Psychology of Adulthood and Aging Notes

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Psychology of Adulthood and Aging Notes:

Chapter 1 Studying Adult Development And Aging

Ageism: The untrue assumption that chronological age is the main determinant of human characteristics and that one age is better than another. A form of discrimination against older adults based on their age.

Gerontology: The study of aging from maturity through old age, as well as the study of older adults as a special group.

Life-span perspective: A view of the human life span that divides it into two phases; childhood/adolescence and young/middle/late adulthood.

Baltes: Four features of life span

perspective-1. Multidirectionality-Development involves growth and decline; as people grow in one area they may lose in another and at different rates.

2. Plasticity-One’s capacity is not predetermined or set in concrete: With limits-Many skills can be trained or

improved with practice.

3. Historical context-We develop within a particular set of circumstances determined by the historical time in which we are born and the culture in which we grow up.

4. Multiple causation-How we develop results from a wide variety of forces, development is shaped by biological, physiological, sociocultural, and life-cycle forces.

Primary implications of a rapid increase in the number of older adults include strains on the Social security, health care, and other human services with the costs having to be borne by the younger smaller generations.

Forces of development:

1. Biological forces - All genetic and health related factors that affect development. Menopause, wrinkling, organ

changes.

2. Psychological forces – All internal-perceptual, cognitive, emotional, and personality factors that affect development.

What people notice about our individualisms.

3. Sociocultural forces – Interpersonal, societal, cultural, and ethnic factors that affect development.

4. Life-cycle forces – Reflect differences in how the same event or combination of biological, psychological, and

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sociocultural forces affects people at different points in their lives

Baltes: Influences that interact to produce developmental change over life span:

1. Normative age-graded influences – Experiences caused by biological, psychological, and sociocultural forces that are highly correlated with chronological age.

a. Biological include: Puberty, Menarche, and Menopause. b. Psychological include focusing on certain concerns at

different points in adulthood, such as a middle-aged persons concern with socializing the younger

generation.

c. Sociocultural examples are the time when first marriage occurs, or when retirement age is decided.

2. Normative history-graded influences – Events that most

people in a specific culture experience at the same time. These events may be Biological (Epidemics), Psychological (Particular stereotypes i.e. generation X or Baby boom) or Sociological (Changing attitudes towards sexuality).

3. Non-Normative influences are random or rare events that may

be important for a specific individual but are not

experienced by most people. Favorable like winning the lottery or unfavorable like losing a job or layoffs or having an accident, such that a life can be changed dramatically.

Controversies in Development

Nature – Nurture Controversy: The extent to which inborn, hereditary characteristics (Nature) and experiential, or environmental influences (Nurture) determine who we are.

Stability – Change controversy: Concerns the degree to which people remain the same over time.

Continuity – Discontinuity controversy: Concerns whether a particular developmental phenomenon represents a smooth

progression over time (Continuity) or a series of abrupt shifts (Discontinuity).

Universal vs. Context-Specific development controversy: Concerns whether there is just one path of development or several.

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Aging:

1. Primary aging – Normal, disease-free development during

adulthood.

2. Secondary aging – Developmental changes that are related to

disease, lifestyle, and other environmentally induced changes that are not inevitable (e.g., pollution). Examples: Alzheimer’s and related forms of dementia.

3. Tertiary aging – The rapid losses that occur shortly before death, i.e. Terminal drop in which intellectual abilities show a marked decline in the last few years before death.

Types of age:

1. Chronological age – How long we’ve been around since birth.

A shorthand way to index time and organize events and data by using a commonly understood standard: calendar time.

2. Perceived age - Refers to the age you think of yourself

as. “Your as young as you feel”.

3. Biological age – Is assessed by measuring the functioning

of the various vital, or life-limiting, organ systems, such as cardiovascular system.

4. Psychological age – Refers to the functional level of the

psychological abilities people use to adapt to changing environmental demands. These abilities include memory, intelligence, feelings, motivation, and other skills that foster and maintain self-esteem and personal control.

5. Sociocultural age – Refers to the specific set of roles

individuals adopt in relation to other members of the society and culture to which they belong.

Research Methods

Measurement in Adult Development and Aging research

1. Reliability of a measure is the extent to which it

provides a consistent index of the behavior or topic of interest.

2. Validity of a measure is the extent to which it measures what researchers think it measures.

4. Systematic Observation involves watching people and carefully recording what they say or do. Typically two

kinds.

a. Naturalistic Observation – People are observed as they behave spontaneously in some real-life situation.

b. Structured Observation – The researcher creates a setting that is particularly likely to elicit the behavior of interest.

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5. Sampling Behavior with Tasks – When investigators can’t

observe a behavior directly, another popular alternative is to create tasks that are thought to sample the behavior of interest. However useful, it cannot prove validity.

Self Reports – Peoples answers to questions about the topic of interest. Also not reliable, due to memory accuracy or answers geared toward what is thought of as the correct answer.

6. Representative sampling – A subset of a population. General Designs for Research

1. Experimental Design – Involves manipulating a key factor that the researcher believes is responsible for a

particular behavior and randomly assigning participants to the experimental and control groups.

2. Independent variables – variables that are manipulated by the experimenter.

3. Dependent variables – the behaviors or outcomes that are measured.

4. Correlational design – A researcher measures two variables, then sees how strongly they are related.

a. r=0 variables unrelated

b. r>0 variables positively related c. r<0 variables inversely related

5. Case studies – An intensive investigation/study of an individual in great detail.

Designs for Studying Development (Age, Cohort, and Time of Measurement)

1. Age effects – Reflect differences caused by underlying processes, such as biological, psychological, or

sociocultural changes.

2. Cohort effects – Differences caused by experiences and circumstances unique to the generation to which one belongs.

3. Time-of-measurement effects – Reflect differences stemming from sociocultural, environmental, historical, or other events at the time the data are obtained from the

participants.

4. Confounding – Any situation in which one cannot be

determine which of two or more effects is responsible for the behaviors being observed.

5. Cross-Sectional Design – Developmental differences are identified by testing people of different ages at the same time.

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6. Longitudinal Design – The same individuals are observed or tested at different points in their lives.

7. Time Lag Design – Measures people of the same age at different points in time.

8. Sequential Design – Represents different combinations of cross-sectional or longitudinal studies, and consists of two or more cross-sectional studies.

