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Mental Health
Chapter 5

I Introduction- Mental stress and mental disorders take a significant toll on the health and productive functioning of anyone, older adults included. Regardless of stereotypes, you will learn that most older people are in good mental health.

  1. An estimated 22% of older adults have a metal disorder, with highest rates being found among older adults living in institutional settings, such as nursing homes. Typically 50% of nursing home residents suffer from some type of mental disorder. 

Nearly a quarter of all hospital costs for older adults are due to treatment of mental health problems.

However, because of the stereotype that all older people become senile as they age, no one becomes alarmed if an elderly person has hallucinations or delusions. It has been widely accepted that people’s minds go away as they age. As you have probably guessed, if senility comes, it is not the result of the aging process. There are many different causes of senility (also known as dementia). This is not normal or usual aging. Do you know what the causes of dementia are?

Most people think that Alzheimer's disease is the only form of dementia. In fact, Alzheimer's is just one form of dementia. It happens to be the most common form but many other things can cause confusion in people.

For example, did you know that alcoholism can result in irreversible brain damage that results in dementia?  Dementia can also be caused by a stroke, or Parkinson's disease. These forms of dementia are chronic, irreversible dementias.

Some dementias are reversible if the cause is removed. These include acute drug interactions, dehydration, infection in the elderly or malnutrition.

Chronic, irreversible dementia usually comes on slowly over time, where acute dementias that are reversible happen over just a few days or weeks. If someone you know becomes suddenly confused first check for a new medication, possible infection or dehydration.

 

Did You Know?

Hallucinations are seeing objects, persons or hearing sounds that are not present. Delusions are false beliefs.

For example:
An hallucination would be "Napoleon is here with me telling me what to do".

A delusion is  "I am Napoleon!"

 

  1. Declining mental health is not a natural consequence of aging. Most non-institutionalized people over the age 65 are in good mental health. 

If they are not, the causes are not due to the aging process itself, but instead to other causes that can usually be pinpointed.

CONSIDER THIS:
We do not yet understand the elements of "effective coping" for the elderly. For example, how should a normal 80-year-old react to the death of his/her mate? Especially if they have been married 60 or more years. What should a normal reaction be to isolation, status loss, income loss, and a host of societal affects of aging (like the inability to find transportation, read signs and labels, or ageist attitudes)? 

Because we don't understand what a normal reaction looks like, we also do not understand interventions that could be applied for a number of normal developmental issues of later life. What is a normal or expected coping style, and what should we consider as abnormal for the following:

  1. Working through life’s transitions - changes from active societal member to isolated elder, the inability to perform home maintenance, or needing assistance with navigating bill and debt mistakes that arise.

    In my home we are wondering who will clean out the second story gutters  when we age? How will we adjust to not just living with clogged gutters but all the other home maintenance issues that come up? What would a normal or abnormal response be? There isn't much research in this area.
  2. Coping with developmental crises - how should one handle the emotional baggage that can accompany anyone into old age? For example, what if an older person arrives at old age with mistrust instead of trust, or shame and doubt instead of autonomy? Erikson's theory (we studied in chapter 3) suggests that we could arrive at old age needing an emotional adjustment. What should the normal response be to these emotional issues?
  3. Attacking the loneliness of later life- As humans we need to be around other people. We punish prisoners by putting them into isolation. How should an elder respond to this involuntary isolation in old age?
  4. Memory training- What curricula should we have to prevent memory loss in old age? Should there be specific exercises? How long should they be? How often should they be practiced?
  5. Decision making skills- As we age, we become more cautious of making quick decisions. There is so much more to consider because, as we age, our knowledge base increases,  and we become more aware of the consequences of our actions. There often is not time to recover from financial mistakes. How long should a complicated decision take? What is normal for someone over age 65?
  6. Developing new skills- Should we have a list of skills one should develop for old age? Should we take certain course work to prepare us for our aging process?

There is not enough research to understand how humans cope with these events. Maybe a normal response to loneliness is to go inside the mind where old memories keep one company. Maybe this then becomes a habit when one is with other people. We need more research to understand these issues.

