Senile Dementia may be defined as an abnormal weakening of the mind
arising in old age. As the word dementia implies, the intellectual
change is quantitative rather than qualitative, the prime
characteristic of the disease being mental loss rather than mental
perversion.
It is commonly stated that a most important cause of the disease is the
general malnutrition incident to age. Since only a small proportion of
the aged develop dementia, this is probably only a cooperating factor.
Other causes mentioned are overwork, emotional strain, traumatisms,
intoxications (especially alcoholism), cerebral arteriosclerosis and
perhaps heredity.
=Pathologic Anatomy.=—The disease is organic, the brain exhibiting
definite pathological tissue changes. There is an atrophy of many nerve
cells and a proliferation of neuroglia fibers, so that the cerebrum
becomes shrunken and hard, with thickened meninges and thinned cortex,
and shows a loss of weight. The cerebral arteries may or may not
exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant
areas of softening. The cells show pigmentary degeneration and many of
the association fibers have disappeared.
=Onset.=—The onset of this dementia is usually very gradual, the
condition not being recognized until rather marked. It occurs mainly
in the seventies and later and in the late sixties, being rare before
sixty. It often follows financial reverses, emotional shock, or
various diseases. The earliest symptoms are a change in the person’s
disposition, slight disorders of memory, and trivial lapses of various
sorts.
As the disease progresses the symptoms become more marked and
fundamental, involving not only the intellectual but also the emotional
and volitional phases of consciousness. Interest in the outside world
begins to flag, attention to wander, perception to be incomplete and
inaccurate, association of ideas to be slow, memory to weaken and
judgment to be impaired. Memory of the most recent incidents is the
first to be lost, of recent years next, and then of middle age so that
the patient may not recognize his own children or know, for example,
that his wife is dead; finally the memory even of youth is lost and the
patient is to all intents and purposes a child, his condition being
an exaggeration and aggravation of that commonly known as “second
childhood.”
Several forms of Senile Dementia exist, of which the most common
is probably the simple or non-delusional type. Other forms are
fundamentally the same as the simple, but with certain superimposed
symptoms. Fairly early in this type it becomes unsafe for the patient
to continue in business. Due to impairment of memory and judgment he
is apt to lose his property. Soon his work is poorly done or neglected
entirely. He becomes garrulous and annoys his associates with tiresome
repetitions of childish reminiscences, continually wandering from one
subject to another. His speech becomes incoherent and his sentences
fragmentary. He grows untidy and indifferent to the ordinary niceties
and conventions of life. His appetite is either poor or voracious; in
the latter case the weight may keep up fairly well. He may be either
apathetic or turbulent. If the former, he seems stupid, indifferent,
and sleepy. He is credulous, docile, and very suggestible. Patients
of the turbulent type are restless and always moving about, either
depressed or elated, giving unreasonable orders and then contradicting
them. Sleeping poorly, they are apt to get up and wander about the
house at night. In men, prostatic disease may cause a recrudescence
of sexual feeling. Patients of either type eventually become filthy,
soiling their clothing, etc. Even in well advanced cases, however,
senile dements are often able to perform well certain habitual
activities, such as signing their names, or playing certain games, such
as checkers or dominoes.
=Confusional Type.=—Another form of Senile Dementia, which may in
severe cases usher in the attack, but which usually, when present, is
sequent to the simple form, of which it is a more severe grade, is
the confusional. The additional symptoms of this type are probably
due to defective elimination and the consequent toxicity. Usually
unsystematized delusions, and sometimes hallucinations are present.
Except for a possible occasional period of remission the confusion is
continuous. It varies greatly in degree, now being mild and passive
and again active, perhaps developing into delirium. Orientation as to
both time and place may be lacking. Such patients may ask for dinner a
few minutes after a meal, go to bed at noon, be unable to find their
own room, or to recognize their own children. They are apt to be
obstinate and peevish. Delusions vary in type but both these and the
hallucinations are usually painful and, being referred to the patient’s
associates, give rise to the thought that they are trying to kill or
otherwise harm him.