9. Longitudinal-Sequential Design – Consists of two or more longitudinal designs that represent two or more cohorts. 10.Extreme Age Groups Design – Age groups that are extremely

different (group of twenty year olds compared to group of 50 year olds) are compared for quick convenient data

gathering.

Ethical research: Investigators must obtain informed consent from their participants before conducting research.

Chapter 2 Physical Changes

Biological Theories of Aging

1. Rate-of-Living Theories: Based on the idea that people are born with a limited amount of energy that can be expended at some rate.

a. Metabolic processes such as eating fewer calories or reducing stress may be related to living longer.

b. The body’s declining ability to adapt to stress with age may also be a partial cause of aging.

2. Cellular Theories:

a. Hayflick limit – Suggests that there may be limits on how often cells may divide before dying (shortening of Telomeres [enzymes] may be the major factor).

b. Cross Linking – Results when certain proteins interact randomly and produce molecules that make the body

stiffer.

c. Free Radicals – Highly reactive chemicals produced randomly during normal cell metabolism, cause cellular damage. Anti-oxidants may postpone the appearance of some age-related diseases.

3. Programmed Cell Death Theories: The appearance of a genetic program that is triggered by a physiological process, the innate ability to self-destruct, and the ability of dying cells to trigger key processes in other cells.

4. Implications of the Developmental Forces – Although biological theories are the foundation of biological forces, the full picture of how and why we age cannot be

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understood without the other three forces (psychological, sociocultural, and life cycle).

Appearance and Mobility

1. Changes in the Skin, Hair, and Voice – Normative changes with age in appearance include wrinkles, gray hair, and thinner and weaker voice.

2. Changes in Body Build – Normative changes include decrease in height and weight in mid-life followed by weight loss in late life.

3. Changes in Mobility –

a. The amount of muscle decreases with age (< 20% at 70 then more than 40% after age 80) but strength and endurance only change slightly.

b. Loss of bone mass is normative: in severe cases,

though, the disease osteoporosis may result, in which bones become brittle and honeycombed.

c. Joints –

(1) Osteoarthritis: A disease marked by gradual onset and progression of pain and disability, with minor signs of inflammation, caused

primarily by overuse of a joint.

(2) Rheumatoid Arthritis: More common and more destructive disease of the joints that develops slowly and typically affects different joints, causes swelling, and a different pain than Osteoarthritis.

Psychological Implications

1. Cultural stereotypes have an enormous influence on the personal acceptance of age-related changes in

appearance. For example where women are seen as becoming inferior with age, men are seen as more distinguished, and experienced.

2. Losses of strength and endurance and changes in the joints have important psychological consequences, especially regarding self-esteem.

Sensory Systems 1. Vision –

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a. Structural changes (age 40) The amount of light which passes through the eye decreases requiring more light to read, however the eyes become more sensitive to glare, and adaptation to light and dark requires more time. The lens of the eye becomes more yellow,

causing poorer discrimination in the green-blue-violet end of the color spectrum. Presbyopia causes a

decrease in the eye’s ability to focus on close objects “necessitating longer arms or corrective

lenses”. Cataracts are opaque spots on the eyes,

which usually can be treated with surgery, and Glaucoma is caused by the eye’s inability to drain excess fluid, treated with eye drops.

b. Retinal changes (age 50) Macular Degeneration results in the loss of ability to see details, and affects roughly 1 in 5 over the age of 75. Diabetic

Retinopathy can involve fluid retention in the macula, detachment in the retina, hemorrhage, and aneurysms. Psychological effects of Visual changes include difficulty in getting around. Compensation strategies must take several factors into account; the more need for illumination must be weighed against the susceptibility to glare.

2. Hearing – The cumulative effects of noise and normative age-related changes create the most common age-related

hearing problem: reduced sensitivity to high-pitched tones, called Presbycusis, which occurs earlier and more severely than the loss of low pitched tones.

a. Sensory Presbycusis – little effect on other hearing abilities.

b. Neural Presbycusis – Seriously affects the ability to understand speech.

c. Metabolic Presbycusis – Produces sever loss of sensitivity to all pitches.

d. Mechanical Presbycusis – Also produces loss of all pitches, but loss is greatest for high pitches. Psychologically, hearing loss can reduce the ability to have satisfactory communication with others, and later in life can cause numerous adverse emotional reactions, such as loss of independence, social isolation, irritation, paranoia, and depression.

3. Somesthesia and Balance:

a. Somesthesia – Changes in sensitivity to touch,

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age-related trends are unclear or inconsistent in most cases.

b. Balance – Dizziness and vertigo are common in older adults and increase with age, as do falls. Changes in balance may result in greater caution in older adults when walking.

4. Taste and Smell – Age related changes in taste are minimal, and the ability to detect odors declines rapidly after age 60 in most.

Vital Functions

1. Cardiovascular system – Some fat deposits in and around the heart and inside arteries are a normal part of aging, and heart muscle is gradually replaced with stiffer connective tissue. The most important change in the cardiovascular system is hardening of the arteries, which can be a lead cause of the following cardiovascular diseases or

Cerebrovascular Accidents (CVA).

a. Congestive Heart Failure – A condition occurring when cardiac output and the ability of the heart to

contract severely decline, making the heart enlarge, increasing pressure to veins, and making the body swell.

b. Angina Pectoris – A painful condition caused by

temporary constriction of blood flow. Same symptoms as a Myocardial Infarction (Heart Attack) but

temporary in duration.

c. Atherosclerosis – A process by which fat is deposited on the walls of the arteries.

d. CVA – An interruption of blood flow to the brain, also known as a stroke

e. Hypertension – A disease in which one’s blood pressure is too high.

2. Respiratory system – The amount of air we take into our lungs and our ability to exchange oxygen and carbon dioxide decrease with age, as with the amount of air we take in. As we age our rib cage and passageways become stiffer making it harder to breath.

a. COPD – Chronic Obstructive Pulmonary Disease: A family of diseases that includes Chronic Bronchitis, and

Emphysema is the most common and incapacitating respiratory disorder in older adults.

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b. Emphysema is the most serious COPD and is

characterized by the destruction of the membranes around the air sacs in the lungs.

