James E. Spar

Dementia in the elderly: the silent epidemic.

The graying of America will be accompanied by an epidemic of major proportions--dementia or intellectual impairment--that will have an impact on all aspects of the helath care system, particularly on the institutional component of the long-term care system. Health professionals; federal, state, and local health planners; families; and others must recognize that many ameliorable or curable physical and emotional diseases in the elderly are associated with intellectual impairment that may be difficult to distinguish from irreversible brain disease of the Alzheimer type. We present information on the cause, physiopathologic mechanism, clinical presentation, appropriate laboratory studies, and anticipated outcomes in the various forms of intellectual impairment found in the elderly. Important new developments will occur in the next decade that will address the cause, pathogenesis, further refinement of laboratory investigation, and specific therapeutic intervention in dementia.

Clinical tests of memory in dementia, depression, and healthy aging.

In Study 1, carefully screened elderly adults with primary degenerative dementia or major depression were compared to healthy aged control subjects on three tests of learning and memory: the Benton Visual Retention Test, Inglis Paired-Associate Learning Test, and the Fuld Object-Memory Evaluation (OME). The sharpest distinction in performance among the groups was observed on the OME, and discriminant equations based on this test correctly classified a high percentage (greater than or equal to 90%) of participants. Study 2 applied the classification rules derived in the first investigation to an unselected series of geropsychiatry inpatients referred for neuropsychological evaluation. There was agreement between memory test classification and general categories of clinical discharge diagnosis (organic vs. functional) for 21 of 25 patients, and with status at follow-up approximately 18 months later. Predictive value computations suggested that the OME is more accurate in confirming true dementia than in detecting dementia syndromes associated with functional disorders.

The late-onset psychoses. Clinical and diagnostic features.

Psychoses of late onset are poorly understood due to a limited number of inconsistent studies. The authors conducted this study to determine the clinical characteristics of a clearly defined group of patients with onset of psychosis after age 65 years and to test the usefulness of DSM-III criteria in diagnosing the condition of these patients. Late-onset psychosis occurred in 8% of the patients admitted to the geropsychiatry unit during the study period. More than three quarters of these patients suffered from either an organic mental disorder or major affective disorder, the remainder having primary psychotic disorder. The diagnoses of the psychotic patients were much less reliable than those of a comparable group of nonpsychotic patients, with more than 5 times as many patients in the psychosis group changing diagnostic categories between the time of their admission and their discharge. DSM-III diagnostic criteria were not well suited for the categorization of many of these patients. For patients with primary psychotic disorder, the criteria artificially subdivided groups of similar patients. For patients with organic mental disorder, the criteria did not provide sufficient guidance for the diagnosis of psychosis in the presence of dementia. All three groups of patients responded to somatic therapies. A subgroup of patients with affective disorder improved without neuroleptic treatment, and several patients with primary psychotic disorder benefited from antidepressant treatment. These results highlight the difficulty inherent in the treatment of patients with late-onset psychosis. Further research is needed to develop adequate diagnostic criteria and to determine which patients will benefit from neuroleptic and/or antidepressant therapy.

Cognitive Impairment in late-life depression: Clinical correlates and treatment implications☆

Elderly depressed inpatients with high vs. low scores on a quantitative mental status examination (the Mini-Mental State (MMS)) were compared with regard to demographic and clinical characteristics, treatment and short-term response, and functional status at 2-year follow-up. Low-MMS patients were less well educated and more likely to be delusional, anxious, and globally impaired than high-MMS patients. The two groups responded equally well to treatment, but the low-MMS group required a lengthier hospital stay and greater use of neuroleptic medications. The two groups also had similar long-term outcomes, although greater attrition was observed among cognitively impaired subjects.

Hospital Treatment of Elderly Neuropsychiatric Patients. II. Statistical Profile of the First 122 Patients in a New Teaching Ward

Data are presented on the first 122 patients admitted to a geropsychiatric teaching ward in a university hospital. A high incidence of medical problems as reflected by abnormal laboratory findings complicated the management of these patients, most of whom had dementia or depression. In all diagnostic categories, the patients appeared to benefit from the intensive inpatient treatment. Difficulties in the areas of diagnosis, treatment, length of hospital stay, discharge placement and program evaluation are discussed.