Experts say improved assessment and treatment of psychopathology (mental illness) among older persons could have a significant impact on the quality of life for older persons and on the economic costs associated with care of older adults with mental disorders.

II. Age Vs. Biological Changes in Mental Status

  1. To understand the psychology of aging, we must understand the differences between age-related changes, and biologically-caused changes. The distinction can be confusing and relates to the concept of normal aging vs. usual aging. In other words, what you usually see may not be normal. Biological changes may not be caused by the aging process alone.  

Sometimes, changes that are thought to be biologically related to aging are, upon closer examination, a result of social structures (institutions or attitudes), opportunities available, poor health habits, stress, or a number of other variables.

Under these conditions, many of the changes we observe in a human as they age may not be the result of just aging alone, but instead a complex interaction of beliefs, diseases, social structures, and values.

CONSIDER THIS
A good example is the statistics regarding abnormal mental health in institutions that are cited above. Why are 50% of elders in nursing homes mentally impaired?

Variables such as activity level, stimulation available (or not), prior social status and contacts, income, and gender must all be considered. In this case, aging may not be the clear cause of these mental disorders. What happens when the mind is not stimulated to prior expected levels? 

Could the mental impairment be caused instead by these social and environmental problems that can then create a biological illness and not the aging process per se? Think of it this way: What comes first, the changes in biology then behavior or do behavioral changes cause a change in biology? If the mind is a muscle and muscles waste when not use, could boredom or fear or a number of other behaviors change biology?

A social scientist must go beyond preconceived or obvious notions and expectations to conduct objective testing.

Extra Learning (not required): Twilight Zone did a great episode called Kick the Can that speaks about attitude. I don't know how long it will be up because CBS is after them for copyright issues. The audio is rough in the beginning but it clears out in just a few minutes. If it's down, try a Google search on Twilight Zone, Kick the Can and see if you can find it.

The Twilight Zone - Kick the Can
 

incase it does not load here is the URL
http://vids.myspace.com/index.cfm?fuseaction=vids.individual&videoid=19615645

 

III. Cognition and the Senses (touch, vision, hearing, smell, taste)

  1. Everything that you think and everything that you feel in your body comes from the outside world through your five senses.

    Cognition is the process of thinking, and your thoughts or reactions are formed in a four-step process.

We first experience the environment through our five senses (see, touch, hear, smell and taste) and our senses relay this environmental information (sensory input) to our brains. Without these senses we would not be able to experience our world. 

Next (step 2), the brain perceives the information that has been relayed by the senses.

Every bit of information that is processed by the brain is sent there by specialized nerves or neurons associated with each of our senses. For example:

The optic nerves reflect vision to the brain, skin neurons relay the sense of touch, taste buds relay taste, and olfactory nerves relay smells to the brain. As we age, these relay processes slow down.

Sensory declines or a slowing of the transmission of the outside world to the brain affects our perception.  If we can not hear clearly the content of a conversation may not be understood. This could give the appearance of disorientation to an observer. In other words, if someone does not hear you, yet pretends to (as many people with hearing loss do), their reactions may seem abnormal. 

Social isolation has been demonstrated to affect our perception.

Step 3.  

Based on our experience of the world, our mood, the activity we are engaged in, or our personality, we evaluate the information. These evaluations are based on our prior experiences, stereotypes, prototypes and expectations. 

 Step 4.

Lastly, the sensory stimuli and perception of the event cause the person to react. This reaction is referred to as motor performance.

There are two types of motor performance--simple and complex.

Simple requires very little decision making or skill (i.e. swat a fly) because it is a reflex.  Complex requires more complicated decision–making skills (i.e. dancing, driving a car). These require multiple senses.

  1. Its important to know that our senses lose sharpness as we age. Although there are individual differences, the old-old (over age75) have the most noticeable declines.

People are able to compensate for these declines with assistive devices such as corrective lenses, hearing aids, larger print, changing routines or habits.