Reproductive System

1. Female Reproductive System –

a. Climacteric - The transition from childbearing years to the cessation of ovulation. The Perimenopausal

stage is the onset of the climacteric and leads to the menopausal stage.

b. Menopause is the point at which the ovaries stop releasing eggs, and is accompanied by a variety of physical and psychological symptoms including thinning of vaginal walls, hot flashes, vaginal dryness, night sweats headaches mood shifts difficulty concentrating and a variety of aches and pains.

2. Male Reproductive System – Sperm production declines

gradually with age, and changes in the prostate gland occur and warrants monitoring, and annual check-ups. Other

sexual performance changes include increase in time required to obtain an erection, and ejaculation with an increased refractory period (time in between) required. Psychological Implications: Healthy adults of any age are

capable of engaging in sexual activity, and the desire to do so does not diminish with age. However societal stereotyping

creates barrier to free expression of such feelings. The Nervous System

1. Central Nervous System –

a. (Brain and Spinal Cord) Neurons are the basic cells in the brain, composed of Dendrites (which pick up

chemical signals), Cell body (converts signal to

electrochemical impulse), the Axon (carries signal to terminal branches) and the Terminal buttons (located at the end of the branches) release neurotransmitters and carry info to next set of neurons. Some neurons develop neurofibrillary tangles, new fibers produced in the Axon that are twisted. Large numbers of these are associated with Alzheimer’s disease. Damaged or dying neurons sometimes become surrounded by protein and form neuritic plaques, large numbers of these plaques also are found associated with Alzheimer’s disease.

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b. Several neurotransmitter levels decrease with age, including those of Dopamine, Acetylcholine, and Serotonin. Some diseases, such as Parkinson’s,

Alzheimer’s and Huntington’s are related to changes in neurotransmitter levels.

c. Three types of brain imaging are used in research: Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET). CT and MRI are used most often in routine diagnosis of brain disease, PET also provide info on brain metabolism. 2. Autonomic Nervous system - (Nerves in the rest of the Body)

a. Regulating body temperature becomes increasingly problematic with age. Older adults have difficulty telling when their core body temperature drops, and their vasoconstrictor response (ability of the body to raise it’s core temp) diminishes. Also when they

become very hot they are less likely to drink water. b. Sleep patterns and circadian rhythms change with age.

Older adults are more likely to compensate by taking daytime naps, which exacerbates the problem.

Effective treatments include exercising, reducing caffeine, avoiding daytime naps, and making the sleep environment as quiet and dark as possible.

Psychological Implications: The term Senility no longer has medical meaning, nor do all (or even most) adults become “senile”. However, many people remain concerned about this issue. Brain changes underlie many behavioral changes, including memory.

Chapter 3 Longevity, Health, And Functioning

How Long Will We Live

1. Average and Maximum Longevity

a. Longevity: The number of years on lives; as jointly determined by genetic and environmental factors. b. Average Longevity: Commonly called average life

expectancy, refers to the age at which half of the individuals who are born in a particular year have died.

c. Maximum Longevity: The oldest age to which any individual of a species lives.

d. Active life expectancy - The age to which one can expect to live independently.

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e. Dependent life expectancy - Living a long time, but with assistance.

2. Genetic and Environmental Factors in Average Longevity

a. Genetic Factors – Are significant factors that help to determine longevity. On average add four years to your parents age to which they lived. However

environmental, ethnic, and gender factors must also be taken into account.

b. Environmental Factors – Diseases (cardiovascular, Alzheimer’s), toxins (air and water pollution),

lifestyle (smoking or exercise) and social class are all environmental factors.

3. Ethnic Differences in Average Longevity 4. Gender Differences in Average Longevity –

a. Females average 7 years over men. Health And Illness

1. Defining Health and Illness

a. Health – The absence of acute and chronic physical or mental disease and impairments.

b. Illness – Presence of a physical or mental impairment. 2. Quality of Life – How someone views their quality of life

has a lasting impact on how long they actually live it by way of choice.

3. Changes in the Immune System – Older adult’s immune systems take longer to build up defenses against diseases. Due in part to a changing balance in T-Lymphocytes.

Autoimmunity – Process by which the immune system begins attacking the body.

Psychoneuroimmunology – Study of relations between

psychological, neurological, and immunological systems that

raise or lower our susceptibility to and ability to recover form disease.

a. AIDS And Older Adults – Because of the immune system changes, progression from HIV to AIDS is much more rapid. Lifestyle changes in older adults are also factored, as older adults are less likely to use condoms, test for HIV, and if diagnosed, less likely to seek support groups.

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a. Acute diseases – Conditions that develop over a short period of time (colds, influenza, food poisoning) and cause a rapid change in health. Most are cured with medication (antibiotics) or allowed to run their course.

b. Chronic Diseases – Conditions that last a longer period of time (at least 3 months) and may be accompanied by residual functional impairment

(arthritis and diabetes mellitus) that necessitates long-term management.

c. As we age, our acute diseases decrease and chronic diseases increase. However, with age acute diseases are much more difficult to overcome, and thereby increasing the risk of serious illness or death. d. Diabetes Mellitus – Disease that occurs when the

pancreas produces insufficient insulin. 5. The Role of Stress

a. Stress and Coping Paradigm - Lazarus & Folkman view stress not only as an environmental stimulus or as a response but the interaction of a thinking person and an event. “ A particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his/her resources and endangering his/her well being.”

b. Appraisal –

(1) Primary appraisal – categorizes events into three groups based on the significance they have for our well-being: irrelevant, benign or

positive, and stressful.

(2) Secondary appraisal – evaluates our perceived ability to cope with harm, threat, or

challenge. (What can I do?)

(3) Reappraisal – involves making a new primary or secondary appraisal resulting from changes in the situation.

c. Coping – Any attempt to deal with stress.

(1) Problem-focused coping – involves dong something directly about the problem.

(2) Emotion-focused coping – involves dealing with ones feelings about a stressful event.

d. Aging and the Stress And Coping Paradigm – As people age, their coping styles differ, younger people tend to try and solve problems in a more defensive posture, whereas older adults commonly use experiences, and a more philosophical approach when dealing with stress. First they determine how much control they have over

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the situation, and then use more of a management type of strategy to del with the conflict.

e. Effects on Human Health – When the stressors are short lived the effects usually have little more effect than momentary loss of temper. However chronic stress can lead to a myriad of health problems including immune system suppression, leading to increased

susceptibility to viral infections, atherosclerosis and hypertension, and impaired memory and cognition. Women may experience inhibited menstruation.

