Geriatric Cognition, Anxiety and Treatment
Brie von Hauzen
Converse College
Geriatric Cognition: Anxiety, Personality Disorders, and Dementia
Introduction
In 1900, the average life span was 47 years. In today’s society, the average life span has increased to 76 years (Qualls & Abeles, 2000). Ban (1978) defines the term geriatric as “the medical specialty concerned with the study, prevention, and treatment of pathological conditions in the aged” (p. 93). Qualls and Abeles (2000) found the geriatric population is growing at enormous rates, with an estimated 835,000 centenarians by the year 2050, compared to only 37,000 centenarians in 1990. Due to the increase of the geriatric population, more emphasis in research needs to be focused on this later-life group.
In the early 20th century the terms anxiety and stress were used to refer to physiological changes within the body when an external stimuli was perceived as threatening or scary. Since then, society has begun to use the terms stressed and anxiety as a way of characterizing how they feel psychologically instead of biologically (Dowbiggin, 2009). Included within this paper will be a discussion on how cognition changes over the lifespan and how developments are made in later-life to accommodate for losses that come with the normal aging process. What do geriatric patients feel (both physiologically and psychologically)? Do they feel frail or do they feel confident? It is important to note that emotion does not stop changing at a certain age. Instead, as noted by Bailey & Henry (2009), the aging process produces emotions that are no longer just found at surface value; the emotions get more complicated and also more difficult to detect in facial expressions. This paper will examine how emotion and cognition change throughout the lifespan, with special interest in the frailty identity crisis, which results in anxiety and the differences between dementia and personality disorders (PD).
The Frailty Identity Crisis
According to Fillit & Butler (2009), by the age of 80, 40% of geriatric patients have some form of functional impairment, with 6-11% of these patients categorized as being frail. These patients will be considered frail until their death. The frailty identity crisis is the last stage before death. During this stage, patients frequently look back on their lives and feel regret, sadness, or disappointment in what they have achieved during their lifetime. They experience psychological distress, which in turn can affect their physical state due to the anxiety levels that are present. Harm avoidance has been linked to the geriatric population. Harm avoidance occurs when a patient has a tendency to worry, fear their future outcome of death, tires easily, and are often physically disabled during their geriatric years. If the geriatric individual experiences these feelings, the end result is often feeling constant worry, which will turn into anxiety. Geriatric patients with high levels of harm avoidance are more likely to have mobility limitations, which does impact the feeling of being frail. From this definition it is clear that body image plays an important role in how a geriatric patient views him or her self and the self-identity is translated into society.
When working with a geriatric patient who has labeled him or herself as frail, it is important to realize the impact this has on his or her view of death. The patients realize that their opportunities are lessened and often experience a sense of loss for the things they did not experience throughout their lifetime. In therapy, it is important to set goals for the patient that are still obtainable. These goals must be able to be met. Having an obtainable goal gives the patient something to look towards before death occurs. Goal setting is a tool frequently used to help the geriatric patient adapt to their new identity of being frail and can often maximize the patients functioning and positive emotion before the end of life. However, it is important to remember that only 6-11% of geriatric patients are categorized as being frail, leaving the rest of the geriatric population without the restrictions that the frailty identity crisis brings (Fillit & Butler, 2009).
Anxiety and the Geriatric Population
In the geriatric population, anxiety and depression are seen as co-morbid disorders. Both of these disorders also effect the quality of life that a geriatric individual will experience as they age. Depression increases the rate of mortality within this population and it is also important to note that the co-occurrence of anxiety and depression increases the severity of psychopathology, which will also become more chronic (Van der Weele, Gussekloo, De Waal, De Craen, & Van der Mast, 2008). Van der Weele, Gussekloo, De Waal et al. (2008) did a study on 90-year-old individuals and the co-occurrence of depression and anxiety. They found that 17% of the subjects had only depression, 4% had only anxiety, and 8% had concurrent depression and anxiety. Of these results, 32% of the subjects with depression had anxiety and 64% of the subjects with anxiety also experienced depression. Within this group, 3% reported a social phobia, with only one subject reporting agoraphobia. These results may be explained by looking at the population studied. As people grow older, they experience anxiety about different aspects of life, such as falling. This fear of falling may also lead to depression if the individual has limited his or her mobility due to this fear. This study reported that anxiety is a good indicator for depression in the geriatric population.