Our reaction time increases because psychomotor speed decreases; partly as a result of the decreased sharpness in our senses.

This decline starts at about age 26, but differences among individuals have been demonstrated. This may be due to the effects of exercise, healthy diet, familiarity of the experience, environmental modifications, or a host of other genetic and/or social variables.

IV. Intelligence and Intelligence Tests-

  1. Intelligence is most often measured by standardized testing. Many such tests are criticized as being ethnocentric (biased towards the major culture), sexist (biased towards boys or men) and ageist (inadequate measure of applied knowledge).

Some tests measure verbal intelligence. These tests are designed to award bonus points for speed. As you can see, this might not be conducive for older adults. 

Most tests measure either:

  1. Fluid intelligence which is our ability to process information from the senses. Remember, information comes through the five senses. The body has to process this input so it can respond. Fluid intelligence is your ability to reason in an abstract way. For example, if I asked you to come up with different possible uses for a book bag, you would have to use abstract reasoning to think about where you would use it; for school books, on a shopping spree or to visit a friend for the weekend.

    Because the senses are less sharp with age, fluid intelligence appears to decline with age.

    When given more time and when thought processes or depth of thinking is measured, older adults actually do better than younger folks. 

  2. Crystallized intelligence- is knowledge one acquires through experience and education - This might be vocabulary tests or how to play a piano. 

Crystallized intelligence (the knowledge acquired through experience and education), does not decline with age.

In other words, verbal scores do not decline with age, but performance scores do.

Although this could be the result of sensory and perception skill decline, it can also be caused by lack of practice or fear of tests.

This pattern is seen so often that it is referred to as the "classic aging pattern" (high verbal scores, low performance scores).

V. Learning and Memory

  1. Learning is the process of acquiring and understanding knowledge. It is defined as a permanent change in an organism's behavior.  When an individual can retrieve information from the memory storage area, learning is assumed to have taken place.

Learning is measured by tests of performance, especially verbal and psychomotor performance. Can you guess how this might affect the classic aging pattern of high verbal /low performance?

  1.  How do older people’s skills compare with younger people’s?

Until the 1960’s, it was assumed that learning declined with age. Can you guess why? Because it takes longer to perceive and process information into the senses, adequate time was not considered in early learning tests. Here are some other variables to consider:

Older learners do best with a slower pace and they perform best with self-pacing.

Older adults may be more uncomfortable with testing situations and experience increased anxiety. This can also decrease concentration and learning.

Did you know? When you experience anxiety, you tend to hold your breath. This shallow breathing increases the C02 (carbon dioxide) in your blood which further increases your anxiety. So when in a stressful situation, remember to take a deep breath and to keep breathing. 

Want to see how you handle stress? Check out this site http://www.pressanykey.com/stresstest.html

Older adults are more susceptible to distraction and lack of motivation when tests are not meaningful to them. As we get older, we want meaning in a subject.

Under certain conditions, older people can learn as well as or better than younger people.

Here is a great site that addresses older adults and creativity http://www.aarp.org/learntech/lifelong/

 

VI. Psychopathologies-

  1. Nature or nurture- what is the source of mental illnesses?

We know a little bit about improving memory, but we know a lot about what makes it worse.

The biggest threat to our memory is Alzheimer’s disease, which robs millions of people of their mental and emotional abilities (more about Alzheimer’s later).

High blood pressure, depression, and many other diseases also rob us of memory. Numerous drugs, particularly alcohol, blunt our ability to remember.

Some psychologists are supporting the notion that biological roots are the causes of many mental disorders. Others insist that the environment we are subjected to determines our mental health. I like to use the analogy of a sunflower seed to make this nature, nurture point. 

Suppose you have two sunflower seeds, a strong seed and a weak one. 

There are also two gardens the seeds can be planted in. One has fertile soil and plenty of nutrients, the other is rocky and provides little of the nutrients the plant will need to grow. 

If a weak seed is planted in the fertile soil, it may grow a stronger plant than if planted in rocky soil. But it will never be as healthy as the strong seed planted in the fertile soil. 

