CHAPTER II
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.