THE SENILE PSYCHOSES
Never until very recently has any great importance been attached to the
psychoses due solely to age or much interest manifested in them. These
forms of insanity in the majority of our textbooks have appeared only
under the designation of senile dementia. This is true of the earlier
editions of Krafft-Ebing and many other writers. Clouston referred to
senile dementia as one of four varieties of mental enfeeblement. "Most
cases,"[156] he says, "fall under three varieties. The first has as its
chief characteristics depression and lethargy. The second consists
chiefly of excitement, sometimes with a certain exaltation, but always
with irritability, restlessness, unreason, suspicion, and change of
affection. The third variety consists chiefly of the abolition of
mind in all its forms, or senile dementia, and of complete dotage. In
some cases those three varieties form three different stages in the
same case. In others they do not change." Régis, in a work on mental
medicine covering 668 pages in all, devoted two and one-half pages to
a consideration of the insanity of old age. Ziehen[157] in 1894 included
"dementia senilis" with general paralysis, epileptic, alcoholic and
terminal deteriorations in his group of "acquired defect psychoses" and
characterized it as "a chronic organic psychosis of advanced years,
the principal symptom of which is a progressive intelligence defect."
Excitements, depressions, confusional states, deliria, deteriorations,
mental mechanisms of any and all kinds, occurring late in life,
were usually disposed of without any effort at differentiation by
the very convenient method of relegating them to the obscure domain
of senile dementia. This is a field which on exploration has been
found to be one of considerable interest. It has been pointed out
that manic-depressive insanity not infrequently occurs in persons of
advanced age. Uncomplicated alcoholic psychoses are not at all rare.
Bleuler has advanced the theory that dementia praecox and certain of
the senile conditions are similar if not identical processes. General
paresis has been demonstrated in the later periods of life by modern
laboratory methods and the diagnosis confirmed at autopsy. Cerebral
syphilis certainly cannot be left out of consideration. Toxic deliria
are encountered now and then. Even the psychoneuroses are possibilities.
Kraepelin first established the importance of involution melancholia
as a form of depression warranting separate consideration. The anxiety
psychoses occurring late in life have since been made the subject of
exhaustive study by various observers. It was discovered that many of
the mental disturbances of the aged could be attributed directly to
arteriosclerosis alone. Korsakow's syndrome has been found to be as
frequently due to senility as it is to alcoholism. Some of our more
modern works on psychiatry have included very elaborate chapters on
purely "presenile" conditions. Kraepelin[158] in his last edition devotes
twenty pages to a review of this subject.
He divides the presenile psychoses into melancholia, anxieties, late
katatonia, depressive delusional conditions, anxious delusional
types terminating in advanced deterioration, depressive states with
deterioration, excitements and paranoid forms. The development of
Kraepelin's conception of melancholia has been fully discussed in
another chapter. He speaks also of the occasional occurrence of anxious
conditions in late life with excitements or an exalted mood with
grandiose ideas or even paranoid manifestations. These may present a
catatonic picture with more or less inaccessibility, stereotypies,
peculiar attitudes and movements, absurd resistance, impulsiveness,
desultoriness and disconnected speech. Our knowledge as to the exact
causation and nature of katatonia still being far from complete, he
knows of no reason why a process of that kind should not be recognized
as one of the presenile conditions. Thalbitzer suggested the name,
depressive delusional insanity (depressiven Wahnsinn), for the
conditions exhibiting numerous delusions and active hallucinations
with an emotional reaction "determined by the course of the disease."
Rehm also described a similar form associated with arteriosclerotic
changes and characterized by hallucinations of hearing, together with
mannerisms and sterotypies.
Kraepelin[159] describes first a group of presenile cases showing the
development of depressive ideas and anxious states with a progressive
mental enfeeblement. Delusions of self-accusation and persecution
present themselves early in the course of the disease. Symptoms of a
more decidedly hypochondriacal type may occur later. Hallucinations and
somatic delusions also develop, often with nihilistic trends. Everyone
is dead, the patient is the only one left in the world, has no legs,
cannot go out of the house, has entirely disappeared, does not exist
any more, etc. The consciousness is usually fairly clear, orientation
is well preserved and there is no marked disturbance of thought.