=Delusional Type.=—A third type of Senile Dementia is the paranoid
form. Dements of this type, owing to delusions of persecution and
auditory hallucinations are sensitive and suspicious. Such cases may
sometimes show good orientation, apparently unclouded minds, and
little evidence of senility, requiring careful study to differentiate
the condition from true paranoia. A patient may, on account of
hallucinations of taste and smell, refuse food in the belief that it
is poisoned. Members of his family who are devotedly caring for him
are suspected of designs on his money, and this suspicious attitude
frequently leads to unjust wills. The delusions and suspicions may
be entirely concealed from the family. Wealthy paranoid elements
are peculiarly apt to become the prey of scheming adventuresses,
particularly in case of the above mentioned sexual recrudescence,
and marry them. Opposition of the family is regarded as part of their
general persecution or as due merely to their desire to get the estate.
Some patients merely appear odd, suspicious, untidy, peevish, and
childish. Some have expansive delusions and exhibit the euphoria so
frequently found in syphilitic dements.
=Senile Delirium.=—A fourth type has been described by some
psychiatrists under the title of senile delirium. This may appear as
the initial form of the disease or as an acute attack in one of the
above forms. It is characterized by great incoherence and restlessness,
entire absence of orientation, and numerous rapidly changing delusions
and hallucinations, the condition resembling delirium tremens. It is
probably due to some somatic cause, such as nephritis, pneumonia, or
cystitis, which is often fatal.
Complications may arise in Senile Dementia, such as apoplectic strokes,
hemiplegia, epileptiform seizures and aphasias.
=Prognosis.=—It is evident from the pathology of the conditions that
the prognosis is not at all good when the disease is well advanced. It
is a chronic disease and usually progressive until death, which is due
to one of the complications, malnutrition, or especially pneumonia.
However, many cases have shown improvement, and in incipient stages
recovery. A cure of advanced cases being impossible, the important
consideration is prevention or arrest in its incipiency.
It is evident that this can be done only by preventing, or removing
as far as possible, the predisposing causes. A glance at the list of
these shows that much depends upon the cooperation of the patient by
regulating his habits of life. Physical and mental overstrain must
be avoided, deleterious habits, such as the use of intoxicants or
narcotics given up. Much can be done by osteopathy to eliminate the
effects of these upon the organism. Cardio-vascular and renal symptoms
are very important and should be watched for in order that early
treatment may check the process initiated. To this end the patient’s
habits and diet must be regulated and treatment instituted to relieve
toxicity and promote elimination. Lesions must be corrected, special
attention being given to the lower dorsal that affect the kidneys, the
upper dorsal that affect blood pressure, and both the upper cervical
and upper dorsal that affect the blood supply and nutrition of the
brain.
=Arteriosclerotic Dementia.=—This is a mental enfeeblement arising
sometimes in the fourth, but chiefly in the fifth, decade of life, and
associated with symptoms of arterial hardening.
The cause is arteriosclerosis, which may be secondary to some form of
nephritis. The arterial hardening may be general or may be confined
to the arteries of the cerebrum. It is likely that the arterioles
supplying the cortical cells are especially involved in an atheromatous
condition. The disease is organic, chronic and progressive. Hemorrhage,
embolism, or thrombosis may occur, producing focal lesions and areas of
softening, with hemiplegia, aphasia, etc.
The earliest symptoms may be headaches and dizziness. The blood
pressure is usually found to be high but not invariably. An
atheromatosis may be present in some one of the palpable peripheral
arteries, such as the radials. Further symptoms on the physical side
are quick fatigue, loss of energy, numbness and paresthesias of the
extremities, and somnolence in the daytime or perhaps insomnia at
night. Strokes may occur, usually slight and temporary, probably due
to spasm in a degenerating artery or perhaps to serous effusion.
Toxic symptoms appear, due to disorder in kidneys, liver, and other
organs. Epileptiform seizures are possible. Mentally the patient shows
impairment of memory, and perhaps some confusion and hallucinations.
Rarely stupor occurs. He may be agitated and irritable or melancholy
and depressed. Suspicious and persecutory ideas of the paranoid type
may appear; also hypochondriacal ideas.
=Osteopathic Theory.=—In these psychoses of the older years of life the
termination is usually dementia, which means mental enfeeblement, and
which results from degenerative changes in the brain substance. As has
been shown it is largely a nutritional question and the nutritional
condition varies tremendously in different elderly people; it is well
known that many old people preserve their brain powers fairly well to
the end; on the other hand others fail relatively early, some even in
the fifties; these cases of earlier failure are referred to as the
“presenile type.” The osteopathic conception would be to find out the
source productive of the nutritional disorder and correct it at the
very outset, therefore making it quite possible to prevent the disease
process from taking place. The prognosis then in the earlier stages is
very good.