Another study, conducted by Rizzini, Vicini Chivoli, Peli, Conti, Rozzini, Trabucchi, and Padovani (2008) reported that detecting an anxiety disorder in the elderly can have many difficulties. The first of which is separating a medical condition from the physical symptoms associated with an anxiety disorder. In addition to medical conditions, separating mild cognitive impairment agitation from anxiety symptoms can also be challenging. Anxiety was found to manifest in a number of ways, such as, frustration and fear of losing control, restlessness and hyperkinesis, and sweating and palpitations. All of these symptoms are usually misunderstood by the caregiver and are often deemed to be a part of mild cognitive impairment or dementia. The researchers found that those patients with mild cognitive impairment and an anxiety disorder were more likely to fail in daily activities and daily functioning. It was also found that this population has higher rates of agitation than those without an anxiety disorder. Due to this difference in daily functioning levels, the researchers predict that those individuals with mild cognitive distortion and an anxiety disorder have a higher likelihood of reaching the realm of full blown dementia within one year of receiving a dual diagnosis of the above-mentioned disorders.
Anxiety and depression are often side effects of memory loss. An individual may become anxious or depressed when memory loss occurs, in addition to limited functioning. However, anxiety usually goes untreated in this population and is usually categorized in as a side effect of cognitive decline. The misdiagnosis of anxiety in the geriatric population can become a serious issue in some cases because it has been found that if the anxiety disorder is treated with proper medications and therapy, then the cognitive decline may no longer be an issue. However, for those individuals who do experience an anxiety disorder as a symptom of their cognitive decline, the anxiety can become a predictor for future cognitive decline and/or cognitive impairment (Sinoff & Werner, 2003).
Dementia and Personality Disorders
Lynch, Cheavens, Cukrowicz, Thorp, Bronner et al. (2007) found that the prevalence of psychological disorders, and the rates at which they occur, are similar between age groups. The rates for depression were also consistent between young and old. However, older adults exhibit fewer cases of borderline personality disorder (BPD), but found more cases of major depressive disorder (MDD) due to older adults meeting criteria for many different categories. In fact, older adults diagnosed with MDD are also frequently diagnosed with more cases of psychological disorders then geriatric patients who do not show depressive symptoms. The difference in the rates of diagnoses can be attributed to limited cognitive functioning, limited mobility, and lack of interpersonal relationship skills, all of which are often common in older adults.
It is important to note the difference subtypes found within dementia. Bouwens, Van Heugten, & Verhey (2009) noted that there are three subtypes to the category of dementia. The three subtypes are Alzheimer’s Disease (AD), frontotemporal dementia (FTD), and Parkinson’s dementia. FTD and Parkinson’s dementia are far less common than AD. However, all three types of dementia are found within the geriatric population. Two methods for distinguishing between the different types of dementia are the Mini-Mental State Examination (MMSE) and the Blessed Dementia Scale (BDS). The MMSE evaluates the patient’s cognitive abilities, while the BDS looks at the daily life functioning of those patients.
The results scored for the MMSE and the BDS are specific to the different subtypes of dementia. The Parkinson’s dementia group did not have a significant score on the BDS while still receiving low scores on the MMSE, which implies that their daily activities are not affected as much as their cognitive abilities. One reason patients with Parkinson’s dementia scored low on the MMSE is that the test requires verbal responses, which is a difficult requirement for patients with Parkinson’s disease. In contrast, patients with FTD scored low on the BDS since FTD does have a large impact on the daily living of those patients. It is important when treating a patient with dementia to identify which subtype the patient falls under and how best to treat the patient due to the different symptoms each subtype has (Bouwens et al., 2009).
Magai, Cohen, Culver, Gomberg, & Malatesta (1997) reported that pre-existing personality characteristics are more prevalent within a patient with dementia then they would be earlier in the lifespan. If a patient is prone to aggressiveness as a young adult, when the patient reaches the later stages of dementia, the patient will exhibit the same tendencies towards aggression, sometimes at a more prevalent rate. The data collected within the researchers study shows that personality characteristics do remain stable over the course of the life span and even into late stages of dementia. This is important to note because looking at a patients personality characteristics prior to them developing dementia can often help the geriatric team to determine how best to treat the patient due to his or her personality traits.
