Social and psychologic factors related to falls among the elderly

Studies on falls are reviewed. Little information exists on which social or psychologic factors predispose an older person to fall or to sustain a fall-related injury. Risk of falling appears to be greater among females, the cognitively impaired, and those who use hypnotics, tranquilizers, and diuretics. The potential significance of depression and senile dementia of the Alzheimer's type on the risk of falling is explored. It is suggested that because of the associated impaired judgment, distraction, and psychomotor retardation, the presence of either clinical condition may increase an individual's risk of falling. In the final section of the article, directions for future research are discussed. Development of a systematic research program is suggested including epidemiologic studies of all falls and of medically treated falls. Such studies should be multidisciplinary and include assessment of social and psychologic factors as well as physical and functional health status, ambulatory function, perceptual acuity, and the circumstances surrounding the fall. The psychologic consequences of falling, particularly in the absence of a serious fall-related injury, is identified as an important research area.

Visual disturbances with focal progressive dementing disease

Symptoms referable to the visual system may be the earliest and most prominent signs of idiopathic dementing disease (Alzheimer's type) despite the lack of objective signs in the eyes or visual system. Three such patients are described. The first patient, who had ultimately proven Alzheimer's disease, initially complained of poor vision and spatial disorientation. Her course was characterized by progressive topographic agnosia during a ten-year period. The second patient first sought ophthalmic consultation for blurring of vision that subsequently progressed during a six-year period to alexia without agraphia and spatial disorientation. The third patient, who had presumed Alzheimer's disease, initially complained of reading difficulties that prompted several ophthalmic consultations. Her problem was initially one of increasing visual agnosia which, together with other perceptive disturbances, gradually deepened during a period of several years.

Sleep apnea in Alzheimer's dementia: correlation with mental deterioration

In a prospective study of sleep-disordered breathing among healthy elderly controls (N = 23), major depressives (N = 17), and demented patients with probable Alzheimer's disease (N = 21), sleep apnea (defined as an apnea index of 5 or more) was found in 42.9% of demented patients, 17.6% of depressives, and 4.3% of controls (chi 2 = 9.90, p less than .01). A significant association between sleep apnea and dementia of the Alzheimer type was found in women but not in men. Moreover, severity of dementia was significantly correlated with apnea index. Possible neuropathologic and clinical implications of these findings are discussed.

Alzheimer's disease in Down's syndrome: clinicopathologic studies

Clinical and neuropathologic evidence points to the development of Alzheimer's disease (AD) in seven Down's syndrome patients above age 40. Dementia was observed in these patients over periods of 2.5 to 9.2 years. The first clinical sign of AD, visual memory loss, was succeeded by impaired learning capacity and decreased occupational and social functioning, and culminated in seizures and urinary incontinence. The morphometric observations of the brains of these seven patients with AD showed that the numbers of plaques and tangles exceeded 20 per 1.5 X 10(6) microns2 area, in both the prefrontal and hippocampal cortices. Plaques and tangles were also evident in the basal ganglia, thalamus, hypothalamus, and midbrain. In addition, we found that four of the seven brains showed small strokes, and five of the seven amyloid angiopathy. This study also indicates that by longitudinal neuropsychological evaluations and lab tests, which exclude other causes of dementia, the diagnosis of AD can be made even in severely and profoundly retarded patients.

Survival in Alzheimer's disease and vascular dementias

Over 5 years, we followed 199 patients with dementia of the Alzheimer type (DAT), 69 with multi-infarct dementia (MID), and 43 with mixed dementia (MIX). All three diagnostic categories had comparable progression of behavioral and cognitive impairment and need for home care or institutionalization at follow-up. However, 50% survival from diagnosis was 2.6 years for MID and 2.5 years for MIX, compared with 3.4 years for DAT. The 50% survivals from onset were longer than previous reports would suggest (8.1 years for DAT, 6.7 for MID, and 6.2 for MIX). Vascular dementias have higher mortality than DAT, even when associated with comparable cognitive and behavioral impairment.

Monoamine oxidase inhibitors as treatment for depressed patients with primary degenerative dementia (Alzheimer's disease)

Two Alzheimer's patients with disabling depression failed to respond to standard antidepressants but improved with a monoamine oxidase inhibitor. The author points out that the cholinergic system is involved in Alzheimer's symptoms and that demented patients have high monoamine oxidase levels.