The healthy seed, would not do as well in rocky soil.

The best sunflowers are a combination of a fat healthy seed and rich dark soil. 

  1. We are not yet clear what we can change about ourselves and what we cannot. That is, when we can overcome our biology (nature) and when is our biology our destiny?

    There is growing evidence that suggests that heredity, and thus our biology, influences disorders like schizophrenia and bi-polar illnesses. But we also live in an age of self-improvement, and millions are struggling to change.

    Many people make sweeping changes in their lives when faced with adversity.

    People work through phobias, depression, anger, alcoholism, stress disorders and a host of other issues.

Aging does not cause mental disorders; however, because younger people with mental disorders eventually grow old, many older adults will have these disorders .

How do we decide just what is mental illness? There are no clear-cut boundaries for defining what is and is not a mental disorder. We all experience some common feelings when we are faced with another person with a mental illness. We may notice that someone's behavior is atypical or maladaptive, we might feel uncomfortable sensing that the person is disturbed . We might even feel in danger. Our discomfort often stems from the unpredictability of the person's behavior.

One definition of a psychological disorder is "behavior that is atypical, disturbing to others, maladaptive and unjustifiable" Many experts include the caveat that the behavior must interfere with your daily life. 

VII. Common Psychological Disorders-

  1. Anxiety Disorders: Anxiety disorders are fairly long-standing disruptions of the normal pattern of living characterized by anxiety. There is a vague feeling of fear and apprehension. Anxiety disorders include :
  1. panic disorders- feelings of intense anxiety characterized by shortness of breath, dizziness, faintness, trembling, sweating, nausea, numbness, chills or hot flashes or fear of dying.
  2. phobias – excessive fears that have no convincing basis in reality, like agoraphobia (afraid of places or situations where one could not escape easily, like a crowd).
  3. obsessive-compulsive disorders- characterized by repetitive thoughts or obsessions, and uncontrollable constant urges.
  4. generalized anxiety – free floating or constant tension not knowing why. In today's world there are many sources of fear, anxiety and stress. Some can be considered a normal part of life, others can be the result of chronic long-term stress (such as wars, poverty, conflict with parents alcoholism).

Often these fears result in a withdrawal where the person physically or mentally runs away from the situation.

  1. Depression

It is mistakenly believed that depression is widespread among the elderly.

The loss of friends and spouse, the presence of physical illness and disability, and the imminence of death would seem to be reasons enough to explain this phenomenon. But epidemiologists do not find an increase in the prevalence of depression in the elderly.

Older people suffer at the rate of 1-2% of the population who are considered clinically or severely depressed, while depression is 4% among younger adults. It is true, however, that depression, when present in older adults, is often over looked. Older people are often treated by their primary physician and not a mental health professional. As a result, doctors often treat the symptoms of depression, such as insomnia, high blood pressure, or heart pain (angina). 

      There are two types of depression: major depression and bi-polar depression. 

  1. Major Depression is not the same as the "blues" that we all feel from time to time.         

Major depression is a clinical syndrome that affects older adults in a variety of ways. When one suffers with this type of depression it is impossible to carry on usual activities. The depression can affect:

  • sleep and eating patterns
  • self-esteem
  • self-care
  • energy level
  • feelings of hopelessness
  • irritability or excessive crying
  • blood pressure and ulcers

People suffering often lose interest in the usual pleasures or activities of their lives and thoughts of death or suicide are not uncommon. 

  1. Because depression can look like other illnesses, with symptoms of headaches, back pain, joint pain, and stomach problems, most major depression of older adults is treated in the context of primary medical care and the underlying depression often goes untreated. These physical symptoms are called somatic symptoms (meaning body symptoms).

Older people, when depressed, often speak of their physical problems rather than of feeling anxious, tired, or sad.

Only a small percentage are treated by a mental health practitioner, and thus, the underlying problem is never treated. 

Because of this, somatic symptoms do not respond to treatment.

