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Date Created: 09/28/16
Issues in Aging COE 4713 & 6713 – Fall 2016 Chapter 6 Part I PERSONALITY AND MENTAL HEALTH IN OLD AGE Learning Objectives 1. The normal developmental changes and stability in personality across the life span. 2 The theories of personality that support change or stability as well as the ‘person environment’ interactions that affect personality development. 3 Emotional expression and regulation with personality development. 4 Stability versus change in selfconcept and selfesteem with aging. 5 Older adults’ responses to life events and stressors. 6 The predictors and critiques of successful aging and active aging/resilience. 7 The major psychological disorders and dementias in old age. 8 The extent to which older people use mental health services. Three Windows into the Phenomena of Gerontology Age: is understood in 3 ways: generations, age classes, and staged life courses based on chronological norms Aging: living; life span perspective and life courses Aged: focus on late life which is the culmination of age and aging (issues in aging) All related to the individual’s unique personality Defining Personality Personality: A unique pattern of innate and learned behaviors, thoughts, and emotions that influence how each person responds to and interacts with the environment. Personality can be evaluated by standards of: Behavior (adaptive or maladaptive) Resilient (or feeling hopeless) 1 Personality styles influence how we cope with and adapt to life changes in early and later age. The process of aging involves some unavoidable stressful life experiences (life events) where personality is demonstrated. Stage Theories of Personality Personality theories emphasize developmental stages (phases) of personality and hypothesize that the social environment influences development. Stage Theories of Personality: 1. Jung’s Psychoanalytic Perspective 2. Erikson’s Psychosocial Model 3. Empirical Testing of These Perspectives 4. Dialectical Models of Adult Personality Stage Theories of Personality C. Jung’s Psychoanalytic Perspective: This perspective emphasizes stages in the development of consciousness and ego; in life, ego moves from extroversion to introversion…to a focus on one’s inner world in old age. For the aging person in this stage, she/he finds meaning in inner exploration and in an afterlife. Carl Jung’s model of personality also assumes changes throughout life; Jung’s Model emphasizes stages in the development of consciousness and the ego from narrow focus of the child to other experiences of the older person; Focus early in life (youth and middle age) is extraversion (focus on external world) to introversion (focus on one’s inner world in old age); This model (Archetype) changes with age people adopt personality traits (animus=M & anima=F) association with opposite sex. All humans have both the feminine side and a masculine side – as they age they adopt psychological traits associated to the opposite sex. Stage Theories of Personality Erick Erikson’s Psychosocial Model: 2 This theory emphasizes that the individual goes through *8 stages of development with the goal of achieving ego identity; the last stage of the model is ego integrity (accepting mortality) vs. despair. In this stage, the aging individual achieves wisdom and a positive perspective, or experiences despair because he/she views life as lacking meaning. Older adults who achieve ego integrity feel more connected with younger generations – and share their experiences and wisdom with them. [* see page 218, Erickson’s Psychological Stages & Goals] Stage Theories of Personality Erikson’s Psychosocial Model: Purpose: to establish a sense of meaning in one’s life rather than feeling despair or bitterness that life was wasted to accept oneself and one’s life without despair; to accept their own mortality and that of others. Older adults developmental stages achieve: Generativity = desire to help and mentor younger persons – most critical for achieving ego integrity Empirical Testing of Stage Theories Generativity: Erickson's 7th stage, examined by researchers; “generative adults” exhibit concerns not just toward their own children, but toward the young in society; attribute more importance to care of younger generations than selfdevelopment. Life Review = is the purpose of sharing one’s memories and life experiences with others. Major studies: Baltimore Longitudinal Studies & Kansas City Studies = research on personality characteristics: examined changes (physiological, cognitive, personality functions) in the same individuals over many years. Outcome: observed changes in adjustment w/age but stability w/specific traits. 3 Grant Study of Harvard University Graduates changes observed from middle to old age offer implications for contemporary family care and responsibilities. Kansas City Studies of Aging (Neurgarten and associates, 195060) Examined personality longitudinally; Provided empirical basis for activity and disengagement theories of aging; Older adults do not resemble each other more in old age, but rather become more differentiated; Older adults grow less concerned about societal expectations. Many of the changes attributed to personality in old age (preference for solitude or slower paced activities) are not personality traits per se but lifestyle preferences that are influenced by life experiences, opportunities, and functional health status. Dialectical Models of Adult Personality Daniel Levinson (psychologist)’s “Seasons of Life” Model: centered in the life structure a person’s life structure is shaped by the social and physical environment Dialectical approach to personality development – consistent with the person environment model; change occurs with interaction of personenvironment; the extent to which one is sensitive to changing the “self”; one can respond to shifting external conditions by altering something within self or by modifying environmental expectations. Dialectical Models of Adult Personality Levinson & colleagues (1977, 1978, 1986): Examined developmental stages in terms of life structures – or underlying characteristics of a person’s life at a particular period of time. Each period in the life structure, or era, lasts approx. 