Aphasia in dementia of the Alzheimer type

Speech and language assessment in 30 patients with dementia of the Alzheimer type and in 70 normal controls revealed that all Alzheimer patients were aphasic. Throughout most of the course, the language disorder resembled transcortical sensory aphasia, and increasing language impairment correlated with increasing severity of dementia. Aphasia was present regardless of age of onset or family history of dementia. Aphasia is an important diagnostic criterion of dementia of the Alzheimer type.

Atypical Alzheimer's disease with spastic paresis and ataxia

An unusual case of Alzheimer's disease (AD) is reported. The patient was a 33-year-old Japanese housewife who had progressive dementia, severe spasticity, and mild ataxia for six years. Postmortem examination revealed severe changes of AD and degeneration of the corticospinal tracts, as well as neuritic plaques and plaquelike degeneration in the cerebellum. This appears to be the twelfth reported case of AD with spasticity and ataxia.

Occurrence of neuropathological changes and dementia of Alzheimer's disease in Down's syndrome

One hundred brains of patients with Down's syndrome (DS) who died in institutions for chronic care were examined for clinicopathological correlation of Alzheimer's disease. Fifty-one were below and 49 were above age 30 years at death. Tissues from the right, prefrontal, and hippocampal cortices were processed for microscopy using H&E and Bodian-periodic acid-Schiff impregnation. Morphometric evaluations of plaques and tangles were carried out. Plaques or plaques and tangles were found in the brains of 56 patients with DS, 7 below age 30 and 49 above that age. A history of dementia was evident in the medical records of 15 of these patients; of these only 2 were below the age of 30. The brains of the patients with DS who also had clinical dementia had more than twenty plaques or plaques and tangles per 1.5 X 10(6) micron 2 of cortex. The numbers of plaques and tangles found in the brains of the patients with DS above the age of 30 greatly increased with age but varied from brain to brain. These observations suggest a correlation among dementia, the density of plaques and tangles, and age. All 100 brains studied showed early arrest of brain growth and brain atrophy, a condition that may have been due to prenatal arrest of neurogenesis mainly in the granular cell layers, prenatal and postnatal arrest of synaptogenesis, and early aging. Plaques and tangles developed twenty to thirty years earlier and dementia was clinically detected at least three times more frequently (20 to 30%) in DS than it is known to occur in the non-DS population.

Organic delusions: phenomenology, anatomical correlations, and review

Organic delusions are common, but have received little systematic study. Review of the literature reveals that they occur most commonly in toxic-metabolic processes and in disorders affecting the limbic system and basal ganglia. A prospective study of 20 consecutive patients with organic delusions revealed four general types of false beliefs: simple persecutory delusions, complex persecutory delusions, grandiose delusions, and those associated with specific neurological defects (anosognosia, reduplicative paramnesia). Simple delusions responded best to treatment, and complex delusions were more resistent. Acting on delusional beliefs was not unusual, and treatment of the delusions was an important aspect of management of the patient.

Dementia of the Alzheimer's type and Huntington's disease

At age 48, a man with a family history of Huntington's disease developed nervousness, depression, chorea, and dementia. He died at age 68, and his brain showed characteristic findings of both Huntington's disease and Alzheimer's disease. Only one other patient has had neuropathologic findings of both diseases.

[Cerebral amyloid angiopathy in Alzheimer's disease: with special reference to its incidence and distribution]

In 10 autopsied cases of terminal stage of Alzheimer's disease, the incidence and distribution of amyloid angiopathy (AA) in the brain were measured under light microscope. Further, the distribution and intensity of Alzheimer's neurofibrillary change (NFT), senile plaque (SP), and loss of neurons (CL) were compared among the individual cases. NFT and SP were frequently seen over wide areas with little individual variations. AA was present in all cases, but its distribution and frequency markedly differed from individual to individual. Generally, AA was relatively common in the pia and cortical upper layers of the frontal, temporal and occipital lobe, orbital gyrus and cerebellum, but there was no particular site showing very high rate of occurrence. SP and NFT had no correlation to AA in regard to their site and frequency. In all cases, the nucleus basalis of Meynert showed marked loss of neurons and very frequent occurrence of NFT.

Amyloid angiopathy and lobar cerebral haemorrhage

Seven cases of lobar cerebral haemorrhage due to amyloid angiopathy were found among 60 necropsy cases of intracerebral haemorrhage. Clinically five patients were demented and two had hypertension. Immediately after the onset of stroke there was a high incidence of headache and vomiting, followed by nuchal rigidity. Amyloid angiopathy was most prominent in the cerebral cortex and the leptomeninges. Senile plaques were noted in all cases. One should suspect that a haemorrhage may be due to amyloid angiopathy, when lobar cerebral haemorrhage occurs in an aged, normotensive patient with or without dementia. Surgical evacuation of the haematoma is inadvisable, because of the diffuse nature of amyloid angiopathy, high recurrence rate and less tendency to cause brain stem compression.