Anxious excitement is often an important feature. The termination
is in mental enfeeblement invariably. This condition manifests
itself usually at about the fortieth year. He is of the opinion that
this symptom complex cannot be considered either as belonging to
manic-depressive insanity or attributable to arteriosclerosis, nor is
it catatonic in its origin.
He finds another group of cases occurring in women between forty-five
and fifty years of age, characterized pathologically by striking
anatomical changes and clinically by a very unfavorable course. A
depression first appears, followed by anxiety with thoughts of suicide.
Hallucinations do not occur as a rule. Restless and agitated excitement
is a prominent symptom leading finally to confusion, clouding of
consciousness, and disorientation. This is followed by a condition of
mental enfeeblement terminating in early death. Well-defined postmortem
changes have been found, such as the "grave alteration" described by
Nissl, proliferation of the glia, swelling of the protoplasmic bodies
with cell enclosures, etc., but no fibril formation. Large quantities
of lipoid material are found in the surrounding vessels and in the
vascular sheaths. This condition, also observed by Nitsche and Döblin,
Kraepelin looks upon as probably a presenile process of autotoxic
origin, there being no other cause demonstrable. He does not consider
this disease process as being related to "late katatonia," genuine
katatonia or manic-depressive insanity.
He would also separate out another smaller group as probably belonging
to the presenile forms—cases with excitements of long duration,
terminating in a marked deterioration. This condition is likely to
be of sudden onset, with depressive ideas of self-accusation, later
showing an active restlessness. These patients soon become clouded
and confused, often with grandiose ideas suggesting general paresis.
They may show memory falsifications. Stuporous states occasionally
intervene, followed by an active excitement. Echolalia is common.
The excitement may last for months or even for a year or more and
often stops suddenly, always with deterioration later. In the
cases which have come to autopsy Alzheimer has reported severe and
widespread cell alterations, fibre loss, glia reactions, and changes
in the vessel walls, somewhat suggesting the pathological findings
in general paresis. The cases in this group usually have been of the
male sex between sixty and seventy years of age. Kraepelin speaks of
the clinical picture as a mixture of the symptoms of general paresis,
katatonia and manic-depressive psychoses and it is usually diagnosed as
one or the other of these conditions.
The paranoid presenile forms occur usually in women. Consciousness is
clear, although there may be a mild anxiety or hypochondriasis. The
persecutory ideas are variable and changeable. Delusions of jealousy
are common although hallucinations are infrequent. Memory is often
somewhat impaired and retrospective falsifications are occasionally
observed. The mood is as a rule anxious and suspicious. Suicidal
tendencies often appear. Restlessness, excitement, impulsive actions
and outbursts of anger are noted at times. Rarely a more cheerful mood
develops. The disease may become stationary and show no marked changes
for years.
Kraepelin himself seems to be very uncertain as to the significance and
the delimitation of these various presenile forms. It must be confessed
that some of the types described very strongly suggest the condition
formerly looked upon by him as involutional melancholia. It will be
noted that he considers as possible etiological factors the disturbance
of metabolism which may result from regressive or involutional
processes. The differentiation from manic-depressive forms, from
arteriosclerotic disorders and from senile psychoses must also be
looked upon as presenting some difficulties which cannot be entirely
disregarded. Many possibilities suggest themselves.
In the senile deteriorations Kraepelin notes particularly a loss in
the capacity of apprehension and perception, with a sluggishness of
the train of thought, a dulling of the emotions, a reduction of energy
and the development of conduct disorders. Ranschburg in psychological
tests noticed a lengthening of the reaction time, with a delay in the
choice of action, the reading of words, the performance of addition,
and the formation of judgment. The retardation was shown particularly
in psychic processes and the association time. The reactions were,
moreover, much more monotonous, irregular and unreliable than in the
young. Memory tests also showed poor associations.
The most advanced form Kraepelin describes as senile dementia, a
progressive mental enfeeblement in which the loss of apprehension
and memory becomes a conspicuous feature. The perception of external
impressions is diminished and delayed and there is a profound disorder
of attention. Memory of the remote past is much better than it is for
current events. Retrospective falsification is a common symptom. The
patient is, moreover, unable to change old viewpoints or acquire new
ones. Delusional manifestations such as childish egotism, foolish
suspicions or notions of impending illness develop. Grandiose ideas
often occur, delusions of great wealth being common. These symptoms
are transitory and come and go without apparent reason. In some cases
the hallucinations resemble those found in the alcoholic psychoses.
