Immediate causes of death of demented and non-demented elderly

Objective – To investigate the immediate causes of death, in autopsied demented and non-demented elderly. Design – Retrospective clinicopathologic correlations. Setting – Acute and intermediate care geriatric hospital. Participants – 342 hospitalized demented and non-demented elderly (mean age 84.94±6.9 years) who underwent consecutive post-mortem examinations: 120 demented patients with either vascular dementia (VaD, n =34), mixed dementia (MD, n =65) or Alzheimer's disease (AD, n =21) neuropathologically confirmed and 222 non-demented elderly. Results – Primary causes of death were similar in both demented and non-demented patients; the commonest were cardiovascular disease and bronchopneumonia. Cardiac causes of death and especially cardiac failure were more frequent in VaD than in AD or MD (respectively P =0.027 and 0.005). Dementia was an underlying but never a primary cause of death. Conclusions – Immediate causes of death are similar in elderly demented and non-demented patients.     

Underlying cause of death in demented and non-demented elderly Canadians

This paper examines the associations between clinical dementia and underlying cause of death (UCD) in a population-based sample of seniors who took part in the Canadian Study of Health and Aging (CSHA). Cause-of-death data were obtained via death certificates for 2,924 of 2,982 deceased subjects. Among the decedents were 823 clinically demented and 670 clinically non-demented participants. Using logistic regression we examined factors associated with a particular UCD in the overall group and also in the subgroup of demented seniors. Dementia was found to be associated with an increased risk of death from pneumonia. Both Alzheimer's disease and vascular dementia appear to decrease the risk of mortality from neoplasm. To our knowledge, this study is the first of its kind that combines a large, representative sample with thorough clinical assessment of cognitive status.     

Outcome of depression in demented and non-demented elderly: Observations from a three-year follow-up in a community-based study

In the Kungsholmen project, a longitudinal study of a total population, samples of non-demented and demented elderly persons with a depressive disorder were followed over 3 years. Of 668 persons who received a full medical examination, 62 were found to have a depressive disorder. Of these, 28 were demented and 34 non-demented. Two-thirds of the 62 had not been previously recognized as having a depressive disorder. There was no difference in this regard between the demented and non-demented samples. After 3 years, only two out of 20 non-demented cases had recovered from their depressive disorder. This is in contrast to the demented cases, where only one of 11 were still depressed. These results indicate the need for greater attention to the recognition and management of depressive disorders in the elderly.     

Brief neuropsychologic differentiation of demented versus depressed elderly inpatients

Recent investigations have suggested the utility of brief, psychometric screening batteries in the early detection of abnormal mental decline. This study extended the investigation of one of these batteries, comprised of three tests (Controlled Oral Word Association, Visual Retention, Temporal Orientation), to the difficult issue of differentiating dementia from depression in a hospitalized sample composed of a group of depressed only patients (N = 50) vs an age-matched demented group (N = 50), some of whom presented mixed dementia/depression syndromes. Demented patients consistently performed more poorly as a group than depressed patients on each of the three measures. This was the case even when three-group (demented only, mixed demented/depressed, depressed only) comparisons were conducted. Impairment was more common on one or more tests with demented vs depressed patients. However, limitations for screening purposes and for the definitive detection of dementia were noted in view of only moderate predictive power of the tests with discriminant function analysis. Nevertheless, the potential clinical utility of the three tests in the general hospital and other primary care settings was apparent.     

The amount of informal and formal care among non-demented and demented elderly persons-results from a Swedish population-based study

BACKGROUND: Developed countries are experiencing a dramatic increase in the proportion of elderly persons, as well as a progressive aging of the elderly population itself. Knowledge regarding the amount of formal and informal care and its interaction at population-based level is limited. OBJECTIVES: To describe the amount of formal and informal care for non-demented and demented persons living at home in a population-based sample. METHODS: The population consisted of all inhabitants, 75 + years, living in a rural community (n = 740). They were clinically examined by physicians and interviewed by nurses. Dementia severity was measured according to Washington University Clinical Dementia Rating Scale (CDR). Informal and formal care was examined with the RUD (Resource Utilization in Dementia) instrument. RESULTS: The amount of informal care was much greater than formal care and also greater among demented than non-demented. There was a relationship between the severity of the cognitive decline and the amount of informal care while this pattern was weaker regarding formal care. Tobit regression analyses showed a clear association between the number of hours of informal and formal care and cognitive decline although this pattern was much stronger for informal than formal care. CONCLUSIONS: Informal care substitutes rather than compliments formal care and highlights the importance of future studies in order to truly estimate the amount of informal and formal care and the interaction between them. This knowledge will be of importance when planning the use of limited resources, and when supporting informal carers in their effort to care for their intimates.     

