The role of high- and low-dose corticotropin tests in the diagnosis of secondary adrenal insufficiency

Mini Mental State Examination (MMSE), Brief Psychiatric Rating Scale (BPRS) and subscales of the BPRS were performed on 73 elderly inpatients (mean age: 67.9 years; standard deviation: 7.2; range: 60-89) diagnosed with DSM-III-R chronic schizophrenia. Forty of the subjects were men and 33 were women. A significant negative correlation was observed between MMSE and the age, factor negative, factor depressive, and total score of BPRS. We believe, however, that it is relatively sufficient to screen for demented illness of schizophrenics using MMSE when considering the age and the psychiatric symptoms (especially negative or depressive symptoms ). Forty-eight (66%) of the 73 patients were categorized as 'demented' by MMSE. These results suggest that the aged inpatients with schizophrenia in a hospital showed certain kinds of cognitive deficits (including senile dementia) more frequently than the general population.     

No increased incidence of Alzheimer's disease in elderly schizophrenics

There is currently controversy as to the morphological basis of cognitive impairment in elderly schizophrenics. In contrast to previous findings, recent studies have found no increased frequency of Alzheimer's disease (AD) pathology in elderly schizophrenics. We examined 99 consecutive autopsy cases of patients over the age of 55 years from a psychiatric hospital who met the DSM-III-R and ICD.10 criteria for schizophrenia (mean age 69.5 +/- 8.25 years; mean duration of illness 35.15 +/- 10.1 years), 56% showing moderate to severe dementia. All brains were blindly reviewed for evidence of AD using CERAD criteria and Braak staging of neuritic AD lesions. "Definite" AD (CERAD C, Braak stage V) was seen in 2 cases aged 56 and 67 years, respectively [2% of total or 1/68 (1.4%) of those over age 65]. "Probable" AD (CERAD B, Braak stages IV-V) were seen in 5 cases aged 71-89 years (mean 79 years; 5% of total or 7.3% of those over age 65), and 1 case each with multiple cerebral infarcts and with Parkinson's disease pathology. In addition, 2 females aged 82 and 89 years, respectively, revealed senile dementia with tangles (NIA, CERAD negative; Braak stage IV), 1 with hippocampal sclerosis. The total incidence of definite and probable AD in this cohort was 7.1% or 8.7% for those over age 65. This is in line with other recent studies showing that the frequency of AD in elderly schizophrenics may be equal or even less than in the general population. The reasons for this negative association and the basis of cognitive deficits in elderly schizophrenics--those with dementia usually showing significantly lower brain weight--await further elucidation.     

Hippocampal sclerosis contributes to dementia in the elderly

OBJECTIVE: To assess the relevance of hippocampal sclerosis (HS) to dementia in the elderly. BACKGROUND: HS is a prominent pathologic finding in some demented elderly, but the anatomic substrate and cognitive profiles of this dementia have not been well established. DESIGN/METHODS: An autopsy series, including dot-immunobinding assay to estimate neocortical synaptic density, of eight patients (three men, five women) with HS on whom extensive antemortem neuropsychological testing was available. RESULTS: Mean age at onset was 72.0 (+/-9.8) (range, 59 to 89) with a mean duration of symptoms of 6.5 (+/-2.9) years. Patients were only mildly impaired with a mean MMSE of 20.9 (+/-4.9) and a mean DRS of 103.1 (+/-12.5) at presentation. Cardiovascular disease was present in 88%, with a mean Hachinski score of 3.4 (+/-2.2). No patient had a history of seizures. Sixty-three percent had depression or depressive symptoms. Neuropsychologically, most patients presented with prominent memory and language deficits and became progressively demented. Neuropathologically, isolated HS was a rare finding; many patients had either very mild or neocortical "plaque only or plaque predominant" Alzheimer's disease (AD) in addition to HS changes. Midfrontal neocortical synaptophysin counts were significantly reduced in all HS patients compared with controls (p = 0.0006). CONCLUSIONS: In the elderly, HS can be a neuropathologic substrate of dementia. Clinically, it can be associated with a course that is difficult to distinguish from AD although cardiac disease and depression are frequent concomitants. Deterioration of cognitive function in these subjects may relate to other pathologic features such as neocortical synapse loss.     