Sooner or later there is a disturbance of consciousness leading to
a dreamlike existence suggesting a delirium. There is a noticeable
dulling of the emotional feelings. The patients become indifferent
and apathetic, losing interest in their surroundings, and are often
irritable and excitable. In a certain number of cases depressive
states develop, sometimes with suicidal tendencies. The delusions
may be hypochondriacal or nihilistic in character. Complaints of
persecution are common. Some of the patients show a simple, childish
deterioration with seclusive tendencies. Stuporous or cataleptic states
may develop. Others become uneasy, wander in the streets, remove their
clothes, collect rubbish, or show sexual excitement. Restlessness at
night is especially suggestive.
Delirious excited states ("Senile Delirium") characterized a certain
number of Kraepelin's cases. In these, clouding of consciousness is
marked. The presbyophrenic complex described by Kahlbaum often occurs.
These cases are fairly clear mentally at first, as far as their
surroundings are concerned, but show memory disturbances, particularly
for recent events. Orientation is lost very soon and they fail to
recognize old friends and relatives. Fabrications are resorted to for
the purpose of remedying these defects of memory and delusions are very
common. Nevertheless, judgment about many things is well retained. In
some instances, however, orientation for time, place and person is
completely lost. Kraepelin is in doubt as to whether presbyophrenia
should be looked upon as constituting a definite entity or only a form
of senile insanity. It may last for years or terminate in a marked
deterioration. In some of the senile cases arteriosclerotic changes
in the cortex are very pronounced. This is more noticeable in the
depressive and anxious forms and in the incoherent varieties. These
individuals become clouded, incoherent, and deteriorate rapidly.
There is also a characteristic paranoid form of senile psychosis.
Delusions of suspicion and jealousy are common in these cases. They
usually develop persecutory trends and often exhibit hallucinations
of hearing. They sometimes show partial disorientation and gaps in
the memory. The mood is usually irritable and often anxious. There is
very likely to be a disturbance of sleep and often signs of physical
enfeeblement. There may be neurological symptoms caused by the
arteriosclerotic complications, such as headache, pupillary changes,
tremors of the tongue and disturbance of the reflexes. Tremors are
also shown in the writing. Paraphasia occurs and there may be sensory
aphasia or apraxia.
In severe cases of senile dementia Kraepelin expects to find definite
lesions at autopsy. The brain weight is always decreased, sometimes
to a very striking degree. The volume of the brain is reduced and the
ventricles enlarged. The cortex is diminished in thickness, the frontal
region being most affected. The parietal region may be involved, but
not to any such extent as in general paresis. There may be localized
areas of atrophy. Pachymeningitis and hemorrhagic membranes are often
found. The microscope shows a proliferation of the glia cells and
there is often some disturbance of the layering of the cortex. Cell
alterations appear, with fatty degeneration, some neurones showing
little more than a darkly colored nucleus. The glia cells are enlarged.
There should be no marked changes in the vessels. Fatty changes in the
ganglion cells are very noticeable. There is also some loss in the
tangential fibres.
Quite characteristic of the senile brain is the occurrence of
the miliary plaques or "drusen" described by Redlich in 1898.
Fischer in 1907 reached the conclusion that these "drusen" were
pathognomonic of presbyophrenia, as he did not find them in senile
dementia, in other psychoses or in normal brains. Hübner, however,
noted them in alcoholics and "circular" cases as well as in normal
individuals. Oppenheim also found them in the brains of the aged
when no psychoses were observed. The interior of the plaque is a
homogeneous, dark-staining, structureless mass. Sometimes there is a
clear space around this center, with club- or spindle-shaped bodies
in the periphery, representing remnants probably of neurones, glia
cells or axis cylinders. The whole structure is encapsulated in glia
fibres. These so-called plaques were spoken of by Fischer as "miliare
Nekrosen" and by Redlich as "miliare Sclerosen." Kraepelin is of the
opinion that they are associated either with senile cases showing
arteriosclerotic changes or presbyophrenia. Alzheimer has described a
senile atrophy of the brain with wedgeshaped areas showing cell loss.
This is due to a gradual occlusion of the smaller vessels extending
down from the meninges into the cortex, and may result in a hemorrhage,
a softening or merely an atrophic area characterized by an absence of
ganglion cells. He has also described another group of cases showing
characteristic cell changes.