Electroencephalography of demented and non-demented Parkinson's disease patients

We investigated the correlation between electroencephalography (EEG) abnormalities and dementia in Parkinson's disease. Three groups of subjects were examined: Parkinson's disease patients without dementia, Parkinson's disease patients with dementia, and healthy age-matched controls. Dementia was assessed with the use of Mini-Mental State Examination. All subjects underwent a routine EEG examination with determination of arousal reaction to eye opening, hyperventilation and photic stimulation. Demented patients with Parkinson's disease more often showed no response to eye opening and presented more slow wave activity in comparison to non-demented patients and healthy controls.     

A 6-year study of cognition and spatial function in the demented and non-demented elderly: the Sydney Older Persons Study

BACKGROUND: Spatial function has been suggested to be disproportionately worse in people with dementia with Lewy bodies (DLB) than other dementia groups, and poor performance on the Mini-Mental State Examination pentagon copying (PC) task has been proposed as adequate for assessing this. We aimed to establish the prevalence of poor PC in the non-demented elderly; determine the validity of the use of PC as a spatial function test, and determine if poor PC is more common in DLB than non-DLB dementias. METHODS: In a population-based sample of 299 participants, 126 were rated as being cognitively normal (clinical rating scale [CDR] = 0), 95 mildly cognitively impaired (CDR = 0.5), and 78 met criteria for dementia, 19 of whom met criteria for probable DLB (pDLB) and 25 with none of the core features of DLB (non-DLB). The accuracy of PC performance was determined across CDR groups, and the relationship of PC to performance on a broad range of cognitive tests was evaluated. The dementia groups were compared cross-sectionally to determine differences in PC and other cognitive test performance, as well as 3 and 6 years earlier to determine cognitive differences at initial stages of cognitive decline. RESULTS: Poor PC was common in the non-demented elderly (39% CDR = 0; 43% CDR = 0.5). In this non-demented group, PC was selectively related to tests of spatial function. Poor PC was not significantly different in the pDLB and non-DLB groups at any assessment time, however it became more prevalent as dementia severity increased. Memory function and verbal fluency were more impaired in the pDLB group in the early stages of the disorder. COMMENT: PC appears to be a good measure of spatial function in the elderly. However, in contrast to other findings of poor spatial skills in DLB when dementia is in the mild to moderate stages, poor PC performance has not been shown to be a good early marker of DLB and its clinical correlates are yet to be determined.     

AD lesions and infarcts in demented and non-demented Japanese-American men

Neocortical neuritic plaques and neurofibrillary tangles are hallmark neuropathological lesions of dementia. Concomitant cerebrovascular lesions increase dementia severity in patients meeting neuropathological criteria for Alzheimer's disease and contribute to cognitive impairment in persons with mild entorhinal Alzheimer lesions. This study investigates whether individuals with sparse neocortical neuritic plaques experience increased odds of crossing the threshold to clinical dementia when they have coexistent cerebrovascular lesions. Dementia examinations were given to 3,734 men during the 1991-1993 Honolulu-Asia Aging Study examination and to 2,603 men during the 1994-1996 examination. Lesion quantification was done without clinical data. Among 333 autopsied men, 120 had dementia, 115 had marginal results, and 98 had normal cognition. In men with neurofibrillary tangles, dementia frequency increased with increasing neuritic plaque density, and increased further in the presence of cerebrovascular lesions. The association was strongest in men with sparse neuritic plaques (1-3/mm(2)) where dementia frequency more than doubled with coexistent cerebrovascular lesions (45 vs 20%). Among all dementia cases, 24% were linked to cerebrovascular lesions. Findings suggest cerebrovascular lesions are associated with a marked excess of dementia in cases with low neuritic plaque frequency. Prevention of cerebrovascular lesions may be critically important in preserving late-life cognitive function.     