Impact of anesthesia on the cognitive functioning of the elderly

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longerterm cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.     

Disability in geriatric depression

OBJECTIVE: The authors' purpose was to identify the relationship of disability to clinical measures that are part of a comprehensive psychiatric examination of depressed elderly patients. METHOD: The disability of 75 elderly inpatients and outpatients with major depression whose cognitive function ranged from normality to mild dementia was assessed with the Philadelphia Multilevel Assessment Instrument. Age at onset of depression, chronicity of depression, severity of depression, cognitive impairment, medical burden, social support and living environment were assessed with standardized instruments. RESULTS: Impairment in instrumental activities of daily living was significantly associated with advanced age, severity of depression, and medical burden. The relationship of depressive symptoms to impairment in instrumental activities of daily living was not influenced by age or medical burden. Anxiety and depressive ideation as well as retardation and weight loss were significantly associated with impairment in instrumental activities of daily living. Interviewer-rated global disability was associated with advanced age at onset of depression, medical burden, and overall cognitive impairment. Specifically, a disturbance in initiation and perseveration was significantly related to global disability. CONCLUSIONS: Impairment in instrumental activities of daily living appears to be a relatively independent dimension of health status that is related to depressive symptoms, particularly anxiety and depressive ideation as well as retardation and weight loss. Global disability may be associated with impairment in initiation and perseveration and with late onset of depression. These findings provide a basis for studies investigating whether psychotherapy aimed at depressive ideation and rehabilitation efforts focused on instrumental activities of daily living can improve the outcome of geriatric depression.     

Prevalence of dementia in a rural setting: A report from India

A study to estimate the prevalence of dementia in a rural population was conducted in a community located on the outskirts of Madras city in South India. Seven hundred and fifty elderly 60 years of age and older, selected using the cluster sampling technique, were interviewed using the Geriatric Mental State schedule (GMS). The prevalence of dementia was 3.5%, the percentage increasing with age. These rural prevalence estimates were higher than in urban settings (WHO multicentre study on cognitive impairment and dementia in developed and developing countries, unpublished) and male/female differences were negligible. The difficulties associated with the use of the GMS in a non-literature rural population are discussed. The implications of these findings for India's growing elderly population are highlighted.     

Elderly patients with schizophrenia exhibit infrequent neurodegenerative lesions

Immunohistochemistry and conventional stains were used to examine the brains of 10 elderly patients with both schizophrenia and dementia to characterize the neuropathology of their cognitive deterioration. Control cases included five nondemented elderly patients with schizophrenia, five age-compatible Alzheimer's disease (AD) patients, and five neurologically normal elderly patients. Only one of the patients with schizophrenia and dementia had AD, another was diagnosed with adult polyglucosan body disease, and the others were devoid of neuropathology that could account for dementia. Quantitation of immunohistochemically detected neurofibrillary tangles and senile plaques revealed similarly low counts for the normal control group and both schizophrenia groups. Typically, the neuropathological causes of dementia can be identified in up to 95% of cases, with AD accounting for 50-60%. The unexpected lack of neuropathological findings to explain the cognitive deterioration in this group of elderly patients with schizophrenia prompts speculation about alternative etiologies.     

Psychiatric hospitalization of senile and arteriosclerotic dementia patients by commitment order under the 1991 Israeli Mental Health Act

Data regarding commitment orders issued by district psychiatrists for elderly patients aged 65 years or older were obtained from the national psychiatric case register. Out of a total of 2,284 commitment orders issued in Israel in the period 1 January 1992 to 30 June 1993 under the 1991 Mental Health Act, 191 (8.3%) involved patients aged 65 and over; these orders were issued for the commitment of 169 patients who suffered from the following ICD-9-CM diagnoses on discharge: senile and arteriosclerotic dementia; transient organic psychotic conditions; schizophrenic disorders; affective psychoses; paranoid states; or other psychiatric disorders. Demographic and clinical characteristics of the senile and arteriosclerotic dementia patients were compared with the same variables in the other diagnostic categories. Results showed that (a) involuntary commitment of senile and arteriosclerotic dementia patients involved a small minority of dementia sufferers; (b) it was usually the patients' first psychiatric admission; (c) most of the patients were discharged within a one-month period; and (d) most of the patients were referred for continuation of treatment in non-psychiatric institutions. Findings (c) and (d) characterized other diagnostic categories as well. The relevance of these findings to the Mental Health Act is discussed.     