Bipolar Disorder in Late Life: A Review

Although there is a broad base of literature on depression among elderly patients and on mania in younger patients, there is a relative paucity of information on bipolar disorder in the elderly population. While the quantities of data reflect the relative prevalences of these illnesses, there is evidence to suggest that classification of mania in the elderly with respect to age of onset, natural course, family history, and pathophysiology may be useful in understanding the heterogeneous etiologies of this syndrome. This paper presents a review of the literature on the incidence and course of illness in late-life bipolar disorder. Further, dilemmas of diagnostic classification in relation to associated risk factors will be discussed.

Altruism and mental disorders

Abstract Data suggest that the theories of kin selection and reciprocal altruism are viable working models to explain altruistic behavior. It remains to be demonstrated if these models can explain the behavior of persons with mentaL disorders for whom altruistic behavior is reported to be reduced. This paper addresses this issue. Part I reviews proximate factors that are thought to influence both altruistic decision making and interindividual variation in altruistic behavior. The focus is on trait signaling by potential beneficiaries and the evaluation of signals and altruistic decision making by potential altruists. In Part II, points developed in Part I are combined with clinical and empirical findings to analyze data on personality disorders and dysthymic disorder. The analysis leads to three causal hypotheses: Reduced altruistic behavior may be an evolved strategy, a consequence of dysfunctional recognition systems or algorithms, and/or a secondary response to an increase in symptoms. Different disorders and features of disorders are explained by each hypothesis.

Desipramine increases circulating growth hormone in elderly depressed patients: A pilot study

Serial blood samples were collected from 15 elderly depressed inpatients, ages 62 to 95 years, following random assignment to a 50 mg oral test dose of desmethylimipramine (DMI) or amitriptyline (AMI). Nine female and six male subjects began the 210-min study at 0800h. Serum growth hormone (hGH), cortisol, and prolactin (hPRL) were determined by radioimmunoassay. Baseline hormone concentrations were related to self and observer ratings of anxiety and depression. There was a trend for the hGH, cortisol, and hPRL concentrations to decline during the period of study. This trend for all three hormones reversed in those subjects receiving DMI, beginning approximately 90 min after drug ingestion. The DMI-induced increase of hGH reached statistical significance at the very end of the sampling period. There was an apparent latency in the DMI-induced effect for all three hormones. There was no stimulatory effect of AMI on hGH, cortisol, or hPRL. The female subjects had higher baseline hGH levels than the men. In addition, a significant negative correlation was found between baseline hPRL levels and self ratings of anxiety.

Quantitative EEG Correlates of Outcome in Older Psychiatric Patients: Part II: Two-Year Follow-Up of Patients With Depression

The authors examined quantitative electroencephalographc (QEEG) coherence in 37 depressed elderly patients and performed 2-year follow-up evaluations. All subjects had equivocal cognitive impairment, but none had delirium or dementia. More than 40% (16/37) recovered from depression, and 38% (14/37) remained well for 2 years. Twenty-four percent (n = 9) had died within 2 years, most from cardiac causes. Low trans-Rolandic coherence from the left hemisphere was strongly associated with mortality: 44% (7/16) of those with low coherence died, and 78% (7/9) of those who died had low coherence. Among survivors (n = 28) at follow-up, low coherence was significantly associated with lower functional status. These findings suggest that the coherence variable measures actual neurophysiology differences between groups of depressed patients and these differences are associated with the heterogeneous outcomes of depression in elderly patients.

Plasma Trazodone Concentrations in Elderly Depressed Inpatients: Cardiac Effects and Short-term Efficacy

Twenty-three depressed patients with an average age of 78.86 were treated with trazodone in dosages averaging 354.3 mg/day. Despite pretreatment cardiac conduction delay in 30%, no electrocardiographic abnormalities were produced or exaggerated during the study. Plasma steady state trazodone levels averaged 1,474.4 ng/ml and significantly correlated with dosage at r = 0.415. In a subgroup of 13 patients, six who sustained good short-term response to trazodone had lower mean steady state plasma levels than seven who did not, suggesting that plasma levels above 1,500 ng/ml may not be therapeutic in the short run.