Senescence, the Last Half of Life

by G. Stanley Hall

When, therefore, in these regressions we start from anatomy and the psychoses connected with it at this age of life, we may seem to overestimate the achievements of histology. We at any rate do not underestimate our ignorance here. But with the great confusion of opinions based on clinical observations we believe we are justified in this point of departure. Ultimately anatomy will very likely be our guide in all clinical work as well as in the field of psychiatry, physiology, and psychology. We shall doubtless also learn very much more about the localization in which the degenerative processes of age begin.

Senile Dementia.—Textbooks and articles on old age generally state that the changes in psychic personality that occur are identical with normal ones, only in intensified degree. The traits most commonly specified are: limitation of the circle of ideas, qualitative and quantitative loss of elasticity, pauperization of interests, dwelling on gemütlicher activity, lapses in attention, Ziehen’s “egocentric narrowing of the life of feeling,” perhaps hypochondriacal symptoms, mistrust, inflexibility, lowered power of activity, and resistance against everything that is new. Works in general pathology, like Hübner, Ranschenburg, Balint, and Lieske deal with these in more detail.

In general, there is a sinking of psychic activity and change of character which suggest physiological involution, and these occur—in some, earlier, and in some later. If we compare these psychic traits it would seem that there is only a quantitative difference between normal old age and senile dementia, the latter having only gone farther or faster. The decision of this question is for pathological anatomy and here Spielmeyer’s studies coincide with those of Simchowicz. The older an individual is, the less sharply either clinically or anatomically can it be decided whether it is normal or senile dementia. There are the same changes in the nerve cells, neuroglia, the myelin sheaths, and the mesoderm tissues; also in the blood vessels the changes are identical, the difference being only in degree. Fatty degenerations of the ganglion cells also occur in both. Sclerotic changes of elements are general. The neuroglia cells with normal seniles have lipoidal material in abundance, and the gliafibers, especially in their upper surfaces in the cortex, are increased. The walls of the blood vessels have undergone the same regressive changes and acquired the same fatty material by infiltration, and even the so-called senile plaques are found. Thus in general there is the same using up of the central organs. We are, thus, not yet in a position to determine from the brain alone, if we know nothing of the individual, whether he was a senile dement or a very old man. The older a man is, the more we find the Redlich-Fischer plaques. Thus the senile dement shows neither anatomically nor clinically any essential differences from those found in the normal senium.

I. L. Nascher[151] thinks that too little study has been given to the physical changes in involution and still less to the mental. Occasionally the approach of senile dementia gives rise to forensic questions. There is a general neglect of the subject of geriatrics. This author thinks the brain reaches its limit of physical development at about 30, but Bunsen and Mommsen both did much of their best work after their brain had grown quite atrophied, so that quality comes in. The integrity of these cells depends upon nutrition. We have few blood examinations of the aged and these do not show any marked clinical or microscopic differences between maturity and senility, while the process of senile involution rests apparently on defective nutrition of cell tissues. Those who do good work in age generally focus into one channel and their degeneration is shown in other fields. We usually do not think of our somatic state until some discomfort compels us to do so. One may have lessened interest in former hobbies or events of the day; but if impairment of reason keeps pace with that of memory, he will not know that his powers are failing. He then begins to think of his body and its preservation as more important than wealth or fame, wants to live, and gives more attention to prolonging life.

There is often a change of temperament into egoism, perverseness, peevishness, loss of ambition, religiosity, inability to bear slight discomforts and depression. The child thinks little of the future, while in maturity hope tends to paint a future haloed by happiness and in senility the future is death, notwithstanding what all philosophers, poets, and preachers say. Our mental attitude is simply a resignation to the inevitable. One patient had a daughter devoted to him whose absence for a moment he could not bear, and once this so angered him that his total attitude toward her changed to one of dislike and suspicion. In another case a woman of seventy-six underwent a complete change of character. Arrogance gave way to humility; in contrast to her former independence, she now craved sympathy. Then later she changed again and made extraordinary demands upon her children, wanted the latest styles in everything, etc. In another case memory, reason, and will grew weak in an old manufacturer. He lost his way on the street, a child could divert him from his purpose, and he clung to a notebook by day and night till complete dementia came. Another man who was noted for carrying through everything he planned, even breaking up partnerships, when old became not only susceptible to advice but could be easily turned from his purpose.

Thus senile mentality shows temperamental changes. There is introspection, with natural fears and unnatural phobias, hope for strength and vitality or even for beauty, and often overweaning biophilism. Action is slow; fatigue, quick. The mind may be often trivial on all other matters but yet sound in the center of interest. Personal attainments and achievements are often magnified, and complaints are exaggerated as calls for sympathy. Moral deterioration may be first. Lapses are condoned that were once condemned. The old man may slowly come to take interest in what is low and vulgar. This moral decadence is entirely apart from the pathological condition in which the cœundi potentia is lost while the desire remains, and the recrudescence of desire may occur in the senile climacteric but is a forerunner of senile dementia.

The æsthetic sense causes the old often to neglect cleanliness in person and clothes, to be untidy in their room, expectorate, scratch in public, make disagreeable sounds, and disregard proprieties generally. Women show these traits, but in less degree, and depression is less pronounced. There is no sudden realizing of aging and fear of death is more often overcome by religion. Sometimes the intellectual faculties deteriorate more rapidly, but moral and æsthetic impulses change less. Sometimes old women take greater care of their appearance and seem to be vain and to fight old age. Men occasionally at a great age take a new interest in their appearance, dyeing their hair and becoming dandified, which may show recrudescence of sex.

After the climacteric depression may pass to apathy. Death is less fearful as the mind weakens; there is less concern for the future and life is more in the present. Even early recollections grow dim, although such cases may be roused momentarily. There may be marked preference for association with children. There may also be childish acts and garrulity. The family history given the physician by an elderly patient is often unreliable. Insignificant symptoms are magnified; so are former attainments. Old patients often claim they possessed wonderful constitutions, perhaps that they were never ill, despite indubitable marks of disease.

In homes for the aged there is much suggestion. If one scratches, the rest do, without pruritus, so that to isolate the author of this contagion cures it. The same is true of groaning and grunts and even tremor may be acquired by association. In one case, cutting off food stimulated to overcome tremor. Pain, cough, and stiffness are magnified for sympathy. The fear of pain of an operation may cause the denial or hiding of symptoms, although weakened mentality makes sense impression less acute, either from peripheral or central causes, so that it is hard to tell whether this is due to local anæsthesia or weakened mentality. Tests used for malingerers may be necessary to determine sensitiveness and other symptoms or even harshness and threats may bring out the truth. Though cruel, these are sometimes necessary for correct diagnosis.

Friends often observe changes sooner than the immediate family but the latter must corroborate the statements. The physician should determine if an oikiomania exists and so must be alone with the patient, as he will not encourage such an attitude in the presence of the object of his hatred. If the physician tries to reason him out of his delusion, he thinks he is in league with the hated person and therefore hates him more. If the physician has incurred the patient’s dislike, he should leave him for a few days so that he may forget. Sometimes the dislike of seeing the doctor grows from day to day. One had a suspicion that the doctor was in league with a daughter, and so put him out. A few days later the doctor was called for, and only when the wife told the patient why he would not come did he remember his suspicions and thereafter refuse to see him. In one case, having incurred an old woman’s displeasure by excusing her son, whom she feared, the doctor left and was soon called again, all being forgotten. The person hated should stay away and the dislike may pass, especially in the case of a physician who has been necessary to the patient.