CHAPTER IITHE 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, theprincipal 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, excitementsand 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 enfeeblementinvariably. 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 entirelydisregarded. 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 andexcitable. 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 thememory. 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 spacearound 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 usuallyappears 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 ofthe 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 agitatedforms, 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 asfollows:—
Four hundred and nineteen cases reported by the Ohio state hospitals in 1920 and not included in the above summary were shown asfollows:—
TypePer CentSimple deterioration49.88Presbyophrenic types6.20Delirious and confused forms18.61Depressed and agitated conditions7.39Paranoid states15.75Presenile types2.14
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."