Lecturer: Dr. Joana Salifu Yendork , Department of Psychology - - PowerPoint PPT Presentation

College of Education School of Continuing and Distance Education

2014/2015 – 2016/2017

Lecturer: Dr. Joana Salifu Yendork, Department of Psychology Contact Information: jyendork@ug.edu.gh

Session Overview

• Just as other aspects that are affected by ageing, mental

health is not spared. Minority of adults develop mental health problems that affect their daily functioning and families. In this session, the focus will be on defining mental health and psychology, problems with assessment in adults, notable risks and symptoms of mental health problems, and symptoms, causes and treatments for selected mental disorders.

• Slide 2

Session Outline

The key topics to be covered in the session are as follows:

• Defining mental health and psychopathology
• Issues of assessment in adult mental health
• Risk factors and signs of mental health problems
• Mental disorders: depression, dementia and delirium

Slide 3

Reading List

• Read Chapter 4 of Recommended Text – Adult development

and aging, Cavanaugh & Blanchard-Fields (2006).

Slide 4

DEFINING MENTAL HEALTH AND PSYCHOPATHOLOGY

Topic One

Slide 5

Defining mental health and psychopathology

• Difficult to explain what is normal or abnormal behaviour
• What is considered mental health depends on the

circumstances under consideration

• Birren and Renner (1980) describe healthy people to possess:

– a positive attitude toward self – an accurate perception of reality – a mastery of the environment – autonomy – personality balance – growth – self-actualization.

• Behaviours must be interpreted in context when defining

normal/abnormal behaviour.

Slide 6

Facts about mental health in adulthood

• The majority of older individuals cope well with the

physical limitations, cognitive changes, and various losses, such as bereavement, that frequently are associated with late life.

• On the other hand, a substantial proportion of the

population age 55 and older, almost 20% of this age group, experience specific mental disorders that are not part of “normal” aging.

Slide 7

ISSUES OF ASSESSMENT IN ADULT MENTAL HEALTH

Topic Two

Slide 8

Assessment

• Aim: helps with measurement, description, understanding

and predicting behaviour

• Involves gathering medical, psychological and socio-cultural

information

• Methods: Interviews, observation, tests and clinical

examination

– Method used should be reliable and valid

• Multidimensional approach by team of professionals is most

effective

– Physician: medication regimen – Psychologists: cognitive functioning – social worker: economic and environment resources – Nurse: daily functioning skills

Slide 9

Assessment

• There are six primary methods of assessment

– Interviews: direct and non-verbal information – Self-report: questionnaires – Report by others: family and friends – Psychophysiological assessment: relation between physical and psychological functioning

• EEG (brain waves activity), heart rates, muscle activity and skin temperature
• Can be used to measure the body’s reaction to stimuli such as when anxious or

scared

– Observation: systematic or naturalistic – Performance-based assessment

• Assessment can be influenced by two main factors:

– Biases: racial, ethnic, age stereotypes – Environmental conditions: where assessment occurs, sensory and mobility problems, health of the clients

Slide 10

Challenges in Assessment and Diagnosis

• Clinical presentation of older adults with mental disorders may

be different from that of other adults, making detection of treatable illness more difficult.

– More somatic complaints and experience symptoms of depression and anxiety that do not meet the full criteria for depressive or anxiety disorders.

• Detection of mental disorders in older adults is further

complicated by high co-morbidity with other medical disorders.

• The symptoms of somatic disorders may mimic or mask

psychopathology, making diagnosis more challenging.

• Older individuals are more likely to report somatic symptoms

than psychological ones, leading to further under identification

• f mental disorders.

Slide 11

RISK FACTORS AND SIGNS OF MENTAL HEALTH PROBLEMS

Topic Three

Slide 12

Who is at risk?

• Elderly individuals who:
• Live alone
• Are economically disadvantaged
• Have no relatives or friends nearby
• Have experienced recent losses
• Have been ill or have a progressive or chronic illness
• Have experienced a head injury causing loss of consciousness

http://www.nursing.uiowa.edu/hartford/nurse/Gatekeeper1.pdf

Slide 13

What should I look for?

• Physical Appearance

1. Dirty clothing or skin 2. Body odor 3. Uncombed or dirty hair 4. Unshaven 5. Inappropriate clothing for the weather/situation 6. Underclothing worn over outer clothes

• Emotional State
• Anxious, nervous, fidgety
• Lack trust, suspiciousness, blaming
• Angry, hostile, irritable
• Rapid mood changes
• Statements such as “no one cares,” or “I’m all alone”

http://www.nursing.uiowa.edu/hartford/nurse/Gatekeeper1.pdf

Slide 14

What should I look for?