Treatment Involving Dialectical Behavior Therapy and Emotion-Oriented Care
Lynch, Cheavens, Cukrowicz, Thorp, Bronner et al. (2007) proposes that since the rates of depression and personality disorders (PD) are consistent across age groups, then the treatment of these diseases should be treated as the same. Dialectical Behavior Therapy (DBT) is the proposed method of treatment. The presence of a PD in a geriatric patient can interfere with the treatment of Major Depressive Disorder (MDD) and anxiety disorders due to the misdiagnosis that the multi-symptoms possibly present. DBT is a therapy in which patients go through three stages. DBT’s main goal is to reformat how the patients regulate their emotions and deals with stressors they may face.
The first stage, as outlined by Lynch et al. (2007), is individual therapy, which targets highlighting behaviors found to be dangerous or harmful to the patient. In this stage, the patient is typically in individual therapy for one year. The second stage of DBT is skills group, which also lasts approximately one year. During this stage, the patient learns new techniques to deal with the patient’s stressors and aims to replace negative behaviors, with more positive ones. Lynch et al. (2007) reports that during the second stage of DBT, the patient focuses and learns the techniques of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. The third stage of DBT is phone calls from therapist to patient, or vice versa, to coach the patient in using the new emotion regulating tools they have learned. Since DBT can be used across age groups, it is important to recognize how to best implement it when working with the geriatric population. Geriatric patients with PD, MDD, and an anxiety disorder are less open to new experiences then their younger counterparts are, in addition to receiving negative feedback from the environment, which can result in them not wanting to participate in new experiences.
When using DBT, it is important that the patient learns emotion regulation skills that work with where they are in their lifespan. As people age, they lose the social networks they once had due to death of friends, family members, spouses, etc. It is a difficult task for a geriatric patient to find a new confidant when the one they have always had is no longer there and they often become rigid when dealing with anyone but themselves. DBT specialized for a geriatric patient would include skills that work on making their interpersonal effectiveness more effective. Telephone calls with their therapist can help the patient work on simple social skills. Memory aids might be found useful in dealing with confusion, which results in anxiety, which is shown as a form of aggression. The use of a memory aid would eliminate the confusion, which in turn would produce no negative emotion (Lynch et al. 2007).
Emotion-oriented care has proved to be a useful tool when combined with traditional medicine when working with the geriatric population. Finnema, Droes, Ettema, Ooms, Ader, Ribbe, and Tilburg (2005) define emotion-oriented care as the goal of integrating emotion modulation with traditional therapies to improve the emotional and social functioning of geriatric patients. Through emotion-oriented care, individuals can have better tools to deal with their cognitive deficiencies often found in later life. Validation therapy, reminiscence therapy, and sensory stimulation are all included within this treatment (Finnema et al., 2005).
Validation therapy was originally developed by Feil in 1967, as mentioned by Schrijnemaekers, van Rossum, Candel, Frederiks, Derix, Sielhorst, and Van Den Brandt (2002), and is a process of communicating with geriatric patients by validating their emotions and allowing the patients to feel that it is okay to feel as they are feeling. This process can be extremely successful in gaining a trusting relationship between the therapists and the geriatric patient and can often open the door for communication. Validation can increase positive affect, decrease negative affect, and can restore well-being in disoriented geriatric patients. It is important to validate how the patient views his or her reality in contrast to the reality in the real world.
Finnema, Droes, Ooms, Ader, Ribbe, and Tilburg (2005) state that reminiscence therapy is a tool that allows geriatric patients to look back on their lives and remember the good times that they have had. Through reminiscence therapy, the patient can also acknowledge regrets they have about their live. This is also a good tool when setting realistic goals for the patient to achieve before they die. In addition to validation therapy and reminiscence therapy, sensory stimulation has also proved to be useful when using emotion-oriented care to treat the geriatric population. Sensory stimulation allows the patient to have their senses triggered by stimuli that they have known throughout their lives and can give the patient something that is stable and that they can still recognize. When treating disoriented geriatric adults, it is important that they begin to feel grounded once again and that they feel as though they have control over some aspect of their life, such as recognizing a smell or touching a soft blanket.