Circulating vitamins in Alzheimer's dementia as compared with other dementias

Blood levels of 12 vitamins were compared in 55 patients with Alzheimer's disease and 58 control subjects (10 intellectually alert, 12 depressed, 28 multi-infarct dementias, 8 with other specific dementias). No significant differences in vitamin blood levels were found between the Alzheimer's disease group and the control groups either individually or in total. Conventional parenteral vitamin treatment of seven patients with vitamin deficits did not benefit their cognitive state. Conventional vitamin malnutrition did not seem to contribute to the disability in these subjects.

Is DH-ergotoxine the best gerontologicum from the ergot source? Experimental comparison with individual components

The effect of DH-ET (dihydroergotoxine = 33% DH-ergocornine (DH-ECO) + 33% DH-ergocristine (DH-ECS) + + 33% DH-ergokryptine (DH-alfa-ECP: DH-beta-ECP = 2:1 and that of the single DH-derivatives on the retention of 14C-uridine (14C-U) in three parts of the brain tissue, blood plasma and liver tissue was estimated (i.e. radioactivity four hours after ip. adm. of 74kBq X 100 g-1). In young male rats DH-ET and DH-ECO enhanced the retention of 14C-U especially in the parietal cortex In one year old males DH-ECS and DH-alfa-ECP had the greatest effect. As a model of undesired effects the influence on peripheral blood flow in the hind limb of urethanised rats was examined using the perfusion' technics. All substances in the dose of 1 microgram removed epinephrine induced vasoconstriction although they themselves in the dose of 100 micrograms enhanced the perfusion pressure, excepting DH-ECO. All substances diminished the liver blood pool in urethanised rabbits (as norepinephrine does), most efficient being DH-beta-ECP and DH-ECO. On the other hand these substances also slowed the velocity of blood stream. The highest toxicity (LD) of DH-ECS and the lowest one of DH-alfa-ECP was found by an infusion technique. All substances diminished heart frequency but had a variable effect on PQ and QT ECG intervals. Ranging all substances according to their desirable properties from the geriatric viewpoint an index for each substance was calculated. This was most advantageous in the case of DH-alfa-ECP and DH-ECS in contrast to DH-ET and DH-ECO.

Juvenile Alzheimer's disease with myoclonus: amyloid plaques and grumose alteration in the cerebellum

A case of juvenile Alzheimer's disease is reported with onset at 34 years of age, a clinical course of 6 years, had myoclonic jerks, generalized convulsions, dysarthria and ataxic symptoms. The neuropathological examination indicated kuru-plaques, amyloid angiopathy and grumose alteration (degeneration) in the dentate nucleus. In this case, the plaques in Alzheimer disease is quite rare. This case also demonstrates the complex interrelationship between Alzheimer's disease and various multisystemic degeneration mainly involving the dentate nucleus.

Subcortical dementia. Review of an emerging concept

Subcortical dementia is a clinical syndrome characterized by slowness of mental processing, forgetfulness, impaired cognition, apathy, and depression. First recognized in progressive supranuclear palsy and Huntington's disease, the concept has been extended to account for the intellectual impairment of Parkinson's disease, Wilson's disease, spinocerebellar degenerations, idiopathic basal ganglia calcification, the lacunar state, and the dementia syndrome of depression. Disorders manifesting subcortical dementia have pathologic changes that involve primarily the thalamus, basal ganglia, and related brain-stem nuclei with relative sparing of the cerebral cortex. Recent studies of neuropsychologic deficits following focal subcortical lesions also support a role for these structures in arousal, attention, mood, motivation, language, memory, abstraction, and visuospatial skills. The clinical characteristics of subcortical dementia differ from those of dementia of Alzheimer's type where prominent cerebral cortical involvement produces aphasia, amnesia, agnosia, and apraxia.

Lithium-induced accentuation of extrapyramidal symptoms in individuals with Alzheimer's disease

Lithium treatment in 9 elderly individuals with Alzheimer's disease led to a marked accentuation of extra-pyramidal symptoms (EPS) in 5 of 6 patients with preexisting EPS. EPS scores significantly correlated with plasma and RBC lithium levels. Lithium treatment had no such effects in the 3 patients without preexisting extrapyramidal symptoms.