Common Chronic Conditions And Their Management

1. General Issues in Chronic Conditions – Having a chronic condition does not mean that older people are

incapacitated. Only about 2% of older people are actually bedridden. Some may experience limitations. The four developmental forces (Biological, Psychological,

Sociocultural, and Life-cycle) must be taken into account to understand how chronic conditions arise.

2. Common Chronic Conditions

a. Arthritis – Rheumatoid and Osteoarthritis afflict many adults. Rheumatoid arthritis is not age related,

however Osteoarthritis is. A primary problem with arthritis is the pain associated. Pain can have a paradoxical effect on arthritis sufferers, due to the way in which they adapt. Non-movement of joints due to pain prevents the flow of necessary fluids through the joints that in turn keep them healthy and

lubricated. This eventually leads to contracture or “freezing” the joints in place, thus people with arthritis are encouraged to keep active.

b. Cardiovascular And Cerebrovascular Disease – A range of cardiovascular diseases occur with age. Most can be managed effectively through lifestyle

interventions. Hypotension: or low blood pressure can cause dizziness or lightheadedness, this can lead to falls and cause serious head injuries. CVAs often create chronic conditions by causing brain damage. Although the number of incidents has decreased by 40%, CVAs can cause serious lifestyle difficulties, if not from rehab, then residual problems from not fully healing.

c. Diabetes Mellitus – Occurs when the pancreas does not produce sufficient insulin, and can cause a person to lose consciousness if blood sugar slips too low, or slip into a coma if blood sugar levels go too high.

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Often associated with obesity in older adults. Common long-term effects include nerve damage, diabetic

retinopathy, kidney disorders, CVAs, cognitive dysfunction, damage to the coronary artery, skin problems, and poor circulation to the arms and legs, which may lead to gangrene. Diabetes also increases the chance of developing atherosclerosis and coronary heart disease.

d. Cancer – The second leading cause of death in the U.S. after Heart Disease. Half of all cancer happens in people age 65 or older. Prostate cancer is most common in men and breast cancer in women. It is estimated that nearly one in every two American men will develop cancer, and one in every three of women.

e. Incontinence – Loss of the ability to control the elimination of urine or feces on an occasional or consistent basis.

(1) Stress incontinence-happens when pressure in the abdomen exceeds the ability to resist urinary flow, for example when sneezing,

coughing, or lifting a heavy object, causes an episode of garment wetting.

(2) Urge incontinence-is usually caused by a central nervous system problem after a Cerebrovascular accident (CVA) or urinary tract infection. People feel the urge to urinate but cannot make it to the toilet in time.

(3) Overflow incontinence-results from improper contraction of the kidneys, causing the bladder to become over distended. Certain drugs, tumors, or prostate enlargement may be the cause.

(4) Functional incontinence-occurs the urinary tract is intact but because of physical or cognitive impairment the person is unaware of the need to urinate.

(5) Iatrogenic incontinence-usually is caused by medication side effects

3. Managing Pain – Pain in older adults is normal, however it is not necessary. Failure to understand pain in older adults can lead to failure in providing adequate steps in relieving it.

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a. Pharmacological approaches to pain management include narcotic and non-narcotic medication, depending on the severity of the pain. Non-narcotic meds include

nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, and acetaminophen, but must be used with caution because they can sometimes have toxic side effects in older adults. Narcotic drugs that work well in older adults include morphine and codeine; other commonly used drugs, such as meperidine and pentazocine should be avoided because of age-related changes in metabolism.

b. Non-pharmacological approaches are many, including message, vibration, acupuncture, meditation,

distraction, hypnosis, ect. The key is to try to find what works best and stick with it unless it is

necessary to change.

Pharmacology And Medication Adherence

1. Patterns of Medication Use – In the U.S. people over 60 take nearly 50% of all prescription and over-the-counter meds. The lack of prescription drug insurance means most older Americans cannot afford them.

2. Developmental Changes in How Medications Work –

Understanding how medications work involves examining developmental changes in the following:

a. Absorption – the time needed for medication to enter the bloodstream, transfer takes longer to reach the small intestine from the stomach in older people, however once in the small intestine, absorption takes no longer than in younger adults.

b. Distribution – throughout the bloodstream depends on the adequacy of the cardiovascular system. Toxic levels of drugs can build up more readily in older adults as well as those who are overweight. Maximum drug effectiveness depends on the balance between the portions of the drug that bind with plasma protein and the portions that remain free, older adults do not absorb as much medication leaving higher portions of free medication in the bloodstream.

c. Metabolism – or the process by which the liver gets rid of excess medication from the bloodstream take longer in older adults, thereby leaving meds in the body longer. This must be taken into account or toxicity potential arises.

d. Excretion – occurs mainly through the kidneys in urine, although some elimination may occur through

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feces, sweat and saliva occurs. Again as we age,

changes in kidney function also change, and drugs are not excreted as quickly, also a setting that may lead to possible toxic effects.

Because of physiological changes in older adults, doctors may prescribe smaller doses, and avoid certain drugs

altogether.

3. Medication Side Effects and Interactions – Drug

interactions can produce symptoms that appear to be caused by other diseases (dizziness, confusion, memory loss, as with Alzheimer’s), therefore taking multiple medications, also known as polypharmacy, must be closely monitored. 4. Adherence to Medication Regimens – The likelihood of

adverse drug reactions increases as the number of

medications increases. Adherence becomes less likely with increase of meds, and diminished sensory, physical and cognitive skills in older adults. The oldest are the most at risk; most forget to take their prescribed medication. Periodic reevaluations should be conducted and medications should be kept to a minimum if possible.

Functional Health And Disability

1. A Model of Disability in Late Life – (Verbrugge and Jette) Emphasizes the relations between Pathology (the chronic conditions a person has), Impairments of organ systems (such as muscular degeneration), Functional limitations in the ability to perform activities (such as restrictions in one’s mobility) and Disability (the effects of chronic

conditions on people’s ability to engage in activities that are necessary, expected, and personally desired in their society). The model also includes risk factors and

intervention strategies (Extraindividual as in

environmental and health care and Intraindividual as in behavioral and personality).

