Class 6: Psychological & Neurological Problems (Chapter 11)
 
Reading: Due today, Chapter 10; due Wednesday Chapter 11
Review Questions from Chapter 10 and Lecture
Multiple answers are possible for some questions
Question 1: According to the text, which of the following is most true about coping strategies
a Problem-focused coping tends to be more effective for young men while emotion-focused coping tends to be more effective for young women
b The elderly tend to use emotion-focused coping while younger adults tend to use problem-focused coping.
c Teaching the elderly problem-focused coping tends to increase their self-efficacy
d Teaching the elderly problem-focus coping tends to decrease self-report measures of stress
Question 2: Major Life Events inventories tend to be problematic for which of the following reasons?
a Life events are assumed to be independent of illness yet many life events may result from major illness
b Life events scales focus on events that are require individuals to adjust yet it may not be possible to adjust to many life events
c Life events scales tend to focus on events that young and middle age adults experience
d Life events may sacrifice simplicity for accuracy
Question 3: Lazarus found that daily hassles, compared to major life events scales, ....
a predicted the outbreak of psychosomatic illness better than life events perhaps because hassles were closer in time to illness
b predicted the outbreak of psychosomatic illness better than life events perhaps because hassles are more stressful than life events
c did not predict psychosomatic illness as well as life events perhaps because they are just a “martyrdom of pinpricks” rather than “stabs”
d did not predict psychosomatic illness as well as life events because of recording inaccuracy (self-report error)
Question 4: Which of these is probably more stressful for the elderly (on average)
a divorce
b death of a spouse
c forgetting a name
d birth of a grandchild
Question 5: As discussed in lecture, a NEW change in the general model of stress is that TOO DIFFICULT
a Some stress is healthful for the individual
b Negative and positive events may cause stress
c Negative emotions lead to physiological changes which may, in turn, lead to disease
d the awareness of physiological changes in one’s body during a stress response may CAUSE the emotion rather than just be a consequent
Discuss Essay Questions
Update
Grandparents march on Washington
Foster parents can get more public support than grandparents
Grandparents increasingly taking care of kids as parents are imprisoned or addicted or die
Dinner (30 minutes)
Incidence v. Prevalence
Incidence
New cases over a population at risk
Prevalence
Total number of cases over population at risk
Note: for most psychiatric problems, decrease in prevalence and incidence with age
DSM-IV r
Axes (Can you give an example for each?)
1 maladaptive
2 personality
3 medical/physical disorders
4 psychosocial/environmental problems
5 global functioning
How to diagnose
Interviews
Advantage: high resolution
Disadvantage: Fright-inducing, boredom, repetitive
Tips: low-pitch voice, repeat, don’t avoid sensitive issues but don’t close with them
Instruments
Advantage: can compare to others (??? greater likelihood of health care reimbursement???)
Disadvantage: time-consuming
Tips; Screening instruments such as the MiniMental State Examination
ACTIVITY
Give the Mini-Mental State Examination to your partner
Alzheimer’s Disease (AD)
Ravel and Bolero
AD is one of the most unpleasant diseases but there is much hope; exciting, rapid, and promising, research
Dementia (AD or vascular etc) loss of cognitive functioning (aphasia, apraxia, agnosia) follow by loss of motor and physical functioning. “Kills victim twice”
Etiology
Tangles and plaques co-occur but how do plaques lead to tangles?
Beta-Ameloid and Tau (“Baptist” v. “Tauist”) We now they work together to make plaques into tangles
AD increases with age to about 20% in 85 y.o. +, “geometric” increase with age
Stages (Note: unlike vascular dementia these stages are gradual, not step-like)
Mild impairment, increase temper, subtle (Noticed in Nun study)
Less subtle changes requiring help
Profound memory loss; who am I
Physical loss (make take 10 years to kill)
How to help
Diagnosis: In a year or two we will be able to use PET scans and spinal fluids
Some drugs might help alleviate symptoms--THIS IS HOT RESEARCH
SSRI MIGHT help
Recent “memory” drug just came on market; special because it is for later stages not early stages
No prevention: BUT MAYBE IBUPROFEN, Vaccines “possible”
More educated people seem to be less likely to get AD; better health care or better mental exercise? How would you design an experiment?
Elderly seem to have lower risk for AD and small strokes by playing board games, reading, music playing, and solving crosswords. By 60%. But...
The Nun and Monk Study
Controlled environment, long-term study, good health care
Brains at death
College v. graduate school
More educated brains seems to better tolerate accumulated proteins. Large difference. greater cognitive reserve: compensation. Does not stop the leak but makes a bigger bucket.
Lesson: This class is good for your brain.
Resources
Support group for caregivers
Adult day care
Video Segment: The Mind (The Aging Mind)
KNOW
Do Hugh and Bert demonstrate that genes determine AD?
What are plaques and what are tangles and which one is more common in AD brains?
Describe one approach to finding the trigger
BREAK (15 minutes)
Omitted from your textbook! Elder Abuse
Less understood than child abuse
Prevalence: about 3 to 6% cases (percent varies greatly based on definition of abuse)
Frequent sign is bruise but is it due to abuse or accident?
Key study JAMA 1997
2000 elders in New Haven, average 74, tracks physical and health. Elders seen by Protective Services 3x risk of death. So this is new? But the cause of death was NOT directly due to mistreatment but indirectly. Less social support.
Elders as victims of cons and frauds.
About 2-3 million older adults a year. But many don’t report; why...?
29% embezzlement involved adult children, about 60% are relatives
BUT NOTE: elder mistreatment is defined differently by cultural-ethnic group.
E.g. Korean-American families often share money; don’t see as a financial exploitation
E.g. African-American elders LEAST tolerant of any form of abuse; majority agreed that elder abuse was just as bad as child abuse
Question for you: Is a homeless man in his 70s on the street mistreated or abused?
Video Segment: Detecting and Reporting Elder Abuse [Skip Segment 1 and went to Segment 2 and 3
KNOW:
Provide an example of each form of elder abuse
Neglect = ulcers
Are clinicians required to report suspected abuse? Suppose a spouse, also your client, is the probable abusers?
What is a mandated reporter?
How and to whom would you report to?
Nursing homes Dept of Aging Ombudsmen
Elsewhere: Community agencies
Care Custodian
Mandated Reporters: law enforcement, psychosocial workers, health care workers
First, call. Then fill out Form within 2 days.
Are mandated reporters protected from suits? Yes. Can they be punished for not reported? Yes.
Very important websites:
OPTIONAL NOT REQUIRED Supplementary Readings
Memory loss v Alzheimer
Drug for Late Stages of Alzheimer’s Is Approved
Unusual Form Of Memory Loss Often Confused For Alzheimer's Disease