Cognitive impairment among elderly coronary heart disease patients

BACKGROUND: Coronary heart disease (CHD) and decline in cognitive functioning and dementia are common problems in the elderly. Cardiovascular diseases (CVDs) are connected with vascular dementia, but less is known about cognitive functioning among elderly patients with CHD based on population studies. OBJECTIVE: To describe the associations between CHD and cognitive impairment among the elderly. POPULATION AND METHODS: Of the total population of the Lieto study (488 community-dwelling men and 708 women, >/=64 years old), the ambulatory patients with CHD (89 men and 73 women) and sex- and age-matched controls without any sign of CHD (178 men and 146 women) were selected to make up the study population. CHD was defined as the presence of angina pectoris or a past myocardial infarction. Cognitive assessment was based on the Mini-Mental State Examination (MMSE). RESULTS: The total MMSE scores, the MMSE subtest scores and the overall test-based cognitive functioning did not differ between patients and controls. Among men, higher MMSE subscores in orientation and language were related to more severe chest pain. According to logistic regression analyses, the cognitive impairment of men was associated with high age, the use of cardiac glycosides and physical disability. Among women, cognitive impairment was associated with high age and the use of antipsychotics. CONCLUSION: In general, CHD has no independent association with cognitive impairment among the non-institutionalized community-living elderly. Among men, however, a complicated CHD may negatively affect cognitive functioning.     

Elbow valgus stress radiography in an uninjured population

OBJECTIVE: The purpose of this study was to determine if P300 latency is prolonged in geriatric depression and if longer P300 latency and deficits in initiation and errors of perseveration in depressed elderly patients are related to risk factors for vascular disease. METHOD: Geriatric patients with unipolar depression (N = 43) and elderly comparison subjects (N = 24) were assessed for depressive symptoms, cognitive functions, risk factors for vascular disease, and P300 latency. RESULTS: Depressed elderly patients had longer P300 latency than normal elderly subjects. In the depressed patients, P300 latency was related to deficits in initiation and errors in perseveration. Risk factors for vascular disease were associated not only with P300 latency but also with deficits in initiation and errors in perseveration. CONCLUSIONS: Functional impairment of the cortico-striato-pallido-thalamo-cortical pathways from vascular disease, implicated in late-life depressive disorders, may explain not only deficits in initiation and errors in perseveration but also longer P300 latency in depressed elderly patients. These results are preliminary and need further examination with brain imaging and more sensitive neuropsychological measures.     

Quantitative analysis of neuropathologic changes in the cerebral cortex of centenarians

1. The quantitative distribution of neurofibrillary tangles and senile plaques was studied in the brains of 65 elderly patients aged from 96 to 104 years by immunohistochemistry. 2. According to the clinical and neuropathological diagnoses, three groups of cases were considered: 19 patients with Alzheimer's disease, 22 patients with mixed dementia (vascular and degenerative) and 24 patients with no or very mild cognitive impairment. 3. Moderate to high neurofibrillary tangle densities were always present in the hippocampus and entorhinal cortex. The inferior temporal cortex was very frequently affected in demented and non-demented cases whereas the superior frontal cortex was spared in the majority of cases independently of the clinical diagnosis. Quantitatively, Alzheimer's disease cases showed significantly higher NFT densities than cases with no clinical findings of dementia only in the CA1 field of the hippocampus. 4. The hippocampus and entorhinal cortex were often devoid of senile plaques in non-demented cases while the vast majority of Alzheimer's disease cases had few SP in these regions. The frontal and temporal cortex were more frequently involved than the limbic structures in both non-demented and Alzheimer's disease cases. The SP densities in layers II and III of the inferior temporal and superior frontal cortex were significantly higher in Alzheimer's disease than in non-demented cases. 5. These observations suggest that the dementing process in nonagenarians and centenarians may differ to that described in younger demented individuals in that neurofibrillary tangles involve principally the hippocampal formation with relative sparing of the neocortex. Furthermore, they indicate that both the neurofibrillary tangle densities in the CA1 field and senile plaque densities in the superficial layers of the neocortex must be considered for the neuropathological diagnosis of Alzheimer's disease in this age group.     

