Psychopathology of senile dementia of the Alzheimer type.
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Biomedical subjects
E H Rubin
Publications and source records attributed to E H Rubin.
Very mild senile dementia of the Alzheimer type. I. Clinical assessment.
We report a longitudinal study of 16 subjects originally enrolled in the Washington University (St Louis, Mo) Memory and Aging Project with Clinical Dementia Rating (CDR) of "questionable" dementia (CDR 0.5). A 0.5 rating was intended to characterize subjects in whom mild cognitive impairment due to senile dementia of the Alzheimer type was suspected but was insufficient in degree to warrant a diagnosis of definite dementia. Over an 84-month follow-up period, 11 of the 16 subjects either had Alzheimer's disease verified post mortem or had clinically progressed to a more advanced CDR stage in which the dementia was clearly evident. These results suggest that the CDR 0.5 stage likely represents the incipient clinical manifestation of Alzheimer's disease and that the majority of subjects with CDR 0.5 have "very mild senile dementia of the Alzheimer type." Performance on several standard clinical scales was significantly different when comparing a larger sample of controls (n = 83), subjects with CDR 0.5 (n = 41), and subjects with mild senile dementia of the Alzheimer type (score of 1; n = 68).
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Psychotic symptoms and the longitudinal course of senile dementia of the Alzheimer type.
Delusions, misidentifications and hallucinations occur frequently throughout the course of senile dementia of the Alzheimer type (SDAT). Rates of psychosis among subjects with moderate to severe SDAT range from 42% to 84% in our study group; at least half of persons with SDAT with no prior psychiatric history will display psychosis at some point during the course of dementia. Furthermore, psychotic symptoms are associated with accelerated cognitive deterioration, but not with increased mortality.
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Psychopathology of very mild dementia of the Alzheimer type.
The authors describe psychiatric abnormalities, including personality and affective changes and psychotic symptoms, associated with very mild senile dementia of the Alzheimer type. The behavioral and affective changes in the subjects with very mild dementia resembled those occurring in subjects with mild dementia, but psychotic symptoms rarely occurred until the dementia had progressed to at least a mild stage.
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Reliability of the Washington University Clinical Dementia Rating.
There is a growing need for methods for measuring and staging the natural history of dementia of the Alzheimer type. One instrument, designed with that purpose in mind, is the Washington University Clinical Dementia Rating. We tested its reliability using multiple clinicians in a videotape-design study, and it proved reliable under these study conditions.
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Mild senile dementia of the Alzheimer type: 2. Longitudinal assessment.
Forty-three subjects with mild senile dementia of the Alzheimer type (SDAT, so-called probable Alzheimer's disease) were studied longitudinally by serial administration of several tests to rate dementia. Comparison was made with 58 healthy elderly controls. The clinical diagnosis was confirmed in all 16 autopsies. At 5 years after entry into the study, the cumulative rate of nursing home placement was 73%, and of death, 30%, rising at 7 years to 84% and 44%, respectively. Four of six clinical measures of dementia were found to correlate with the natural history of SDAT. Several measures are better than a single one in carrying out longitudinal studies of the disorder.
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Electroconvulsive therapy in the treatment of combined depression and Parkinson's disease.
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Symptoms of "depression" in dementia of the Alzheimer type.
The frequency of symptoms of depression (Feighner criteria) was evaluated in subjects with dementia of the Alzheimer type (DAT) and matched controls enrolled in a longitudinal natural history study of DAT. Despite enrollment criteria which excluded subjects with affective disorders, the collateral sources of subjects with DAT described these subjects as having significantly more "depressive" symptoms than controls without dementia at entry, and at 15- and 34-month follow-up. The collateral sources of the subjects with DAT reported that these demented individuals experienced significantly greater loss of interest, decreased energy, difficulty in thinking and concentrating, and psychomotor agitation or retardation then did the control group. The subjects with DAT reported fewer symptoms than did their collateral sources, but like their collateral sources, they did not report a global elevation of all Feighner symptoms, but rather related significantly greater difficulty in thinking and concentrating than the controls and a tendency toward loss of interest and psychomotor changes. No subject became clinically depressed. The results suggest a significant overlap between the symptoms of dementia and depression. The frequency with which the above symptoms occur in DAT confounds the use of Feighner and, by extension, DSM-III criteria in diagnosing depression in cognitively impaired individuals with DAT.
Alzheimer Disease↗
Overlapping symptoms of geriatric depression and Alzheimer-type dementia.
The occurrence of geriatric depression and dementia of the Alzheimer type, two of the most common diseases of late life, is certain to increase as the proportion and absolute number of Americans over the age of 65 grow larger. Overlapping symptomatology can sometimes make it difficult to determine whether a patient suffers from geriatric depression with cognitive abnormalities, Alzheimer-type dementia with depressive symptoms, or coexisting depression and dementia. In this review of the course, symptomatology, and pathophysiology of Alzheimer-type dementia and geriatric depression, the authors describe the symptoms often shared by these diseases as well as the characteristics usually associated with one or the other. Factors that complicate diagnosis, such as the presence of other medical illnesses and pharmacokinetic and pharmacodynamic changes associated with aging, are also discussed.
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Electroconvulsive therapy for the elderly: a review.
Treatment of psychiatric disorders among the elderly is complicated by such factors as high incidence of medical illness and changes in drug metabolism; electroconvulsive therapy (ECT) is considered a reasonable treatment alternative for the elderly for several psychiatric syndromes. The authors review indications, complications, and precautions related to ECT for older patients. The primary indication is major depression; about 80 percent of elderly patients respond favorably. ECT appears less effective for depression secondary to dementia or somatization disorder. Although ECT is relatively safe for the elderly, up to one-third may experience a complication that interferes with treatment. Careful pre-ECT medical evaluation is essential, with special attention to cardiovascular factors and to concurrent medications.