This condition has been given the name "Alzheimer's disease" by
Kraepelin.[160] It is marked clinically by a gradual senile deterioration
with organic brain changes. These eases show some thought defect,
loss of memory, confusion, and clouding. Later they become restless,
talkative, sing and laugh, etc. Aphasic disturbances develop early,
with paraphasia or apraxia. There are speech disturbances ending
in a senseless jargon and writing becomes impossible. An advanced
deterioration ensues. Physically there is a general weakness and
uncertain gait, sometimes with epileptiform attacks. The pupillary
reaction may be lost and evidences of arteriosclerosis usually appear.
The disease may last for many years. At autopsy "drusen" are common
in the cortex and almost a third of the nerve cells are found to be
destroyed. These are replaced by darkly-staining fibril bundles. There
is marked neuroglia reaction, particularly around the "drusen" and
retrogressive changes are found in the vessel walls. This disease
usually appears about the fortieth year and may be looked upon,
Kraepelin says, as a "senium praecox," although its significance is not
clear.
He finds the senile psychoses occurring usually between the ages of
sixty-five and eighty, although they occasionally appear before sixty.
Seven and sixty-seven hundredths per cent of his cases were between
sixty and sixty-five years of age; ten per cent between sixty-five
and seventy; thirty-five per cent between seventy and seventy-five;
27.8 per cent between seventy-five and eighty; 22.2 per cent between
eighty and eighty-five; 10.5 per cent between eighty-five and ninety;
and 2.78 per cent were over ninety years of age. Of 183 cases studied,
twenty-three per cent were cases of presbyophrenia; sixty-three per
cent of simple deterioration; eight per cent of arteriosclerotic
origin; and the remainder, of delusional forms. More than half of the
cases of presbyophrenia occurred in persons over seventy-five. The
paranoid and arteriosclerotic forms occurred in younger individuals. In
the alcoholic cases the Korsakow complex was common. The analysis of
presenile psychoses made by Kraepelin is, to say the least, exceedingly
interesting. Such clear-cut differentiations as he describes are,
however, not always possible or necessary. Very few other writers have
gone into the question so exhaustively, nor is his classification of
these conditions generally accepted. Bleuler[161] in 1918 in discussing
the presenile psychoses quotes Kraepelin's classification and
also refers to Gaupp's anxious depressive forms. Under the senile
deteriorations he describes "dementia senilis" and presbyophrenia. He
also calls attention to the fact that Binswanger spoke of a "pre-senile
dementia" occurring between the fortieth and fiftieth years of age and
characterized by an emotional dulness and a diminished capacity for
work. Bleuler speaks of the affective disturbances in advanced years
as senile mania and melancholia, which he says may recover, the former
frequently, the latter more rarely.
The American Psychiatric Association has only attempted to cover
the principal groupings of the characteristic senile forms. The
differentiation of these conditions as suggested in the statistical
manual is as follows:—
"A well defined type of psychosis which as a rule develops gradually
and is characterized by the following symptoms: Impairment of retention
(forgetfulness) and general failure of memory more marked for recent
experiences; defects in orientation and a general reduction of
mental capacity; the attention, concentration and thinking processes
are interfered with; there is self-centering of interests, often
irritability and stubborn opposition; a tendency to reminiscences and
fabrications. Accompanying this deterioration there may occur paranoid
trends, depressions, confused states, etc. Certain clinical types
should therefore be specified, but these often overlap:
"(a) Simple deterioration: Retention and memory defects, reduction
in intellectual capacity and narrowing of interests; usually also
suspiciousness, irritability and restlessness, the latter particularly
at night.
"(b) Presbyophrenic type: Severe memory and retention defects with
complete disorientation; but at the same time preservation of
mental alertness and attentiveness with ability to grasp immediate
impressions and conversation quite well. Forgetfulness leads to absurd
contradictions and repetitions; suggestibility and free fabrication are
prominent symptoms. (The general picture resembles the Korsakow mental
complex.)
"(c) Delirious and confused types: Often in the early stages of the
psychoses and for a long period the picture is one of deep confusion
or of a delirious condition.
"(d) Depressed and agitated types: In addition to the underlying
deterioration there may be a pronounced depression and persistent
agitation.