Alzheimer's disease is the single most common cause of dementia, a chronically progressive brain condition that impairs intellect and behavior to the point where customary activities of daily living become compromised. Over 4 million Americans have Alzheimer's disease. Its high prevalence may lead people to believe that dementia is always due to Alzheimer's disease and that memory loss is a feature of all dementias.

However, an article by Alzheimer's disease expert M.-Marsel Mesulam, M.D., in the Oct. 16 issue of The New England Journal of Medicine reports that nearly a quarter of all dementias, especially those of presenile onset, may be caused by diseases other than Alzheimer's disease and that some of these so-called atypical dementias involve cognitive abnormalities in areas other than memory.

Mesulam is Ruth and Evelyn Dunbar Professor of Psychiatry and Behavioral Sciences and professor of neurology at the Feinberg School of Medicine and director of the Cognitive Neurology and Alzheimer's Disease Center at Northwestern University.

Mesulam described, for example, primary progressive aphasia, an unusual dementia of unknown cause that is characterized by a relentless loss of language but with memory relatively preserved. Once considered a rare condition, primary progressive aphasia is now commonly included among dementia syndromes and has been reported in several hundred individuals.

Alzheimer's disease patients have forgetfulness, usually accompanied by apathy. They misplace personal objects, repeat questions and forget recent events. However, while these patients may forget people's names, word-finding during conversation is not a major problem.

In contrast, patients with primary progressive aphasia come to medical attention because of the onset of word-finding difficulties, abnormal speech patterns and glaring spelling errors. Some patients cannot find the right words to express their thoughts. Others cannot understand the meaning of words either heard or seen. Still others cannot name objects in their environment.

In some patients with primary progressive aphasia, the ability to write language may be less impaired than the ability to speak it. Others develop agrammatism, using inappropriate word order and misusing word endings, prepositions, pronouns, conjunctions and verb tenses.

Language is the only area of prominent dysfunction for at least the first two years of primary progressive aphasia. In these patients, structural brain imaging studies do not reveal a specific lesion, other than atrophy, that can account for the language deficit, Mesulam said. Language difficulties may be the patient's only symptoms for 10 to 14 years. Other cognitive impairments may emerge, but the language deficit remains the primary feature throughout the illness and progresses more rapidly than deficits in other areas.

Also in contrast to many patients with Alzheimer's disease, who tend to lose interest in recreational and social activities, some individuals with primary progressive aphasia maintain and even intensify their involvement in complex hobbies such as gardening, carpentry, sculpting and painting. One patient Mesulam described continued to fly his airplane until aphasia prevented him from communicating with ground control.

In patients with suspected primary progressive aphasia, evaluation by a speech therapist is useful for exploring alternative communication strategies, Mesulam said. Unlike patients with Alzheimer's disease, who cannot retain new information in memory, patients with primary progressive aphasia can recall and evaluate recent events even though they may not be able to express their knowledge verbally.

Currently, there is no effective pharmacologic treatment for primary progressive aphasia. However, from the vantage point of research, the condition provides a rare opportunity for investigating the molecular mechanisms of focal neurodegeneration and the neuropsychological organization of language function, Mesulam said.

This story has been adapted from a news release issued by Northwestern University.
October 18, 2003

Drug for Late Stages of Alzheimer's Is Approved
By THE ASSOCIATED PRESS

ASHINGTON, Oct. 17 — The Food and Drug Administration on Friday approved a new option for people with Alzheimer's disease, the first treatment specifically for late stages of the illness.

The drug, memantine, has long been sold in Germany, and many people in the United States have bought it over the Internet.

Now that memantine has been approved, Forest Laboratories will sell it in the United States under the brand name Namenda for patients with moderate to severe symptoms of Alzheimer's. The company said the drug should be on pharmacy shelves in January.

Memantine does not offer miraculous benefits. The drug agency's  scientific advisers, in evaluating it last month, worried that memantine's availability could give false hope to families of the most severely ill.

In studies, some patients who took memantine have experienced improvements in memory and thinking skills. But for the vast majority, the drug merely slows the pace of deterioration, letting patients maintain certain functions a little longer.

The nation's four other Alzheimer's medications — Aricept, Exelon , Reminyl and Cognex — work in the early stages of the disease. Those drugs work very differently than memantine does. They delay the breakdown of a brain chemical called acetylcholine, which is needed for nerve cells to communicate.

Memantine, in contrast, blocks excess amounts of another brain chemical, glutamate, which can damage or kill nerve cells.

About four million Americans have Alzheimer's disease, and one million are believed to suffer severe symptoms.

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