2. Determining Functional Health Status – Helps to identify older adults who need help with everyday tasks.

a. Frail Older Adults: Those individuals who have physical disabilities, are very ill, and may have cognitive or psychological disorders who need

assistance with everyday tasks. Determined by ADLs. b. ADL: Activities of Daily Living-include basic

self-care tasks such as eating, bathing, toileting, walking, or dressing. A person may be considered frail if he/she needs help with one or more of these tasks.

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c. IADL: Instrumental Activities of Daily Living-are actions that entail some intellectual competence and planning.

The number of older adults who need assistance with ADLs and IADLs increases with age, 5% age 65 – 74 and 20% for those over 85. All adult over 85 need some assistance, and about half with all ADLs.

3. What Causes Functional Limitations and Disability in Older Adults? Boult and associates identified two chronic

conditions as being strong predictors of functional limitations, cerebrovascular disease and Arthritis. Additionally, in a longitudinal study other predictive factors included coronary artery diseases, smoking, heavy drinking, physical inactivity, depression, social

isolation, and fair or poor perceived health.

A. How Important Are Socioeconomic Factors? The only difference between those in an affluent community is that they are expected to have the disabilities for a longer period of time, and that there are no

differences in socioeconomic status, as people age they develop the need for managed care.

B. Do Gender And Ethnicity Matter? Women’s health is poorer across cultures, especially in developing countries. Ethnic group differences are also

important. The validity of measures of functioning sometimes differs across ethnicity and gender.

Chapter 4 CLINICAL ASSESSMENT, MENTAL HEALTH, AND

MENTAL DISORDERS

Mental Health And The Adult Life Course

1. Defining Mental Health and Psychopathology

A. Definitions of mental health must reflect appropriate age-related criteria, what may be abnormal for younger people, may well in fact be normal for an older person who is trying to adapt to their surroundings.

Psychopathology is often referred to as the absence mental health.

B. Behaviors must be interpreted in context. Mentally healthy people have positive attitudes, accurate perceptions, environmental mastery, autonomy, personality balance, and personal growth.

2. A Multidimensional Life-Span Approach to Psychopathology A. Biological Forces – Various chronic diseases,

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behavior. In addition genetic factors often underlie important problems. Physical problems such as changes in appetite may be symptoms of depression, or

irritability can be a sign of thyroid problems, or memory loss can be due to certain vitamin

deficiencies. Physical health and genetic factors should be taken into account when diagnosing

psychopathology.

B. Psychological Forces – Normal changes in ability to remember, pay attention, and other intellectual performance that happens with age can mimic certain mental disorders, these changes can also help hide symptoms of actual psychopathology.

C. Sociocultural Forces – Because customs differ across culture, behaviors that may be normative in one

culture, may be viewed as indicating problems in another. Is the person cautious because of a high crime rate or just plain paranoid? Sociocultural factors must be considered, and whether the person is acting appropriate in a normative setting.

D. Life-Cycle Factors – The meanings of symptoms may change with age. Early morning awakenings may be an indicator of depression in younger people, but a normal action for older adults.

3. Ethnicity, Aging, and Mental Health – There are both

similarities and differences in the incidence of specific types of pathology across different ethnic groups. Little research has been done to examine ethnic differences in the definition of mental health and psychopathology in older adults.

Developmental Issues In Assessment And Therapy

1. Areas of Multidimensional Assessment – Usually done by a team of professionals, consisting of a physician (examine the person and medication regimen, psychologist (cognitive skills), nurse (daily living skills/ADLs/IADLs), and social worker (economic and environmental resources).

A. Mental status exams-are especially useful as quick screening measures of mental competence that are used to screen for cognitive impairment. Psychological function is typically assessed through interviews, observation, and tests or questionnaires.

B. Social factors constitute the final area of

assessment. Three dimensions (Rook) include: ties with one’s social network, content of interactions

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with members of the social network, and the number of quality interactions with the network members.

2. Factors Influencing Assessment – Two areas of concern are bias, and environmental conditions.

A. Bias either positive or negative can lead to

misdiagnoses because of either ethnic bias or ageism bias.

B. Environmental concerns are also prevalent due to an examination being done in less than optimum

conditions, which can also lead to missed, or wrong diagnoses.

C. In either case, when assessing patients, all four life forces (Biological, Psychological, sociological, and Life-Cycle) need to be considered in order for an accurate assessment.

3. Assessment Methods

A. Interview – Clinical interviews are the most widely used, and provide both direct information in response to questions, and nonverbal information such as

emotions.

B. Self-report – Usually questionnaires surveys. Reliability and validity are often in question. C. Report by others – Family members or friends can

provide viable information.

D. Psychophysiological assessment – EEG, heart rate monitoring, and skin temperature can provide

information with regards to the correlation between the physical and psychological factors.

E. Direct observation – Done either systematically or through naturalistic observation, and is especially useful when the problem involves a specific behavior. F. Performance-based assessment – Involves giving the

patient a specific task to perform. This approach underlies much cognitive and neuropsychological assessment. Examples would be a memory or drawing test.

4. Developmental Issues in Therapy – The two main approaches are medical therapy (usually involving drugs) and

psychotherapy.

With Psychotherapy, clinicians must be sensitive to changes in the primary developmental issues faced by adults of

different ages.

Clear criteria have been established for determining “well established” and “probably efficacious” psychotherapies.

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THE BIG THREE: DEPRESSION, DELIRIUM, AND DEMENTIA

1. Depression – 2-5% of adults all ages have clinical

depressive disorder. Rate of clinical depression declines across adulthood. Young adults (30-44) most at risk.

Depression commonly accompanies other chronic conditions (diabetes, cancer, or heart disease).

A. General Symptoms and Characteristics of People With Depression –

(1) Most prominent symptom is dysphoria (feeling down or “blue”).

(2) Physical symptoms include insomnia, changes in appetite, diffuse pain, troubled breathing, headaches, fatigue, and sensory loss.