"(e) Paranoid types: Well marked delusional trends, chiefly persecutory
or expansive ideas, often accompany the deterioration and in the early
stages may make the diagnosis difficult if the defect symptoms are mild.
"(f) Pre-senile types: The so-called 'Alzheimer's disease.' An early
senile deterioration which usually leads rapidly to a deep dementia.
Reported to occur as early as the fortieth year. Most cases show an
irritable or anxious depressive mood with aphasic or apractic symptoms.
There is apt to be general resistiveness and sometimes spasticity.
"(g) Other types."
The frequency of senile cases is shown by the fact that of 84,143
admissions to the New York hospitals during a period of sixteen years,
12,017, or 14.2 per cent, were over sixty years of age, while 8.4
per cent were between sixty and seventy years old, and 4.5 per cent
between seventy and eighty. Of 49,640 first admissions to the New York
state hospitals during eight years 4,724 cases, or 9.52 per cent,
were diagnosed as senile psychoses. They constituted 9.63 per cent of
the admissions in Massachusetts during 1919 and 10.61 per cent of the
18,336 admissions to twenty-one hospitals in fourteen other states. Of
70,987 admissions to all of the institutions referred to, 6,961, or 9.8
per cent, were senile psychoses.
During a period of eight years in the New York state hospitals, when
the present classification was not adhered to absolutely, 4,724 senile
psychoses were divided into types as follows:—Simple deterioration,
52.01 per cent; presbyophrenia, 5.75 per cent; delirious and confused
states, 12.99 per cent; depressed and agitated forms, 8.25 per cent;
and paranoid varieties, 16.23 per cent. During the same period less
than one per cent of presenile psychoses were reported. Since the
Association's classification has been in use the same institutions
show the following distribution of 1,351 senile psychoses during 1918
and 1919:—Simple deterioration, 56.24 per cent; presbyophrenia, 4.14
per cent; delirious and confused states, 13.53 per cent; depressed
and agitated forms, 18.65 per cent; and paranoid varieties and
presenile forms, less than one per cent. The senile psychoses in the
Massachusetts hospitals during 1919 were divided as follows:—Simple
deterioration, 56.94 per cent; presbyophrenia, 7.79 per cent; delirious
and confused states, 7.45 per cent; depressed and agitated forms, 7.11
per cent; paranoid conditions, 18.64 per cent; and presenile forms,
2.03 per cent. In nineteen hospitals in other states 1,823 cases
were classified as follows:—Simple deterioration, 64.39 per cent;
presbyophrenia, 11.62 per cent; delirious and confused states, 9.59 per
cent; depressed and agitated forms, 4.71 per cent; paranoid conditions,
6.91 per cent; and presenile forms, .27 per cent. The total of 6,842
cases referred to above were, therefore, distributed as to type as
follows:
_Type_ _Per Cent_
Simple deterioration 55.52
Presbyophrenia 7.40
Delirious and confused states 11.83
Depressed and agitated forms 7.26
Paranoid conditions 13.85
Four hundred and nineteen cases reported by the Ohio state hospitals in
1920 and not included in the above summary were shown as follows:—
_Type_ _Per Cent_
Simple deterioration 49.88
Presbyophrenic types 6.20
Delirious and confused forms 18.61
Depressed and agitated conditions 7.39
Paranoid states 15.75
Presenile types 2.14
These constituted in all 14.4 per cent of the 2,895 first admissions
during the year, a much higher rate than that shown in other states. In
analyzing these findings it should be borne in mind that the American
classifications do not take into consideration presenile conditions
as such, they being all reported with the senile psychoses, with the
exception of involutional melancholia, which is, of course, shown
separately.
Southard[162] has called attention to the margin of error in the
diagnosis of senile psychoses. Forty-two cases unanimously diagnosed
as "senile dementia" were "reviewed clinically and anatomically, with
a surprisingly low general percentage of accuracy (sixty-six per cent)
where either cerebral atrophy or cortical arteriosclerosis or both were
regarded as confirmatory, and with still lower percentages: (48 per
cent) where cortical arteriosclerosis was considered essential and (38
per cent) where cerebral atrophy was considered essential for a correct
diagnosis." It is significant that exactly one-third of the cases
studied were found by Southard to more properly "belong in a group of
acute psychoses or other mental diseases occurring in old age but not
dependent on recognizable senile changes."