20 years Dialectical approach suggests change occurs because a dynamic person interacts with a dynamic environment. 4 Trait Theories of Personality Traits are relatively stable characteristics of personality: Extrovert to introvert Passive to aggressive Optimistic to pessimistic Assumption of trait stability has led researchers to examine personality traits longitudinally – McCrae and Costa (1984, 1990) proposed 5factor model of personality traits. Trait Theories of Personality Trait Theories: focus on personality traits that describe individuals with characteristic or “typical” attributes that remain stable with age. Five factor model of personality traits (w/5 independent dimensions) 1. Neuroticism (mild psychiatric disorder) 2. Extroversion (interest in other people/sociable) 3. Openness to experience 4. Agreeable 5. Conscientiousness SelfConcept & SelfEsteem Major adjustment required in old age is the ability to redefine one’s selfconcept (belief about oneself). Selfconcept is one’s cognitive image of the self as social roles shift and new roles assumed. To the extent that a person’s selfconcept is defined independently of particular social roles one adapts more readily to role losses. In old age selfesteem needs to be recharged to ensure mental health. SelfEsteem Is defined as an evaluation or feeling about one’s identity relative to some ideal of standard (emotional evaluation of selfworth); Selfesteem is based on an emotional assessment of the self; 5 Affective quality of selfesteem makes it more dynamic and more easily influenced; In contrast selfconcept is the cognitive definition of one’s identity. SelfConcept & SelfEsteem SelfConcept Is defined as a cognitive representation of the self; emerges from interactions with the social environment, social roles, and accomplishments. SelfEsteem: evaluation or feeling about one’s identity relative to an “ideal self”; differs from selfconcept in being more of an emotional, not cognitive, assessment of self. Stress, Coping, and Adaptation Selfconcept and selfesteem are 2 important elements that play a role in copying styles Very significant when making the transition into older age. This may explain why some adjust readily to major life changes while others have difficulties. Adaptation requires readiness and positive outlook of life. Key Concepts Life Events (or life experiences) – refer to internal or external stimuli that cause some change in individual’s daily lives may be positive or negative. Ontime and offtime events normative and nonnormative suggesting that an older adult anticipates some life experiences because they are the ‘norm’ for most people of a given age. Stress – many researchers have explored: Antecedents Components Consequences of stress (Selye, 1970) to understand the impact on an older person’s life. Stress, Coping, and Adaptation Life events identifiable, discrete life changes or transitions that require some adaptation to reestablish homeostasis (state of equilibrium). 6 A distinction is made between positive life events and negative life events. A distinction is made between ontime events and offtime events. Adaptation & Coping in Later Years Adaptation: includes range of behaviors such as coping, goalsetting, problem solving, and other attempts to maintain psychological homeostasis. Coping: manner in which a person responds to stress includes cognitive, emotional, and behavioral responses made in face of internally and externally created events. Stress, Coping and Adaptation Coping responses to stress, determined by nature of stressor, personality, support and health problemfocused vs. emotionfocused Classification of Coping Responses General Strategies of Coping Coping with Terminal Illness Dimensions of Coping Older adults have very personal and culturallybased coping skills. Stress, Coping and Adaptations Defense Mechanisms = unconscious responses to stress determined by nature of stressor, personality, social support, and health unconscious reactions that an individual adopts to defend or protect the self from impulses and memories that threaten one’s identity or wellbeing. Major Ego Defense Mechanisms Denial Projection Representation Reaction Formation Regression & Fixation Displacement (reduces anxiety by taking up opposite feeling) and (defense and denial) Acceptance of Change 7 Control over external events may become less important with age; while the need to make uncontrollable events more acceptable to one’s values and believes become more important. Older adults with strong support system showed less deterioration in their functional health and more acceptance to any type of changes. A higher level of selfefficacy = that is a feeling of competence in one’s ability to deal with new situations (also predictors of healthy cognitive abilities). Resilience = ability to thrive under adversity or multiple life changes – making adversity into a catalyst for growth and development. Successful Aging Defined as a combination of: Physical and functional health High cognitive functioning Active involvement with society (Rowe & Kahn, 1987, 1997). Psychological dispositions: Hopefulness Altruism Selfesteem Coping dispositions Life satisfaction Figure 6.1 A Model of Successful Aging