(3) Symptoms must last at least two weeks. (4) Other causes must be ruled out. Either

physical or other psychopathological that may cause same symptoms. For example, other

health or neurological disorders, metabolic conditions or alcoholism. All can affect appropriate treatment decisions.

(5) Clinical depression involves significant impairment in daily living.

B. Gender And Depressive symptoms – Women tend to be diagnosed as being depressed more often than men. Classic depression declines with age, but depletion syndrome (Masked Depression) increases.

C. Assessment Scales – Numerous scales are currently in place, the most recent for older adults is the

geriatric scale, which omits the physical aspect of assessment. Even with the use of scales, further physical and psychological assessment must be done on the patient before diagnosing clinical depression. D. Causes of Depression – Two theories, Biological, and

psychological.

1) Biological theories focus on genetic

predisposition and changes in neurotransmitters or ineffective use of them (serotonin, or

noeprinephrine), they also cite abnormal brain function or physical illness.

2) The most common Psychological theory of

depression is loss (Bereavement). Loss can be real, threatened, or imaginary.

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E. Treatment of Depression – Medications (SSRIs, HCAs, MAOs) Electroconvulsive therapy, Psychotherapy.

1) Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft) Heterocyclic antidepressants and in the last line of treatment, Monoamine Oxidase

Inhibitors are all usually used for more severe cases of depression, as well as

Electroconvulsive therapy.

2) Psychotherapy consists of 100 different types of therapies including; Behavior Therapy-which

focuses on attempts to alter behavior without necessarily addressing the underlying causes, and Cognitive Therapy-which attempts to alter the ways people think. These therapies seem to work best for depression. For older adults, two versions of psychoanalytic therapy are used, review therapy, and reminiscence.

4. Delirium – Characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time. Changes in cognition can include difficulties with attention, memory, orientation, and language. It can also affect perception, the sleep-wake cycle, personality and mood.

A. Can be caused by any of a number of medical conditions (stroke, cardiovascular disease, metabolic condition), medication side effects, substance intoxication or withdrawal, exposure to toxins, or any combination of factors.

B. 50% of postoperative patients experience delirium. C. Can be fatal or result in permanent brain damage. 5. Dementia – A family of diseases that are characterized by

cognitive and behavioral deficits involving some form of permanent damage to the brain.

A. The Family of Dementias – Alzheimer’s, Vascular

dementia, Parkinson’s disease, Huntington’s disease, Alcoholic dementia, and AIDS dementia complex.

B. Alzheimer’s Disease – The most common form of progressive, degenerative, and fatal dementia, accounting for as many as 70% of all cases of dementia.

1) Neurological Changes in Alzheimer’s disease – Rapid cell death, neurofibrillary tangles,

neuritic plaques all happen at an increased rate when compared to normal aging of the brain, and can only be seen upon performing an autopsy. 2) Symptoms and Diagnosis – Gradual changes in cognitive functioning: declines in memory,

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learning, attention, and judgment;

disorientation in time and space; difficulties in word finding and communication; declines in personal hygiene and self-care skills;

inappropriate social behavior; and changes in personality. Symptoms are vague in the

beginning and may mimic other psychological problems, such as depression or stress

reactions. Symptoms are worse in the evening, called sundowning.

3) Searching for a cause – No certain reasons for Alzheimer’s exists, some hypotheses link

chromosome 21 to the disease and some new

researchers are finding chromosome 19 may play a central role. All agree that the disease has an autosomal dominance pattern, in which only one gene from the parent is necessary to produce the disease, meaning there is a 50% chance that a child of a parent with Alzheimer’s may also be affected by the disorder. This {autosomal} is also the case in Pick’s disease and Huntington’s disease.

4) Intervention Strategies – Most research being done is in the form of drug and hormone

research, nothing has had any definitive effects but some medications can be used to treat the symptoms, or help the patient cope with

impairments, at least in the early stages of the illness.

5) Caring for patients with dementia at home: Usually done by female family members, and is liken to an unexpected career.

6) Effective Behavioral Strategies: Differential reinforcement of incompatible behavior, spaced retrieval, medication and behavior modification are all actions to be considered when caring for persons with dementia.

C. Other Forms of Dementia

1) Vascular Dementia – possibly caused by a series of CVAs, which may produce the global pattern of cognitive decline.

2) Parkinson’s Disease – A cluster of

characteristic motor problems: very slow walking stiffness, slow tremors. These behavioral

symptoms are caused by a deterioration of the neurons in the midbrain that produce the

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neurotransmitter dopamine. 14-40% of people with Parkinson’s will develop dementia.

D. Huntington’s Disease – Autosomal dominant disorder usually beginning between 35-50. Symptoms include inability to sustain a motor act, involuntary flicking movements of the arms and legs, later, psychiatric disturbances, hallucinations, inability to care for ones self or control functions such as swallowing, cognitive loss becomes prominent, death is imminent. E. Alcoholic Dementia – (Wernicke-Korsakoff syndrome)

caused by a chronic deficiency of thiamine, causes major memory loss and other cognitive functioning. Treatable with vitamins if caught early and the alcoholic must cease drinking.

F. AIDS Dementia Complex – Due to the HIV producing a protein called gp120 death of neurons occurs, which in turn cause dementia.

OTHER MENTAL DISORDERS AND CONCERNS

1. Anxiety Disorders – Include anxiety states, in which

feelings of severe anxiety occur with no specific trigger; phobic disorders, characterized by irrational fears of objects or circumstances; and obsessive-compulsive disorders, in which thoughts or actions are performed repeatedly to lower anxiety.

a. Symptoms and Diagnosis of Anxiety Disorders – Include physical changes that interfere with normal social functioning, and personal relationships or work.

Changes include dry mouth, sweating, dizziness, upset stomach, diarrhea, insomnia, hyperventilation, chest pain, choking, frequent urination, headaches and a sensation of a lump in the throat. All happen more often in older adults due to a myriad of reasons. b. Treating Anxiety Disorders – Both drugs (Valium,

Librium and other Benzodiazepines) and psychotherapy are used to treat anxiety disorders. Drugs should be closely monitored and may produce effects similar to those with dementia.