• Personality Change
• The person’s usual character or personality may seem different than

earlier years…

a. Decreased social contacts b. Sloppy appearance c. Lack of eye contact or excessive staring d. Excessive orderliness (to cover memory loss) or preoccupation with health

• Living Conditions

1. Walks not shoveled, lawn not mowed 2. Neglect of pets or farm animals 3. Little or no food 4. Old newspapers or dirty dishes lying around 5. Calendar on wrong month 6. Shades drawn, garden/flowers neglected

7. http://www.nursing.uiowa.edu/hartford/nurse/Gatekeeper1.pdf

Slide 15

MENTAL DISORDERS: DEPRESSION, DEMENTIA AND DELIRIUM

Topic Four

Slide 16

Common mental disorders

• Depression
• Delirium
• Dementia
• Anxiety
• Psychoses
• Drug Abuse and Misuse
• Late-life Schizophrenia

Slide 17

Prevalence of mental disorders by age

Slide 18

Mental disorders: the big three

• Depression, delirium and dementia have overlapping symptoms

and may co-exist

• Depression: one of the most common and most treatable, in
• lder adults, but is mostly under-diagnosed and undertreated
• Prevalence: 2-5% of adults of all ages meet strict criteria and

15% have some symptoms

• For older adults, 1-2% with clinical depression and 16% have

some symptoms (Kasl-Godley et al., 1999; Smyer & Qualls, 1999)

• Rate declines across adulthood and younger adults are the most

at risk

• Depression co-exist with other chronic conditions, e.g.,

diabetes, cancer, heart conditions

Slide 19

Depression: symptoms

• Dysphoria: feeling down or blue
• For older adults, dysphoria may present as

pessimism or helplessness

• Also, they may more likely show apathy (lack of

interest), expressionlessness, and changes in arousal than are younger people (Reifler, 1994).

• Older adults may withdraw, not speak to anyone,

confine themselves to bed, and not take care of bodily functions

• Younger adults may show these signs but to a

lesser extent

Slide 20

Depression in the Elder Population

Common atypical features :

• Psychotic features (paranoid delusions)
• Somatization

Potential Issues:

• Suicide risk is high
• Depression is an unusual sole cause of

cognitive impairment

• Depression often co-exists with

dementia

Slide 21

Vincent van Gogh, who himself suffered from depression and committed suicide, painted this picture in 1890 of a man that can symbolize the desperation and hopelessness felt in depression.

Depression: symptoms

• Physical symptoms: insomnia, changes in appetite,

diffuse pain, troubled breathing, headaches, fatigue, and sensory loss (Smyer & Qualls, 1999)

• These symptoms must be evaluated carefully because

some may reflect normative changes that are unrelated to depression

– These symptoms may also reflect underlying physical disease that is manifested in depression

• Symptoms should last for at least 2 weeks
• Other causes must be ruled out
• Determination of the impact of symptoms on daily life

Slide 22

Depression: causes

• Biological theories

– Genetic predisposition – changes in neurotransmitters-norepinephrine and serotonin – Abnormal brain functioning – Physical illness

• Psychosocial theories

– Common theme is loss – Loss could be real and irrevocable, threatened and potential or imaginary and fantasized – Likelihood vary with age e.g., middle-age adult-loss of physical attractiveness; older adults-loss of a loved one

Slide 23

Depression: Causes

• Cognitive-behavioural theories

– Behaviour approach-depressed people engage in fewer pleasant activities and receive less pleasure from the activities – cognitive-behavioral approach emphasizes internal belief systems, which focuses on how people interpret uncontrollable events

• Uncontrollable events leads to feelings of helplessness
• Personally responsible for their plight
• Things are unlikely to get better
• Their whole life is a mess
• Balance among biological dispositions, stress, and protective

factors determine who develops depression (Gatz, 2000)

Slide 24

Risk Factors for Depression

• Personal history of :
• Chronic medical illnesses
• Chronic pain
• Loss of physical functioning
• Prior depressive disorders
• Recent significant loss
• Multiple recent stressors
• Social isolation
• Family history of:
• Recurrent depression
• Bipolar disorder
• Alcohol abuse or dependence
• (www.positiveaging)

Slide 25

Depression: treatments

• Psychotherapy

– CBT

• Medication: antidepressants-prozac, sertraline,

nefazodone

• Electroconvulsive therapy

– Effective for severe depression

• Combined antidepressant medication and

psychotherapy

Slide 26

Delirium

• Delirium is characterized by a disturbance of

consciousness and a change in cognition that develop

• ver a short period of time (American Psychiatric

Association, 1994)

• Changes can include: Difficulties with attention, memory,
• rientation, language, perception, the sleep–wake cycle,

personality, and mood.

• Prevalence: 30% of older persons during medical

hospitalization and in 10 to 50% of older adults during surgical hospitalization.