  1. Older adults with long standing, unresolved issues often act out their losses in later life.

Un-grieved loss is pushed below consciousness and becomes a part of their personality and resurfaces in full strength as they age.

These adults are often labeled as difficult by caregivers. Because gerontologists believe that all behavior in older adults has meaning, providers need to explore what losses the client may need to grieve.

 

  1. Bi-Polar Depression- Also called mania (or manic depressive disorder)

People who suffer from bi-polar disease experience extreme mood swings from deep clinical depression to high euphoric mania.

Symptoms may range from moderate to severe. When mania is moderate, only people close to the affected person may be able to spot the symptoms. These symptoms may include:

 

  1. Causes of Depression

Depression can be caused by illnesses (such as strokes, cancer, diabetes, or hormonal disorders) or it can be caused by medications to treat those illnesses (drugs used to treat high blood pressure and arthritis). It might be caused by genetics (depression runs in families), personality (low self-esteem or very dependent on others) or life events (death of a loved one, divorce, moving, money issues) or any sort of loss.

Sadness and grief are normal responses to loss, but if four or more symptoms last more than two weeks, experts warn that professional help should be sought.

It is important to note that depression can also present with confusion, distraction, and irritable outbursts, which may be mistaken for dementia.

  1. Help for Depression

There are three major types of treatment for clinical depression:

  1. Psychotherapy – cognitive therapy which looks at the person's thought process and flaws in thinking. This rarely works in the end stages of life. The goal then is to validate the person's feelings and the usefulness of the life they have lived (look for Gerontology 330 and 334 in the school's catalogue for more information on these techniques).
  2. Medication - medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder. A mineral called lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, may be used with other mood stabilizers. 
  3. Biological treatments (such as electro convulsive or shock therapy for severe cases or surgery). Electro convulsive therapy (also called ECT therapy) has been around for many years. It is the center of passionate debate about its usefulness in depression. Many say, without ECT their lives were unmanageable, others say it ruined their lives. Here is a link to the BBC News service so you can learn more if you would like. 


http://news.bbc.co.uk/hi/english/health/medical_notes/newsid_1079000/1079436.stm

  1. Suicide - While your text covers suicide under the chapter on special problems I like to include it here because it is so often associated with untreated depressions. You might skip ahead and read the section first.

You learned in previous chapters that suicide is most prevalent among older Americans. Often suicide follows a period of depression.

Nearly 5% of older primary care patients who are depressed are suicidal. That is almost double the number of the general population.

White males are at the highest risk of suicide . Researchers think it is because aging often brings about a big step down in status.

Men are more likely to kill themselves by violent means (such as using a hand gun), and women are more likely to overdose with medications or poisons.

The danger period is when the patient seems to be coming out of the depression. Depressed people lack the energy level and motivation to carry out a suicide attempt. When the depression starts to lift one might gain the energy to carry out well laid plans to end his/her life. For that reason experts suggest prevention strategies for severely depressed individuals when they seem to be regaining their strength.  

Watch for signs such as giving away treasured items, talk of not being around for holidays, or gift giving early (e.g. a Christmas gift in October or November).

It is even ok to ask the person if he/she has ever thought of suicide.

3. Personality Disorders

  1. Personality is developed early in life and is based on inborn traits, relationships with others, and our environment. There are many types of personalities. One may be an extrovert or introvert, optimistic or pessimistic, accepting or suspicious, or a variation of many other traits.  

Theory points to continuity in our basic personality throughout life. We are not likely to change who we are, instead we just fine tune our qualities and become more fixed or inflexible. It is not impossible to change our personalities, but it is very difficult.

For example, if one ‘s personality is extremely assertive when young that trait may develop into aggressive behavior when older. Or being thrifty with money may develop into the inability to purchase needed supplies when older. 

As adults, personality disorders or antisocial behavior may manifest itself in an inability to hold down a job, in marital and parental irresponsibility, or in criminal behavior.

People with personality disorders usually have long-standing, rigid, maladaptive, and inflexible ways of relating to stress throughout their lives .

