DISORDERS



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