A Critique of the Successful Aging Paradigm Wide variation of defining and measuring ‘successful aging’; Successful aging may include mental disorder, chronic disabilities & quality of life; Conveying a white, middleaged, middleclass norm combined with remaining active to show exception to peers (not really old & not aging); Successful aging models is places emphasis on activity and productivity – typical of western cultures; 8 Does not take into consideration culture & ethnicity; religious customs, SES status and historical marginalization (discrimination against some groups) Part II Successful Aging Defined as a combination of: Physical and functional health High cognitive functioning Active involvement with society (Rowe & Kahn, 1987, 1997) Psychological dispositions: Hopefulness Altruism / selflessness Selfesteem Coping dispositions Life satisfaction See Figure 6.1 A Model of Successful Aging A Critique of the Successful Aging Paradigm LateLife Psychopathology Wide variation of defining and measuring ‘successful aging’ Successful aging may include mental disorder, chronic disabling health conditions & quality of life; Conveying a ‘White’, middleaged, middleclass norm combined with remaining active life to show exception to peers (not really old & not aging); Successful aging model places emphasis on activity and productivity – typical of western cultures; Does not take into consideration culture & ethnicity; religion, SES and historical marginalization (discrimination against some minority groups). Psychological development with aging includes some changes but most older adults adapt very well 9 Prevalence of mental disorders in old age range is 5 45% Three Most Prevalent Disorders: Depression Dementia Paranoia Irrational suspiciousness of other people may result from memory loss, social isolation, sense of powerlessness, progressive sensory decline Schizophrenia mostly diagnosed in adolescence or midlife) lateonset schizophrenia may have paranoid features. Mental Disorders among Older Persons Depression Dementia Delirium Alzheimer’s Disease Parkinson’s Disease Alcoholism Drug Abuse Paranoid Disorders and Schizophrenia Anxiety Depression Most common Consistent with personenvironment fit; Risk factors for depression in older adults include: Female & unmarried Comorbidity (multiple chronic diseases) Financial strain or poverty & lack of support Family history of depressive illness Estimates of depression for communitydwelling elders are: 1030% for minor depression 14% for major depression 2% for Dysthymic disorder (less acute type) 0.1% for Bipolar disorder 10 Depression in older adults ‘Masked depression’ may occur in which few mood changes are reported Instead – patient/client complains of vague pain, bodily discomfort, sleep disturbance; reports problems with memory; is apathetic; withdraws from others Because of the selfreported memory complaints (more so than when dementia actually exists) older adults could be misdiagnosed or labeled with other types of dementia. Coexistence of Medical Problems Some medical conditions produce depressive symptoms which must be assessed and treated: Parkinson’s disease Rheumatoid arthritis Thyroid dysfunction Diseases of the adrenal glands Heart disease Stroke Secondary Depression and Symptoms Most older adults respond well to supportive psychotherapy that allows patient to review and come to terms with stresses of late life. Symptoms of depression (not to be confused with normal aging): Reports or evidence of sadness for a long period Feelings of emptiness or detachment w/no precipitating major life event (bereavement) Expression of anxiety or panic w/no apparent cause Loss of interest in the environment Neglect of selfcare (lack of hygiene) Changes in eating & sleeping patterns Antidepressant Medications & Therapeutic Interventions Consistent with the personenvironment perspective(Model) – Environmental and social interventions (recreational & social activities); combined with psychotherapy – are more effective than antidepressant medications for minor depression. 11 Side Effects can include: Postural hypotension and Increased vulnerability to falls and fractures Cardiac arrhythmias and Urinary retention Digestive discomfort and Constipation Disorientation, Skin rash and Dry mouth Risk Factors for Depression in Older Adults Women Unmarried (men/women) Comorbidity (multiple chronic diseases) Financial strain and poverty Lack of social & familial support Social isolation Unfriendly living environment [Aranda et.al., 2001; Zarit, 2009] Suicide Among Older Adults 17 25% of all completed suicides occur in persons 65+ National rate (1997) was 11.4 per 100,000 population; rate for over 65+ was over 18 per 100,000 Range was 13.2 per 100,000 for 6570 of age, to 21 per 100,000 for 85+ Highest rates found among older white males 43,3 per 100,000 in this population group More than x2 rate for nonwhite males (17.5) X7 rate for older white women (5.8) X15 the rate for older nonwhite women (2.8) Suicide among Older Adults & Explanation for Suicide Rate Older people are at greater risk of suicide than any other age group. Highest suicide rates are among white males age 85 and older. Incongruence between older white males’ ideal selfimage (worker, decisionmaker, holder of relatively high status in society & among family systems). Realities of advancing age (mortality) 12 Social isolation older widowed men x5 greater suicide rates than married men. Lack of strong social support networks. Growing availability of firearms 78% of suicides 1996 among older men involved firearms; 36% among older women. Benign Senile Forgetfulness & Mild Cognitive Impairment (MCI) The most feared sign of aging is forgetfulness Benign senescent forgetfulness – mild