Determinants of satisfaction with care and emotional distress among informal carers of demented and non-demented elderly patients

Little research has been carried out into determinants of both carer satisfaction in the caregiving role and how these compare with determinants of emotional distress among carers. Principal informal caregivers to 91 patients with dementing or non-dementing disorders were identified from consecutive referrals to community psychiatric nurses in an old age psychiatry service. Clinical, demographic, service and carer satisfaction variables were recorded. Emotional distress in carers was measured with the 28 item General Health Questionnaire. Dissatisfaction with caregiving was weakly correlated with emotional distress (r=0.21, p=0.042). Multiple linear regression revealed two variables which were associated with greater dissatisfaction with the caregiving role, the carers' overall rating of the degree of difficulty in the caregiving role (p<0.001) and younger age of the carer (p=0.014). Emotional distress was independently associated with the degree of difficulty in the caregiving situation (p<0.001) and inversely with the dependency of the patient on the care (p=0.038). The caregiver's assessment of the difficulty in caregiving was associated with both carer dissatisfaction and emotional distress in the caregiving role. While emotional distress was associated with the perception that the patient could do more for themselves, carer dissatisfaction was associated with younger age of the carer. There were competing demands on younger carers, particularly work.     

Violent crime in an elderly demented patient.

I present here a case of an elderly, severely demented gentleman who is being charged with the violent murder of his wife. These patients, although uncommon, represent a sensitive and difficult area of management for the old age psychiatrist. I examine what literature there is available in this area and draw the conclusion that it is an important and understudied area of psychiatry.     

Changes in survival in demented hospital inpatients 1957–1987

Seven cohorts of demented elderly patients who died in Crichton Royal Hospital between the years 1957 and 1987 were identified and their survival time during their terminal admission noted. There was an increase in mean survival time over this period which did not appear due to changes in age or in level of disability at the time of final admission, or in willingness to treat concurrent physical illness following admission. There was some evidence that treatments available for concurrent physical illness were more effective in postponing mortality in the later cohorts. It is suggested that, over the study period, medical advances have extended the life expectancy of the general population including those who develop dementia. Within the latter subgroup, however, there is no evidence that the time of onset or rate of decline to terminal disability of dementia has changed.     

Usefulness of primitive reflexes in demented and non-demented cerebrovascular patients in daily clinical practice

The aim of this study was to investigate the usefulness of primitive reflexes (PRs) as additional alert signs in a routine clinical setting of cognitive decline in an elderly population of chronic ischemic cerebrovascular patients. We considered the occurrence of grasp, palmomental, glabellar and snout reflexes in 75 demented (VaD) and 75 non-demented (VaND) patients, and in 75 healthy elderly controls. We never elicited more than two PRs in controls. The occurrence of three or four PRs provided the strongest correlation with dementia (p < 0.0001), with 93% specificity irrespective of low sensitivity. In conclusion, the occurrence of more than two PRs might serve as an additional warning sign of possible mild cognitive impairment in chronic ischemic cerebrovascular patients.     

Psychological autopsy of an elderly suicide

The case of an elderly woman who committed suicide is presented. Clinical and sociological concepts and empirical findings are discussed in the context of this case. Depression, substance abuse, cognitive dysfunction, exacerbation of preexisting personality disturbance, and medical illness and disability appear to contribute to geriatric suicide in older people. Relocation to a nursing home, while often necessary, has significant emotional value and may function as a precipitant to suicidal behaviour.     

The prevalence of psychotic,depressive and anxiety syndromes in demented and non-demented 85-year-olds

One-month prevalence of mental syndromes in demented and non-demented subjects was studied in a representative sample of 85-year-olds living in Gothenburg, Sweden (N = 494). All subjects were examined by a psychiatrist. Schizophreniform syndrome was significantly more common in subjects with Alzheimer's disease than in nondemented subjects (13% vs 1%, p < 0.001), and more common in severe dementia (p > 0.01). Depressive syndromes were significantly more common in subjects with mild dementia than in non-demented subjects (34% vs 20%, p > 0.05). Phobic syndrome was less common in demented than in non-demented subjects. It is hypothesized that the occurrence of mental syndromes in demented subjects may be related to structural and neurochemical brain changes.