System of natural killer lymphocytes in Alzheimer's type dementias

Cytotoxic activity and quantity of natural killer (NK) lymphocytes were measured in 25 patients with Alzheimer's disease (AD), in 13 patients with senile dementia of Alzheimer's type (SDAT) and in 31 normals of different age (controls). In mentally healthy elderly individuals of the same age as the patients, functional activity of a subpopulation of NK lymphocytes was significantly decreased in comparison with healthy young people, meanwhile a number of these cells wasn't changed. In patients with AD and SDAT the tendency was found to increasing of functional activity of NK lymphocytes in comparison with elderly normals, which achieved the degree of significant differences only in SDAT patients with moderate dementia. Direct dependence of cytotoxic activity of NK lymphocytes on AD duration was determined. Such correlation was not observed in SDAT. This permitted to suppose a destructive influence of lymphocytes with increased cytotoxic activity on either CNS cells or their components in AD.     

Clock-face drawing, reading and setting tests in the screening of dementia in Chinese elderly adults

Comprehensive neuropsychological batteries focus on the subtle cognitive deficits in dementia, but a brief screening instrument is also of immense practical value. As the clock-drawing test encompasses a number of cognitive domains frequently disturbed by the dementing process, it is considered to be a suitable screening instrument for the disorder. We documented the usefulness of a new scoring method of the clock-drawing test for screening of dementia in the elderly Chinese in Hong Kong. Fifty-three demented individuals and 53 healthy elderly controls were assessed. At a cutoff score of 3/4, the sensitivity and specificity of the clock-drawing test in screening of dementia was 83% and 79%. With a composite test of clock reading and clock setting, the positive predictive value of the clock face test was 98%. This new scoring method of clock-drawing proved to be a valid measure for screening of dementia. It is applicable in non-English speaking populations and should be a useful adjunct for quick screening assessment of dementia.     

Regional distribution of neuritic plaques in the nondemented elderly and subjects with very mild Alzheimer disease

BACKGROUND: Identification of the neuropathological lesions that are most closely associated with the earliest symptoms of Alzheimer disease (AD) is crucial to the understanding of the disease process and the development of treatment strategies to affect its progress. Do the classical neuropathological lesions of AD precede, follow, or occur in synchrony with the earliest signs of cognitive deterioration? DESIGN AND OUTCOME MEASURES: We examined the extent of neuritic plaque (NP) formation in 5 neocortical regions and the hippocampus, entorhinal cortex, and amygdala in 66 elderly subjects with no dementia, questionable dementia, or mild dementia as assessed using the Clinical Dementia Rating Scale (CDR). SETTING AND PATIENTS: Postmortem study of nursing home residents. RESULTS: Even questionable dementia (CDR, 0.5) was associated with a significant (P = .04) increase in neocortical NP density. The density of NPs increased further with increasing dementia severity in all brain regions examined. However, subjects with questionable dementia or definite but mild dementia did not differ significantly from each other. Density of NPs was nearly maximal in subjects with moderate dementia (CDR = 2.0), suggesting that other neuropathological changes may be responsible for cognitive deficits beyond this level. Dementia severity correlated significantly with the density of NPs in all brain regions examined (r range, 0.47-0.56; P < .001), even when subjects with a CDR of 0 were excluded. CONCLUSIONS: These findings are consistent with the hypothesis that NPs are among the earliest neuropathological lesions in AD. Even very mild or questionable dementia is associated with increased density of neocortical NPs that do not distinguish between clinically questionable vs definite dementia.     

The Stimulation Program Health Research. X. Evaluation of the program section 'Psychogeriatrics'

In the programme section 'Psychogeriatrics' of the SGO Health Research Promotion Programme a longitudinal study was carried out in Amsterdam from 1989 until 1994, concerning the course of mild cognitive decline in elderly people (the AMSTEL project). The scientific aims were the development of diagnostical instruments for the early diagnosis of dementia, the development of criteria which predict the course of mild cognitive impairment and the expansion of knowledge on the relationship between somatic and psychiatric pathology and dementia. The programme also had aims regarding medical education and patient care. The results include the following: in order to diagnose dementia in general practice questions regarding orientation and short-term memory are helpful. Risk factors for cognitive deterioration in elderly people include hippocampal atrophy on the MRI scan, a low level of education and subjective complaints regarding memory. Subjective complaints regarding memory are not primarily caused by a depressive mood, as is often thought, but are important as correct self-observations of cognitive deterioration, and go with an increased risk of developing dementia. Besides the AMSTEL project a feasibility study was carried out concerning a psychogeriatric case register in Amsterdam.     