Through emotion-oriented therapies, geriatric patients can gain a sense of control over their declining cognitive functions and can still feel empowered, especially with the help that validation therapy provides. Emotion-oriented care integrated into traditional care of geriatric patients benefited the patient’s value of self-worth and self-identity. Emotion-oriented care had a more positive effect in the treatment of both mild to severe cases of dementia then did traditional nursing home practices (Finnema et al., 2005).
Discussion
I chose to apply anxiety disorders to the geriatric population because the geriatric population is close to my heart. Both anxiety and cognitive decline are found within my family of origin, and I assume that I will also experience cognitive decline when I reach my geriatric years. As many of the sources in this paper mentioned, not much research has been done on anxiety and the geriatric population, except as how it relates to cognitive decline and/or impairment. Losing ones memory can be, and usually is, a scary time. Anxiety is a common emotion felt by these individuals. While writing this paper, my hope was to explain how anxiety and other disorders, can effect the treatment and outcome of those in their later years who suffer any form of cognitive decline. I would also like to note that from my own experience I have learned that an anxiety disorder at any age can bring about a form of cognitive decline. It is important that people keep in mind the importance of treating anxiety, no matter the circumstances, and by doing so may help the elderly stay cognitively strong in their later years.
References
Bailey, P., & Henry, J. (2009). Subconscious facial expression mimicry is preserved in older adulthood. Psychology and Aging, 24(4), 995-1000.
Ban, T. A. (1978). A treatment of depressed geriatric patients. American Journal of Psychotherapy, 32(1), 93-104.
Bouwens, S., Heugten, C. V., & Verhey, F. (2009). Association between cognition and daily life functioning in dementia subtypes. International Journal of Geriatric Psychology, 24(7), 764-769.
Dowbiggin, I. R. (2009). High anxieties: The social construction of anxiety disorders. Canadian Journal of Psychiatry, 54(7), 429-436.
Fillit, H., & Butler, R. (2009). The frailty identity crisis. Journal of the American Geriatrics Society, 57(2), 348-352.
Finnema, E., Droes, R., Ooms, M., Ader, H., Ribbe, M., & Tilburg, W. v. (2005). The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: A randomized clinical trial. International Journal of Geriatric Psychiatry, 20(4), 330-343.
Lynch, T., Cheavens, J., Cukrowicz, K., Thorp, S., Bronner, L., & Beyer, J. (2007). Treatment of older adults with co-morbid personality disorder and depression: A dialectical behavior therapy approach. International Journal of Geriatric Psychiatry, 22(2), 131-143.
Magai, C., Cohen, C., Culver, C., Gomberg, D., Malatesta, C. (1997). Relation between premorbid personality and patterns of emotion expression in mid- to late-stage dementia. International Journal of Geriatric Psychiatry, 12(11), 1092-1099.
Qualls, S. H., & Abeles, N. (2000). Psychology and the Aging Revolution. Psychology and the Aging Revolution: How We Adapt to Longer Life (1 ed., pp. 3-9). Washington: American Psychological Association (APA).
Rozzini, L., Chilovi, B., Peli, M., Conti, M., Rozzini, R., Trabucchi, M., & Padovani, A. (2009). Anxiety symptoms in mild cognitive impairment. International Journal of Geriatric Psychiatry, 24(3), 300-305.
Schrijnemaekers, V., Rossum, E. v., Candel, M., Frederiks, C., Derix, M., Sielhorst, H., Van Den Brandt, P. (2002). Effects of emotion-oriented care on elderly people with impairment and behavioral problems. International Journal of Geriatric Psychiatry, 17(10), 926-937.
Sinoff, G., & Werner, P. (2003). Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline. International Journal of Geriatric Psychiatry, 18(10), 951.
Van der Weele, G. M., Gussekloo, J., De Waal, M. M., De Craen, A. M., & Van der Mast, R. C. (2009). Co-occurrence of depression and anxiety in elderly subjects aged 90 years and its relationship with functional status, quality of life and mortality. International Journal of Geriatric Psychiatry, 24(6), 595-601.
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