2. Psychotic Disorders – Psychoses involves losing touch with reality and disintegrates personality. The two behaviors associated are Delusions (belief systems not based on reality) and Hallucinations (distortions in perception).

a. Schizophrenia – characterized by severe impairment of thought processes, including style of thinking,

distorted perceptions (hearing voices), loss of touch with reality (believing they are Jesus), a distorted

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sense of ones self (believing they’re bodies are changing), and abnormal behavior (laughing at tragic events).

b. Treating Schizophrenia – Usually through medication because a schizoid personality is not going to

cooperate due to lack of trust, or belief that

anything is wrong with them. Most psychotherapy is aimed at adaptation rather than curative.

3. Substance Abuse – Problematic throughout the adulthood

spectrum, only change is with regards to type of substance. Younger adults abuse more illicit (cocaine, marijuana)

drugs, whereas older adults end up dependant on

prescription or over-the-counter meds. Older adults often respond to education and awareness, but sometimes still need to be monitored to ensure inadvertent overmedication does not happen.

Chapter 5 PERSON-ENVIRONMENT INTERACTIONS AND OPTIMAL

AGING

DESCRIBING PERSON-ENVIRONMENT INTERACTIONS

1. Competence and Environmental Press - B = f(P, E)

Behavior(B) is a function (f) of both the person(P) and the environment(E).

a. Competence – The theoretical upper limit of a person’s capacity to function.

(1) Five Competencies: Biological health, Sensory-Perceptual functioning, Motor skills, Cognitive skills, EGO

b. Environmental Press – The classification of varying demands environments place on a person.

(1) Can include any combination of three types of demands: Physical, Interpersonal, and Social.

c. Adaptation – Point at which competence and environmental press are in a balance.

2. Congruence Model – People with particular needs search for environments that meet the needs best.

a. Kahana’s Congruence model proposes that people search for environments that best meet their needs.

Congruence between the person and the environment is especially important when either personal or

environmental options are limited.

b. The congruence model helps focus on individual

differences and on understanding adaptation in nursing homes.

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3. Stress and Coping Framework – Schooler applied Lazuarus’s model of stress and coping to a person-environment

interactions. Schooler claims that older adults’

adaptation depends on their perception of environmental stress and their attempts to cope. Social systems and institutions may buffer the effects of stress.

4. Loss Continuum Concept – Based on view of aging as a progressive series of losses (children leaving, loss of

social roles, loss of income, death of spouse or close

friends and relatives, loss of sensory acuity, and mobility due to poor health) that reduces one’s social participation

and makes them especially sensitive to even small

environmental changes. Thus, home and neighborhood take on more importance. This approach is a guide to helping older adults maintain competence and independence.

5. Common Theoretical Themes - The common theoretical themes focus on the interaction between the person and the

environment, not one or the other. Also no one environment meets everyone’s needs. Rather a range of potential

environments may be optimal.

6. Everyday Competence – A person’s potential ability to

perform a wide range of activities considered essential for independent living.

a. Involves physical, psychological and social functioning. LIVING IN LONG-TERM CARE FACILITIES

1. Types of Long-Term Care Facilities – Nursing homes, Assisted living, and Adult foster homes (adult family home).

A. Nursing Homes – Two main types: Skilled nursing, consists of 24 hr care including skilled medical and other health services. Intermediate care – Also 24 hr care including nursing supervision, but in a less intense level.

B. Assisted living facilities – Provide a supportive

living arrangement for people who need assistance with personal care (bathing/medication) but who are not so impaired physically or cognitively that they need 24 hour assistance.

C. Adult Foster Care – Another alternative to nursing homes for adults who do not need 24 hr care. Not Govt’ regulated so quality may differ, usually only 5 to 6 clients per facility.

2. Who is Likely to Live in Nursing Homes – Usually single female over 85 white European decent with no siblings or

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children, some cognitive impairment and has one or more problems with instrumental activities of daily living. Afro-American women are closing the gap due to health problems. Baby boomers are getting older and may pose a problem with rising cost of health care to the Govt’. 3. Characteristics of Nursing Homes – Are examined on two

dimensions, physical and psychosocial. Little is measured in the physical side as they vary in detail. However they provide a good platform for psychosocial study.

A. Kahana – Congruence approach-Emphasizes the importance of fit between the person and the nursing home, seven environmental and individual dimensions. Members of residents’ social network are important.

B. Moos – MEAP Multi Environmental Assessment Procedure C. Langer – Treatment of clients can be detrimental to their well being and internal attitude toward their abilities, they become dependent on the environment to make decisions for them.

4. Can a Nursing Home Be a Home? – Given circumstances can help the client to feel that they are in a home

environment, but this is not true all the time depending on the stimuli. By having the patient involved in several of the decisions made, including placement, factor in to the process.

5. Communicating with Residents – Inappropriate speech to older adults that is based on stereotypes of incompetence and dependence is called Patronizing Speech.

A. Secondary baby talk is also called infantilization which involves the unwarranted use of a persons first name, terms of endearment, simplified expressions short imperatives, an assumption that the recipient has no memory, and cajoling as a way to demand

compliance. All have a demeaning effect on the cognitive persons feeling of self-respect.

B. Recognition of clues with regard to the patient will assist in learning how to develop positive interaction while still treating the patient with deserved

respect.

6. Decision-Making Capacity and Individual Choices A. Takes an interdisciplinary team of

professionals, residents, and family members working together to create an optimal solution. B. PDSA works well in theory but not usually in

practice because most people admitted into nursing homes have some form of cognitive impairment.

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C. PDSA (Patient Self-Determination Act) – Mandates all facilities receiving Medicare and Medicaid funds comply with five requirements regarding advance care planning.

1. Provide written information to people at the time of their admission about their right to make medical treatment decisions and to

formulate advance directives (i.e., decisions about life-sustaining treatments and who could make medical decisions for them if they were incapacitated).

2. Maintaining written policies and procedures regarding advance directives.

3. Documenting the completion of advance directives in the person’s medical chart. 4. Complying with state law regarding the

implementations of advance directives.

5. Providing staff and community education about advance directives.

OPTIMAL AGING

1. A Framework for Maintaining and Enhancing Competence – By applying key adaptive mechanisms of Selection,

Optimization, and Compensation. By applying these

principles we an address the social facilitation of nonuse of competence. Nonuse of competence stems from people becoming the stereotypes of which they have been labeled. They tend to become dependent, where under other

circumstances they would be more competent within their environment.