form of memory dysfunction; not dementia American Academy of Neurology – Mild cognitive impairment Classification of persons with memory impairment who are not demented (normal general cognitive function and intact ADL). Between 625% of MCI patients progress to dementia or AD each year (www.aan.com 2001) Dementia All dementias have in common a change in: Producing a coherent speech or understanding Ability to recall events in recent memory Recognizing or identifying objects & people’s names Problems with comprehension, attention span, judgment Thinking abstractly and performing a task Disorientation to time, place and person Some older adults with mild cognitive impairment (MCI) may develop dementia. Major Dementias of Late Life Reversible: Drugs Alcohol Nutritional deficiencies Normal pressure hydrocephalus Brain tumors Hypo/hyperthyroidism 13 Neurosyphilis Depression (pseudodementia) Delirium Irreversible: Alzheimer Vascular Lewy body Huntington’s disease Pick’s disease CreutzfeldtJacob & Kuru disease Korsakoff syndrome Delirium A reversible dementia with a more rapid onset than other types of demendue to rapid changes in brain with function with physical or mental illness. Signs of delirium: Abrupt changes in behavior Fluctuation in behavior Inability to focus Speech that makes no sense or is irrational Disturbance in sleep patters Hallucinations Worse symptoms are at night or when first awake. Require oneonone 24 hours daily care. Alzheimer’s Disease (AD) The most common irreversible dementia in late life = 6080% of all dementias. The brain of AD patients have reduced # of cholinergic cells; important for learning and memory because they release important chemical messenger, acetylcholine, that transfers info from one cell to another 14 Accumulation of amyloid, protein which is a group of proteins found in the neurofibrillary tangles that characterize an Alzheimer brain precursor protein, betaamyloid, coded by gene located in chromosome 21, also responsible for Down syndrome. Characteristics of Alzheimer Disease Deficit in: Attention Learning Memory Language skills ADL skills Judgment Concentration Structural changes: Premature loss of nerve cells in brain Deterioration of free radical metabolism Impaired neurotransmitter function = plaques & tangles in brain areas Treatment for AD Treatment Options: Researchers focusing on nerve growth factor, naturally occurring protein that replenishes and maintains the health of nerve cells. Cognitive therapies to restore neurotransmitter activity in the brain (“cholinergic enhancers”) Aricept (donepezil) Reminyl (galantamine) Exelon (rivastigmine) Cognex (tacrine) –less frequently used. Therapies & Other Strategies in Alzheimer’s Care Behavioral Therapies Medications to Treat Behavioral Problems Interventions to enhance personenvironment congruence (psychosocial group work) Wandering: Daily care to avoid wondering Caregiving education and support; respite for all stages of AD – 15 Stages 1 – 3 = Mild dementia Stages 4 – 5 = Moderate dementia Stages 6 – 7 Advance dementia Very costly healthcare for this chronic condition. Takes a toll on family who provides the dailycare. Older Adults Who are Chronically Mentally Ill Psychotherapy with Older Persons include: Life review Reminiscence therapy Group therapy Cognitivebehavioral therapy Remotivation therapy Mental health services are underutilized by older adults. Alcoholism (use & abuse) Unhealthy drinking patterns = 4 or more drinks in any single day during a typical months. Estimates of prevalence of alcoholism vary from 210% of all communitydwelling older adults Accompanied by depression in 30% cases and by dementia in another 20% Older men are 4X more likely to have alcohol problems (midlife 40+ onset) Alcoholics are less likely to be found among 65+ because of higher death rates at young age among alcoholics How alcoholism affects in old age? Most likely alcoholism has been a longtime problem. Increasing age exacerbates the condition – Central nervous system (CNS), liver and kidneys become less tolerant of alcohol due physiological changes Less muscle tissue & body mass, decrease liver kidney functions. An individual who has been heavily drinking for many years has accumulated irreversible damage. Medication prescribed for other chronic health conditions may enhance the effects of alcohol. Detoxification of the body may be almost impossible. 16 Drug Abuse Abuse of prescription drugs & overthecounter drugs. Common problems: taking more than the prescribed amount of meds (quick cure) combining drugs (for better result) taking another person’s meds (maybe it works for me too) Mixing with alcohol (to sleep faster/longer) Other Mental Health Disorders Drug Abuse: polypharmacy (multiple medications) Paranoid disorders: irrational suspiciousness of other people Causes: social isolation, sense of powerlessness, progressive sensory decline, memory problems Schizophrenia: much less prevalent with old age; usually diagnosed early in life and continue to display behavior symptomatic of schizophrenia. Use of Mental Health Services Psychotherapy with Older adults: Several therapies have been explored with this population Life Review = encourage introspection through active reminiscence of past achievements and failures Reminiscence Therapy = more focused, problemsolving therapy Group therapy = groups offer peer support, social interaction, and role modeling Remotivation Therapy = successful for those withdrawn from social activities. Significantly underutilized by older people, especially ethnic minorities – all groups are disproportionate represented in MH hospitals. Barriers to utilize services: societal stigma & access. 17 ****** 18
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