Screening for cognitive deficits in a sample of hospitalized geriatric patients: a re-evaluation of a brief mental status questionnaire

A 30-item screening examination for cognitive deficits was administered to 65 hospitalized elderly patients and to 60 elderly controls. A high proportion (73 per cent) of the hospitalized patients were found to have low cognitive scores indicative of probable organic mental syndrome (OMS). Especially high deficits were found among the patients with orthopedic and cerebrovascular conditions. The test correctly identified the 15 cases of established OMS. The percentage of false positive results in the normal controls was reasonably low. The importance of routine cognitive measurements in medical wards is stressed.     

The study of senile symptoms and home care on the elderly living in Korea

The purpose of this study is to investigate the daily life and care condition of elderly people living in Korea, and to observe the symptom of senile dementia among them. In the first survey, 713 subjects were screened and 42 subjects were diagnosed as suffering from senile dementia. In the second survey, 26 elderly and their caregivers who agreed to participate in this program, were interviewed. The results were as follows. 1. About 25% of the 713 subjects needed some kind of help in their daily life. 2. 85% of the subjects could go out and about their houses without help. Only 5% of them had a complete or a partial loss of activity. 3. Of all the subjects, 42 were diagnosed as suffering from senile dementia. The prevalence of this disease was calculated at 5.6% in the survey. 4. Each demented elderly person had 5.3 mental symptoms on the average. Depression was observed more among women and violence was observed more among men. 5. The elderly who had a lower CPR score (Caretaker-Patient Relationship Score), indicating a poor relationship between the patient and caretaker, had a higher prevalence of mental symptoms than those who had a higher CPR score.     

Neuropsychologic method in diagnosis of mild dementia in elderly and senile patients

Clinical neuropsychologic investigation was performed in 95 patients of elderly and senile age with mild dementia: 20 individuals with Alzheimer's disease (AD), 25 patients with senile dementia of Alzheimer's type (SDAT), 25 patients with vascular dementia (VD) and 25 patients with combined dementia of vascular and Alzheimer's types (DAT/VD). Clinical diagnosis of mild dementia was performed according to ICD-10. Neuropsychologic study was based on the theory and method of A.R. Luria. Syndrome of disorder of high psychic functions (HPF) in patients with mild SDAT was characterised by pathology of frontal cerebral structures and by significantly less defects of profound cerebral structures. According to the examination results the group of patients with mild AD was divided into 2 subgroups: 1) patients in which syndrome of HPF disorders was determined by pathology of parietal-temporal and profound cerebral structures and 2) patients with dysfunction of profound and frontal cerebral structures. Symptoms associated with profound cerebral structures were the main ones in patients with mild VD. Syndrome of HPF disorder included in mild DAT/VD symptoms connected with subcortical and profound brain structures as well as with frontal structures too. Besides, there were also defects in posterior frontal and parietal structures of the brain.     

Remembering with and without awareness in a depressed mood: Evidence of deficits in initiative.

We propose that depressive deficits in remembering are revealed in tasks that allow the spontaneous use of strategies; tasks that bypass or direct the use of strategies should not produce depressive deficits. College students received depressive- or neutral-mood inductions after answering questions worded to reflect homophones' less common meaning. After the inductions, subjects spelled old and new homophones and showed no effect of the depressive inductions on unaware memory for the old homophones. Subsequent tests of recognition did, however, reveal differences according to the induced mood or the presence of naturally occurring depression (in Experiment 3). The differences, evidence of nondepressed subjects' use of strategies, tended to disappear when all subjects were provided with strategies for spelling or recognition. The results indicate that depressives experience deficits in cognitive initiative. We review the literature on depressive memory from this perspective. (PsycINFO Database Record (c) 2010 APA, all rights reserved)