A. A key issue in the powerful role of stereotypes is to differentiate usual from successful aging.

B. Successful aging involves avoiding disease, being engaged with life, and maintaining high cognitive and physical functioning.

2. Health Promotion and Disease Prevention – Key strategies are sound health habits; good habits of thought, including an optimistic outlook and interest in things; a social network; and sound economic habits.

A. Issues in prevention –

1) Primary prevention – Any intervention that prevents a disease or condition from occurring (immunizations, or controlling risk factors i.e. cholesterol and smoking)

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2) Secondary prevention – Instituted early after a condition has begun (but may not yet have been diagnosed) and before significant impairments have occurred. (Cardiovascular disease/Cancer screening and routine medical testing for other conditions.

3) Tertiary prevention – Involves efforts to avoid the development of complications or secondary chronic conditions, manage the pain associated with the primary chronic condition, and sustain life through medical intervention. (Does not focus on functioning but rather on avoiding additional medical problems and sustaining life.)

4) Quaternary prevention – Is efforts specifically aimed at improving the functional capacities of people who have chronic conditions.

3. Lifestyle Factors – Staying fit, eating right.

CHAPTER 6 Attention And Perceptual Processing

The Information-Processing Model

1. Overview of the Model – The information processing model assumes an active participant, both quantitative and qualitative aspects of performance, and information processing through a series of hypothetical stages.

A. Information enters the brain, is transformed based on what the person already knows. The more the person, the more easily the information is incorporated. B. Researchers look for age differences in how much

information is processed and what types of information are remembered best under various conditions.

2. Sensory Memory – Where new incoming information is first registered. The earliest step in information processing. A. Sensory memory has a large capacity, but information

resides only for a very short time.

3. Attentional Process – Processing information usually uses more than one Attentional function. Attentional processes are influenced by the capacity to direct and sustain

attention and the speed with which information is processed.

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Attention

1. Selective Attention – The way in which we choose the information we will process further.

A. Visual Search involves responding to specific stimulus or target data and is useful in measuring reaction time, spatial cueing.

B. Attention Switching is the ability to switch attention from one set of stimuli to another i.e., narrow

condition to broad conditions.

2. Divided attention – The degree to which information competes for our attention at any time.

A. Divided attention does not change with age. Rather, task complexity is a primary determinant of

age-related decrements; older adults are at a disadvantage when they must perform two or more complex tasks

simultaneously

3. Sustained Attention (Vigilance) – The ability to maintain attention or focus in performing a task over a long period of time.

A. There is no age difference in the rate at which

performance declines over time but as task complexity increases, age difference on vigilant tasks increase. 4. Automatic Processing – Places minimal demands on

attentional capacity.

5. Effortful Processing – uses all available attentional capacity.

6. Attentional Resources – Suspected that as people age the available attentional resources diminish, however this is inconclusive as the attentional resources have not been defined.

A. Automatic processes – are those that are fast, reliable and insensitive to increased cognitive demands (e.g., performing other tasks.

B. Automatic attention response – the processing of a specific and well-trained stimulus can automatically capture attention.

Speed of processing

1. A major explanation on age-related decline in cognitive performance is cognitive slowing.

2. Basic Psychomotor Speed: Reaction Time Tasks –

A. Simple reaction time involves responding as quickly as possible to a stimulus.

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B. Choice reaction time involves making separate responses to separate stimuli as quickly as possible.

C. Complex reaction time involves making complicated decisions about how to respond based on the stimulus observed.

3. Processing Speed – Mental processing speed, as measured by reaction time, is sensitive to aging, and may be a

contributing factor to age-related decline in memory and attention.

A. Evidence shows that age-related slowing is specific to particular levels.

4. What Causes Age-Related Slowing? –

A. Crella - Efficient thinking means making the fewest connections of neurons from the point of input and the point of reaction/output. Age related slowing may be due to remapping of neurons due to broken connections in the neural network.

B. Myerson – Information loss model - Uses the same network idea but assumes that at each step of the process, information is lost. The more the same

information is processed, the more information is lost along the way (photo copy of photo copy effect).

5. Slowing Down How Much We Slow Down – Although practice improves performance, age differences are not eliminated. However “Experience” allows an older adult to compensate for loss of speed by anticipating what is likely to happen. The span of anticipation appears to be the reason that

experience helps.

Driving and Accident Prevention

1. Driving And Highway Safety as Information Processing – Human factors research is intended to optimize the design of living and working environments, however most design comes from younger adults. Older drivers have several problems, including reading highway signs, seeing at night (Dusk is worse time) noting warnings and performing various operating skills due to changes in information-processing abilities and can make older adults more susceptible to accidents. Hard to document this fact because older adults don’t drive as much as the norm.

2. Home Safety and Accident Prevention – Declines in sensory functioning and physiological (motor skills) are causes in accidents (trip/falls) in older adults. Chap. 2 PHYSICAL CHANGES

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Language Processing

1. Language Comprehension and Sensory Systems – Language

comprehension involves attaching meaning to incoming words. The less meaning attached, the less the process of

remembering them later.

A. Language production involves coming up with an

appropriate word or phrase. Speech recognition is not usually affected by Presbycusis (Reduced sensitivity of high pitched tones) until age 80. The faster speech is presented, the greater the age differences in understanding it.

B. Language Comprehension and Information Processing – Lexical decision task is deciding if a string of

letters is a word. By attaching different connections of information you already know is Contextual

Encoding. Older adults do not take advantage of contextual cues when they encode information.

Chapter 7 MEMORY

Information Processing Revisited

1. Three general steps in memory processing –

A. Encoding: The process of getting information into the memory system.

B. Storage: The manner in which information is represented and kept in memory.

C. Retrieval: The process of getting information back out of memory.

2. Working Memory – The active process and structures involved in holding information in mind and simultaneously using that information, sometimes in conjunction with incoming information, to solve a problem, make a decision, or learn new information.

3. Long-Term Memory – The ability to remember extensive

amounts of information from a few seconds to a few hours to decades.

A. Explicit Memory: The deliberate and conscious remembering of information that is learned and remembered at a specific time.

B. Episodic Memory: The general class of memory having to do with the conscious recollection of information from a specific time or event.

Figure

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References

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