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The nature of psychotic symptoms in senile dementia of the Alzheimer type.
The Alzheimer Disease Research Center at Washington University's medical school has gathered a large sample of subjects with senile dementia of the Alzheimer type (SDAT) who are free of other potentially complicating medical, neurologic and psychiatric disorders. Using this homogeneous population, we have characterized psychotic symptoms associated with SDAT. Three groups of symptoms occur commonly: paranoid delusions, misidentification syndromes, and hallucinations. The nature and frequency of these syndromes are discussed.
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Aging and mania.
Geriatric psychiatry involves the study of the interaction of age, medical illnesses, psychopathology, and treatment responsivity. Many of these interactions are demonstrated by reviewing mania in the elderly. Studying geriatric aspects of psychiatric disorders may give clues to understanding the pathophysiology of the same disorder in younger patients. For instance, localization of lesions associated with late onset mania suggests brain areas which may be involved in the early onset form of bipolar affective disorder. Reviewing the use of lithium in the elderly patient with mania provides the opportunity to review general geriatric psychopharmacologic principles.
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Behavioral changes in patients with mild senile dementia of the Alzheimer's type.
Behavioral changes in 44 subjects with well-characterized mild senile dementia of the Alzheimer's type (SDAT) and 16 subjects with only questionable SDAT were compared to a control group of 58 subjects. Answers to both open-ended questions and personality items from the Blessed Dementia Scale were examined. Seventeen items were classified into seven categories by factor analysis and then further categorized into four clinically useful groups: passive, agitated, self-centered, and suspicious. Over 75% of subjects with mild SDAT had behavioral changes compared to 10% of controls. Passive symptoms were the most common, occurring in two-thirds of mild SDAT subjects. Agitated and self-centered symptoms were also common, occurring half as frequently as passive symptoms. Passive symptoms occurred alone in 25% of those with mild SDAT, whereas passive symptoms, together with agitated and/or self-centered symptoms, were present in 11-16% of subjects with mild SDAT. Agitated or self-centered symptoms rarely occurred alone. Characterizing the behavioral symptoms of SDAT is important for their clinical implications and for an approach to understanding brain-behavioral relationships.
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Senile dementia of the Alzheimer's type: an important risk factor for serious falls.
In a longitudinal study of senile dementia and healthy aging, the occurrence of serious falls was examined in participants with senile dementia of the Alzheimer's type (SDAT) (n = 44) and in cognitively healthy elderly control participants (n = 56) over a 4-year period. Falls occurred in 36% of SDAT individuals versus 11% of controls. The higher frequency of falls in demented participants was not explained by greater neurologic deficit nor by increased drug use compared with controls. However, males with SDAT who reported falls, had higher mean blood pressures and were more likely to be medicated than males with SDAT who did not fall. These differences were not observed in women. Falls in SDAT participants were associated with an increased rate of institutionalization. SDAT is an important risk factor for serious falls, and falls are associated with loss of independence in demented patients.
Accidental Falls↗
The safety of ECT in geriatric psychiatry.
Electroconvulsive therapy (ECT) is often described as an effective and safe treatment of depression in the elderly. However, we have previously reported that there may be increased morbidity in this population, particularly in the very old. This paper extends this work to a second, larger sample of 136 subjects of whom 40 are over 60 years of age. We have again found that while ECT is efficacious, complications increase with age (r = .26; P less than or equal to .003), occurring in 35% of the elderly as opposed to 18% of the younger group. This increased rate of complications appears to be accounted for by problems in the very old; six of eight subjects over 75 years of age had some untoward event. Common complications in the elderly included severe confusion, falls, and cardiorespiratory problems. Complications in the whole sample were related to health status (r = .22; P less than or equal to .008) which in turn correlated with age (r = .50; P less than or equal to .0001). Those taking a greater total number of medications and a greater number of cardiovascular medications had significantly more complications during ECT. There was no relationship between either complications and outcome or complications and the number or laterality of treatments. These findings confirm the effectiveness of ECT in the elderly but suggest there may be unappreciated risks of ECT in this population. At particular risk are the very old, those in poor general health, and those taking multiple medications, particularly cardiovascular agents.
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The progression of personality changes in senile dementia of the Alzheimer's type.
Passive, agitated, and self-centered behavioral changes were noted on initial evaluation in two-thirds, one-third, and one-third, respectively, of subjects with mild senile dementia of the Alzheimer's type (SDAT). Over a 50-month follow-up period, the percentage of patients who exhibited agitated and self-centered behaviors doubled. The percentage of subjects who demonstrated all three behavioral changes increased from 11% at entry to the study (mild SDAT) to over 50% when the dementia had reached a severe stage. The presence of personality changes at a mild stage of dementia did not predispose subjects to more rapid progression to a more advanced stage of illness.
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Erotomania and senile dementia of Alzheimer type.
A case of erotomania in a 75-year-old female with senile dementia of Alzheimer type (SDAT) is described. This case demonstrates the presence of an elaborately systematised delusion in SDAT, and the influence of the progression of SDAT on this delusion.
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Psychiatric correlates of chronic solvent abuse.
Eleven chronic solvent abusers admitted for inpatient treatment were retrospectively identified and their records reviewed to determine associated medical and psychiatric illness and other substance abuse. Antisocial personality disorder and narcotics abuse were common in the group, as were symptoms suggesting neurological or gastrointestinal dysfunction. The patients' response to substance abuse treatment was poor. The findings indicate that persons who abuse solvents over a long period tend to have associated behavioral patterns that may contribute to poor social adjustment and to poor response to the treatment of their substance-abuse problems.
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