What should we do if we were wrong and Alzheimer was right?

For more than 2,000 years cognitive decline and dementia were considered a part of aging, like graying of hair, wrinkling of skin, or (more recently) reduction of pulmonary capacity or glomerular filtration rate. Thus, our recent predecessors considered “senile dementia” a normal consequence of the aging process. Their confidence increased after Martin Roth and colleagues added specificity to the concept by differentiating it within the broader category of “senile psychosis” (which, consequently, became obsolete). A diagnosis of “Alzheimer's pre-senile dementia,” by contrast, was reserved for people with earlier onset of dementia.

Geriatric Psychiatry in the 1950s and 1960s: Recollections

CLASSIFICATION, CLINICOPATHOLOGICAL CORRELATIONS, AND FUNCTIONAL-ORGANIC OVERLAP In this millennial issue, I shall recall some of the issues in the psychiatry of old age that were current in England half a century ago, based on my experiences at the Maudsley Hospital, Graylingwell, Stockholm, and Newcastle. In 1946, Aubrey Lewis, then Professor of Psychiatry at the Maudsley Hospital, lamented that while the numbers of old people being admitted to mental hospitals had steadily increased, the clinical psychiatry of old age was neglected (Lewis, 1946). Classification was in a state of confusion. Senile and vascular degenerations characterized the aging brain, and though affective and paranoid states occurred, they were widely regarded as depressive and paranoid forms of senile psychosis and not clearly distinguished from purely functional states. In the presence of degenerative changes in the brains of normal old people and the apparent lack of a clear quantitative relationship between clinical severity and neuropathology, the presence or absence of symptoms was determined by the premorbid personality and the ability to resist the effects of the cerebral changes (Rothschild, 1937).

Clinical Heterogeneity in Senile Dementia

Roth and Morrisey (1952), in isolating senile dementia (senile psychosis) as a distinct nosological entity, used as their definition “an illness of insidious onset pursuing a uniformly progressive course with steadily augmenting mental decay”. In 1955 Roth defined senile psychosis as “a condition with a history of gradual and continuously progressive failure in the common activities of everyday life and a clinical picture dominated by failure of memory and intellect and disorganization of a personality, where these were not attributable to specific causes such as infection, neoplasm, chronic intoxication or cerebral vascular disease known to have produced cerebral infarction”. Kay (1962) defines dementia as a “gross deterioration of intellectual capacity and of memory, together with severe and persistent disorientation for time and place”. He diagnosed senile dementia “when there was no evidence of focal brain disease”. Roth et al. (1966) describe senile dementia as “the extreme form of intellectual decay of old age”.

Memory and the Senile Psychoses: A Follow-up Note

The concept of memory disorder in senile psychosis as solely a function of non-psychogenic learning decay intimately related to the breakdown of a short-term memory storage unit is criticized. The same psychogenic interferences blocking memory can retard the senile's initial learning. Treatments discussed include individual psychotherapy dealing directly with fears of escalating disadvantage, increasing disability and imminent death, in conjunction with group psychotherapy focusing on the “here and now.” Specific research proposals are made for the analysis of learning and recall deficits such that conflicting hypotheses of senility can be more objectively assessed.

Psychosis Occurring in the Senium a Review of an Industrial Population

Roth and his associates (1952, 1955, 1956) making observations on the classification and prognosis of psychotic illness occurring in elderly people found that the majority of patients fell into five main diagnostic categories; about half were cases of affective psychosis, most of which responded to E.C.T., and the rest suffered from arteriosclerotic and senile psychosis, paraphrenia and delirium. All the groups, with the exception of the senile psychotics, showed a considerable proportion of physical illness, particularly the cases of affective psychosis whose first attacks occurred after the age of sixty years. Most of the cases of delirium were physically ill and of the paraphrenics 30 per cent. were either blind or deaf.