They exhibit patterns such as attention-getting, or exaggerated self-importance that impairs a person's social functioning.

Certain personality types in young adults lend themselves to disorders. These might include:

It is important to remember that personality disorders are not the result of aging, but the result of a life-time of unresolved personality difficulties.

  1. Schizophrenia

Schizophrenia is a cluster of disorders in which there is a split from realty that shows itself in disorganized thinking, disturbed perceptions, and inappropriate emotions and actions. It is usually diagnosed in early adulthood.

Often the person affected perceives things that are not there and they hear voices from outside their head that give orders which often causes withdrawn behavior.

These perceived things are called delusions (false beliefs such as "I am Napoleon") and hallucinations (an image or vision that is non-existent such as, "Napoleon is here with me.") Hallucinations and delusions affect their speech and thoughts. These two dimensions were dramatized in the movie "A Beautiful Mind".

Word Salad: Many schizophrenics exhibit something called word salad. This is language that at first seems like normal conversation. However, upon close listening ,it is obvious that the ideas do not connect and the words used are not part of the language spoken. 

Here is a close example of word salad:
I was gonna and my kettywamp got in there but no one was there

Often one affected with this mental illness can be suspicious or angry about supposed enemies. They may also feel tormented by the delusions and hallucinations. 

  1. Causes of schizophrenia

The exact cause is unknown but the disease does run in families.

A prenatal virus is suspected because babies born in Winter are more prone. The theory is that they may be exposed to a flu virus while still in utero.

A neuro-transmitter called dopamine is excessive at the receptor sites. This may increase the brains signals to fire excessively. It is interesting that a lack of dopamine causes Parkinson's disease, one in which many patients suffer dementia and brain impairments. 

  1. Organic Brain/ Dementia

Dementia is a generic term which descries a global loss of cognitive function—the ability to remember, make judgments, learn, think critically, remain oriented, remain emotionally stable, and communicate.

There are two types, reversible and irreversible dementia, which are referred to as  acute (sudden and reversible) and chronic (long-term and irreversible).

Reversible (acute) develops quickly – possible causes could include:

  • dehydration
  • malnutrition
  • stroke
  • heart damage
  • vitamin deficiency
  • brain tumor
  • infection
  • thyroid dysfunction
  • liver disease
  • drug overdose
  • alcohol abuse
  • depression
  • sensory deprivation

If these conditions are treated, the dementia will usually disappear.

Irreversible Dementia (chronic) develops gradually and becomes progressively worse. The symptoms are caused by brain cell deterioration and degeneration. Examples of irreversible dementia include:

 

There is a great three minute video entitled, "The Brain on Cocaine" in the LRC (Learning Resource Center) you can view. There is  no sound to this short video but it compares the damage of chronic drug use to  dementia. My  point for this video is to  show you how a stroke and Alzheimer's affects the brain.

The pictures are done by injecting dye into the veins of the patient. Everywhere there appears to be a hole is where the dye is not taken up because there is no blood supply. Where there is no blood supply the tissue is dead. This is a great visual on the effects of Alzheimer's and the effects of drug use. So you can see that with dementia the last part of the brain to deteriorate are the temporal lobes. This is why Alzheimer's patients still like music and they can still sing songs from their past.

If you would like to see it, ask for it in the LRC during regular school hours they are open late nights and Saturdays. The LRC is located in the parking lot beside Davis Hall. I'm sorry It is not available on other campuses. After you view it, send me a synopsis explaining what you have seen (five extra credit points).

 

  1. Alzheimer’s Disease (AD)

The telltale signs of  Alzheimer's disease are tangles in the nerve fiber of the brain cells and plaques (called amyloid plaques) found in areas around cells. These  are considered the signature of Alzheimer's disease. Destruction begins in the hippocampus which is critical for memory. It is a brain disease and not normal aging.

This dementia is not caused by hardening of the arteries or blood vessels. Most AD victims have normal blood flow to the brain but not within the brain itself.