• Also, up to 60% of residents in nursing homes may have

delirium (www.positiveaging.org)

Slide 27

Delirium – Core Features (DSM-IV)

• Disturbance in consciousness (i.e., reduced clarity of

awareness of the environment) with reduced ability to focus, sustain, or shift attention;

• A

change in cognition (i.e., memory deficit, disorientation, language disturbance)

• r

the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia; and

• The disturbance develops over a short period of time

(usually hours to days) and tends to fluctuate during the course of the day.

Slide 28

Symptoms of Delirium

• Altered awareness, disorientation, clouding of consciousness
• Impaired attention, concentration, and memory
• Inability to process visual and auditory stimuli
• Increased motor activity (e.g., restlessness, plucking, picking)
• Anxiety, suspicion, and agitation
• Misinterpretation, illusions, delusions, or hallucinations
• Speech abnormalities
• Reduced wakefulness
• Sleep disturbance

(www.positiveaging.org)

Slide 29

Delirium: causes

• Medical conditions (e.g., stroke, cardiovascular disease,

metabolic condition)

• Medication side effects
• Substance intoxication or withdrawal, exposure to toxins,
• Combination of factors (Smyer & Qualls, 1999)

– Head trauma, lack of sleep,

• Severity depends on the underlying cause
• If cause can be detected and addressed, then delirium

can be cured

• Delirium can be fatal and result in permanent brain

damage

• Second Semester\PSYC 336_Slides\Delirium 101.mp4

Slide 30

Delirium: causes

• General metabolic causes
• Body temperature problems (hypothermia, heat stroke)
• Infection (sometimes independently of fever)
• Nutritional deficiency
• Allergic reactions and autoimmune diseases
• Circulatory
• Intracranial Hypertension
• Lack of essential metabolic fuels, nutrients, etc.
• Hypoxia,
• Hypoglycemia
• Electrolyte imbalance (dehydration, water intoxication)
• Toxication
• Intoxication from various drugs, alcohol, anesthetics
• Poisons (including carbon monoxide and metabolic blockade)
• Medications including psychotropic medications

Slide 31

Delirium: causes

• Mental illness
• Mania
• Depression
• Schizophrenia
• Psychological stressors
• Pain
• Hunger
• Thirst
• Distraction (basic need unmet or concern for same in
• thers, etc.)
• Emotional shock/emotional pain (great fear, grief, anger,

etc.)

Slide 32

Dementia

• Dementia is the term used to refer to a group of disorders

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

• Prevalence: Dementia affects between 5-7% of adults over

age 65 and 40 percent of those over age 85 (American

Psychological Association, 1998)

• Types include: Alzheimer’s disease (the most

common), vascular dementia, Parkinson’s disease, Huntington’s disease, alcoholic dementia, and AIDS dementia complex

Slide 33

Symptoms of Dementia

– Marked loss of memory for recent events Losing items Getting lost in ‘familiar’ places Missing appointments – Loss of ability for abstract thought; planning and doing complex tasks Trouble cooking, paying bills, driving Can’t understand books, movies, or news items – Difficulty finding common words and names Substitution of approximate phrases Misidentifying people Use of ‘empty phrases’ – Difficulty inhibiting behavior Impulsivity ‘Thoughtless’ comments Socially inappropriate behaviors

Slide 34

Alzheimer’s Disease

• The most common form of progressive, degenerative, and fatal

dementia, accounting for perhaps as many as 70% of all cases of dementia (Fromholt & Bruhn, 1999).

• Neurological changes:

– rapid cell death mostly in the hippocampus, cortex and basal forebrain – neurofibrillary tangles in several areas of the brain: accumulations of pairs

• f filaments in the neuron that become wrapped around each other
• The number of tangles is related to the severity of the disease/memory

impairment

– neuritic plaques – changes in neurotransmitter levels, e.g., increase in plasma homocysteine

• Second Semester\PSYC 336_Slides\Inside the Brain_ Unraveling

the Mystery of Alzheimer's Disease [HQ].mp4

Slide 35

Alzheimer’s Disease

• Major Symptoms: gradual changes in cognitive functioning
• Declines in memory

– beginning with loss of recent memory and progressing to loss of remote memory, 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 – changes in personality – Symptoms are vague initially but gradually becomes worse

• Wandering due to problems with orientation
• Emotional problems e.g., depression, paranoia, and agitation
• Incontinence and in ability to self-care

Slide 36

Alzheimer’s Disease

• Alzheimer’s Disease symptoms are similar to other disorders
• Definite diagnosis depends on autopsy
• Without autopsy, thorough attempts should be made to rule
• ut other disease with similar symptoms
• Diagnostic process may include:

– history of the symptoms – documenting the cognitive impairments – conducting a general physical and neurological exams – performing laboratory tests to rule out other diseases – obtaining a psychiatric evaluation – performing neuropsychological tests – assessing functional abilities

Slide 37

Alzheimer’s Disease

• Main cause in unknown but several hypotheses exist
• Alzheimer’s disease is incurable but there are drugs to improve

cognitive functioning

– tacrine (Cognex), donepezil (Aricept), galantamine (Reminyl), and

rivastigmine (Exelon)

• Behavioural strategies could enhance QoL

– Involving the patient as much as possible in decisions – identifying the primary caregiver, – reassessing the patient’s living situation, – setting realistic goals, – Making realistic financial plans, – identifying a source of regular medical care, – making realistic demands of the patient – using outside services as needed

Slide 38

Other forms of dementia

• Parkinson’s Disease: defined by a cluster of motor problems

– very slow walking, stiffness, difficulty getting in and out of chairs, and a slow tremor

• Caused by a deterioration of the neurons in the midbrain that

produce the neurotransmitter dopamine (Lieberman, 1974)

• L-dopa helps to alleviate symptoms
• 14 to 40% of people with Parkinson’s disease will develop

dementia (Raskind & Peskind, 1992)

• Second Semester\PSYC 336_Slides\Parkinsonian tremors.mp4

Slide 39

Other forms of dementia

• Huntington’s disease: autosomal dominant disorder that usually begins

between ages 35 and 50

– involuntary flicking movements of the arms and legs; – inability to sustain a motor act e.g., sticking out one’s tongue; – psychiatric disturbances e.g., hallucinations, paranoia, and depression – clear personality changes e.g., swings from apathy to manic behavior – Cognitive impairments appear later in the disease

• Onset is gradual and course progressive
• Loss of self-care skills, difficulties with walking, and swallowing, and

cognitive loss becomes profound

• Decrease in the neurotransmitters -aminobutyric acid (GABA) and

substance P (neurotransmitter family composed of peptides-compounds that contain at least 2, and sometimes as many as 100 amino acids)

• Second Semester\PSYC 336_Slides\Huntington's disease_ A family

tragedy.mp4

Slide 40

Risk Factors for Dementia

• Age
• Vascular disease
• Diabetes mellitus
• Female gender
• Sedentary lifestyle
• Low education level
• Race/Ethnicity

– Increased risk among African Americans and Latinos, even when controlled for educational level

• HIV-positive status, especially with co-morbid hepatitis C
• History of:

– Cardiovascular accident – Alcohol abuse – Head trauma

(www.positiveaging)

Slide 41

Other mental disorders

• Anxiety disorders: a group of conditions that are based on fear or uneasiness

– Generalized anxiety – Specific phobias – Obsessive-compulsive disorders

• Occurs in 33% of older adults
• Symptoms include:
• Physical changes that interfere with social functioning, personal relationships,
• r work

– dry mouth, sweating, dizziness, upset stomach, diarrhea, insomnia, hyperventilation, chest pain, choking, frequent urination, headaches, and a sensation of a lump in the throat

• Symptoms occur in adults of all ages but more in older adults due to:

– loss of health, relocation stress, isolation, fear of losing control over their lives – Symptoms may be an acceptable response to a situation or an underlying physical condition

Slide 42

Risk Factors for Anxiety

• Personal history of:

– Depression – Anxiety disorder – Chronic medical illness, – Loss of significant person during childhood – Cognitive impairment – Alcohol abuse/dependence – Social isolation

• Family history of:

– Alcohol abuse – Anxiety disorders – Mood disorders

• Other factors:
• Female gender
• Exposure to traumatic event

(www.positiveaging) Slide 43

Other mental disorders

• Anxiety disorders can be treated with medications

and psychotherapy

• Psychotic Disorders: involve losing touch with reality

and the disintegration of personality

– Delusions are belief systems not based on reality – Hallucinations are distortions in perception

• Symptoms are secondary characteristics of other

conditions such as dementia

Slide 44

Sample Questions

• Explain three risk factors for mental health problems in
• lder adults
• Describe four main symptoms of depression
• Explain two challenges in assessment of the mental

health of older adults.

Slide 45

References

• Baltes, P. B. (1987). Theoretical propositions of life-span

developmental psychology: On the dynamics between growth and decline. Developmental Psychology, 23, 611– 626.

• Baltes, P. B., Lindenberger, U., & Staudinger, U. M. (1998).

Life-span theory in developmental psychology. In R. M. Lerner (Ed.), Handbook of child psychology, Vol. 1. Theoretical models of human development (5th ed., pp. 1029–1143). New York: Wiley.

• Ghana Stattistical Services (2013). 2010 population and

housing report: The elderly in Ghana. Retrieved from http://www.statsghana.gov.gh/docfiles/publications/2010p hc_the_elderly_in_Gh.pdf

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