Some people have been found to have an increased amount of aluminum (which acts as a toxin) in the brain. But no one is sure if that is the cause of just an effect of the disease. In fact, many experts deny that aluminum plays a role at all. Yet many concerned individuals have thrown out their aluminum cookware and use only stainless steal and other metal baking and cooking pans. 

AD may be the result of a slow growing virus, a genetic abnormality (abnormal chromosome that impairs protein metabolism) or an immune problem, but the most reliable theory is the possibility of a missing neurotransmitter called acetylcholine.

As of now, there is no known cause or cure and the symptoms are varied.

All patients have memory problems and over time develop difficulty speaking and carrying out routine daily activities, such as dressing, bathing or eating.


Demographics of Alzheimer's Disease-

AD occurs most commonly in people over the age of 65; however, the German pathologist who first identified the brain changes that occur in this disease (which bears his name) described the illness in a 51-year-old woman.

For that reason, we have come to distinguish between early onset (before age 60) and late onset AD.

AD affects more women than men (because women live longer and the incidence of AD increases the longer one lives) and occurs in every country in which people live long enough to survive other illnesses.

 Diagnosis-

There is no single test for AD. It is diagnosed by ruling out all other curable or incurable causes of memory loss.

A positive diagnosis can only be made by studying a small piece of brain tissue after death (on autopsy).

A working, or clinical diagnosis, can be made by health professionals trained in various testing procedures.

One test often used is to have the patient draw the face of a clock and place the hands on the clock to read various times such as 10 minutes after 11.

This test can determine normal aging from patients who have dementia and thus difficulty drawing a clock .

The 'clock test' tests an individual’s cognitive, graphic and visual-spatial abilities.

People with unilateral hemisphere deficits (problems on one side of the brain) may neglect to draw one side of the clock.

The inability to space numbers evenly or to sequence numbers appropriately can indicate "planning" deficits.

Experts can also tell about a person's mental status by watching them draw the clock.

While the clock test is sensitive to dementia, it can not diagnose different types of dementia such as Alzheimers. 

 Symptoms or stages of AD

During the first two to four years, AD patients generally experience memory loss for recent events and disorientation. They may go out to the local store and are not able to find their way home.

Later the patient will often have problems with progressive memory loss, judgment, concentration, speech and physical coordination. This is the time when the patient may forget to take a bath and will have problems with once-routine chores. In advanced stages victims are often afraid of running water and refuse to bathe. This can be overcome with sponge baths. 

In time, the patient's family and/or caregiver will probably have to provide full-time supervision because of the patient's tendency to wander off and engage in meaningless and often socially unacceptable behavior.

Do You Ever Worry?

When we forget something, most of us wonder if we are developing this terrible disease. One test I use is this: When you go to the supermarket and you can not remember where you parked your car, that's probably just plain old forgetfulness. When you come out of the market and look at your keys and don't know what they are for, you should probably seek help.

Treatment

Because of the chronic stress AD places on the entire family as they watch their loved one slowly regress in front of their eyes, AD is often called a family disease.

Although there is no way to prevent or cure AD, comprehensive treatment must address the needs of the entire family. This includes:  emotional support, counseling and educational programs about AD for patients and family members (to provide a safe and comfortable environment at home), respite care, the use of a companion, a homemaker or an aide at home, or special AD care programs (such as adult day care centers).

Family members may want to obtain early legal consultation concerning how they can financially and responsibly provide for and make treatment plans for the afflicted family member when he/she can no longer care for him/herself. 

The life span of AD patients can range from 2 to 20 years or longer. Often they outlive the person who is caring for them. Especially given the immunity problems often associated with stress and care giving (refer to week 9 lecture on Health). 

Recommended readings

For more information I recommend the following book:

The 36-Hour Day, Nancy Mace and Peter Rabins 1981, John Hopkins University Press.

Also, see your handout: "What Is Alzheimer's Disease? Helpful Tips for Caregivers and Behavior Management Strategies". There is also a great handout on Legal Planning for Incapacity.

 

Check out this link for a visual look at dementia >
 http://www.alz.org/brain/08.asp.

Contributed by Machi Phan, Student, Fall 08

An artist named William Utermohlen who after being diagnosed with Alzheimers's Disease decided to continue painting until he could paint no more. What resulted was a collection of amazing self-portraits that captured the emotion and changes that occurred as he progressed deeper into the disease. It was incredibly heart-wrenching to see him as he sees himself, growing with suspicion and anger and disassociation. The link to his work is below (note that the first image is a self-portrait from when he was younger). I hope you appreciated it as much as I did...http://www.newsday.com/entertainment/arts/ny-utermohlen-pg,0,6786257.photogallery?coll=ny-arts-headlines

 

  1. Multi-Infarct Dementia- Unlike AD, people with MID do have small, often unrecognized strokes that are the result of arterial and vein damage in the brain. If you would like to see what this looks like, come by my office to see the video I offered earlier in this lecture. It is a great visual aide for brain damage caused by AD, MID and drug addiction. 

VIII. Good Mental Health

Have you ever broken a bone and had the doctor apply a cast? If not, let me tell you that when the cast is removed, the limb looks smaller than it did going in and is stiff and hard to use. That is because the lack of use created a lower blood flow to the limb. If the limb were left in the cast forever, it would deteriorate and become unusable. Like a limb in a cast, when unused, the brain deteriorates. 

With dementia we don't actually lose brain cells. It appears instead, that nerve cells not only shrink in size but there is also a reduction in the production of specialized brain chemicals needed to conduct nerve signals from one neuron to another (neurotransmitters) and the sheath that conducts nerve impulses hardens and nerve transmission is slowed. Both of these factors are now thought to contribute to age-related memory changes. The brain has a remarkable ability to adapt when challenged. For example, the brain can often compensate for damage to speech or motor centers after a stroke by rerouting nerve singles through new pathways. 

When a certain part of the brain is stimulated by life and the tasks of living, more blood flows through the part of the brain being used. 

  • For example, your vision is focused in the back of your brain. When you perform a visual task, the back of the brain receives increased blood flow and therefore receives oxygen and nutrients. Anything that affects oxygen flow in the blood can therefore affect your vision (such as smoking).
Intellectual challenges and enrichment thereby cause actual structural changes in the brain. It grows just like your biceps do when you perform chin-ups. The tiny branches of brain cells sprout new connections when the brain is stimulated.

Dr. Walter Bortz, author of Dare to be 100 , says that "The natural world has little tolerance for organisms that cease to grow. Your brain is no exception"( Bortz, p.143).

So how do we keep the brain growing? This is an area that needs a lot of research. No one is sure exactly how the chemicals of the brain work. Studies during the early 1990's (sponsored by the MacArthur Foundation and published in Psychology and Aging) identified three key factors associated with lifelong mental sharpness. 

  1. Education and mental activity: People with college degrees consistently appear to be less vulnerable to memory loss and dementia than those with less education. This is possibly due to their participation in mentally challenging activities throughout life.
  2. Physical activity: The brain requires more oxygen than any other organ. It utilizes about 25% of all the oxygen taken in by the lungs. Oxygen is vital in the growth and development of new brain cells. 
  3. Emotional well-being: Having a strong sense of purpose and meaning in one's life is found in people who thrive into old age. Frequent contact with family and friends, community activates and satisfaction with one's accomplishments are all important. A sense of humor, religious or spiritual convictions, and good general heath are helpful as well.  

 

Some amino acids may be responsible for our brain's work, but until we discover what those are and how they work, Dr. Bortz thinks we need brain exercises.

The details of such a curriculum have not been worked out yet, but he suggests we do the following:

  • write a letter a day
  • do volunteer work
  • learn a language
  • be physical
  • stay social
  • learn to play a musical instrument
  • care a lot about things
  • be necessary

Along with Dr. Bortz's recommendations, experts also agree to

  • exercise
  • find meaningful activity
  • keep a large convoy of family and friends 
  • remember to engage in relaxation
  • laugh and play
  • and learn something new everyday!