Nominal dysphasia and the severity of senile dementia

Previous research has shown that nominal dysphasia occurs commonly as a language disorder in senile dementia (Alzheimers' type). This study provides evidence that the degree of nominal dysphasia shown by a patient may be a reliable index of the severity of dementia, as measured by both behavioural and cognitive rating scales.

The dexamethasone suppression test in patients with presenile and senile dementia of the Alzheimer's type

The dexamethasone suppression test (DST) was performed on 18 patients with presenile and senile dementia of the Alzheimer's type. Objective cognitive testing showed that 13 patients were mildly to moderately impaired and five were moderately to severely impaired. The Hamilton Depression Scale yielded normal results in all patients. The DST results were abnormal in only one of the mildly impaired patients but in four of the five moderately impaired patients. These data suggest that the DST may be a useful clinical tool in mildly impaired patients with Alzheimer's disease but is likely to be confounded by disease in moderately to severely impaired patients.

The value of histopathological examination of surgically removed blood clot in determining the etiology of spontaneous intracerebral hemorrhage

The surgical specimens from all evacuated spontaneous intracerebral and intracerebellar hemorrhages at the Toronto General Hospital from 1976 to 1981 were reviewed. Cases resulting from trauma or from pre-operatively diagnosed aneurysms or arteriovenous malformations were excluded, leaving 84 cases in which the etiology was unknown. Seventy-five of the cases were intracerebral hemorrhages, while 6 were intracerebellar and 3 were intraventricular. Brain tissue was received with the blood clot in 54 cases (64%). From this tissue, an anatomic diagnosis was made in 37 cases; and in 14, the specific etiology of the hemorrhage could be determined. The specific etiologic diagnoses were tumor (7), amyloid angiopathy (6) and abscess (1). In 4 other cases, vasculopathy associated with hypertension was suggested as a possible etiologic diagnosis. The high incidence of a specific etiologic diagnosis made from specimens in which tissue was included (25%) suggests that biopsy of adjacent brain tissue or preservation of tissue fragments identified at the time of surgery is of diagnostic value.

Retrograde amnesia in Parkinson's disease

Retrograde amnesia was assessed in demented and non-demented Parkinson's patients using a test of remote memory spanning the years from 1920-1979. Results indicated that the demented patients 1) scored significantly below normal controls and 2) had equal impairment for all time periods. This pattern was like that seen in other dementing illnesses (i.e., Huntington's and Alzheimer's diseases), but different from that in amnesic disorders, such as Korsakoff's syndrome. The data, therefore, suggest qualitative differences in pattern of remote memory loss between the dementias and amnesic syndromes.

The association of motor neuron disease and Alzheimer-type dementia

An elderly woman is described who developed senile dementia of the Alzheimer type, followed within eight months by classical and electromyographic features of sporadic motor neuron disease. Although amyotrophic lateral sclerosis is generally believed to affect the voluntary motor system and spare intellectual function, with the exception of certain familial forms and geographic isolates in the Pacific, pathological involvement of the cerebral cortex and posterior columns has often been demonstrated. A small number of cases of concomitant amyotrophic lateral sclerosis have been reported, but an association has not thereby been proven. With the incidence of dementia increasing, it is possible that epidemiologic studies may show an increase in the incidence of motor neuron disease, and thereby suggest an association. A unitary hypothesis for causation of amyotrophic lateral sclerosis, Parkinson's disease, and Alzheimer's disease has been proposed. Closer investigation of patients with motor neuron disease for dementia, and inquiry into the incidence of motor dysfunction in demented patients, may yield evidence in support of such a hypothesis.

Cued recall and the nature of the memory disorder in dementia

The study investigated the retrieval deficit hypothesis of forgetting in senile dementia, using a cued recall technique. Memory for lists of words was tested with either no cues given at the time of recall, or alternatively by cueing the patient either with the word's first letter or its semantic category. Results do not support a retrieval deficit explanation of forgetting in dementia, but instead suggest the possibility of a processing deficit at the acquisition stage.

Neuropathological findings in a case of coexistent progressive supranuclear palsy and Alzheimer's disease

A 66-year-old man was investigated for increasing forgetfulness and frequent falls. Following appropriate investigations, the cause was presumed to be senile dementia of the Alzheimer type. He was reviewed one year later and found to have impaired vertical gaze and a hoarse voice. Progressive dementia, nuchal rigidity, anarthria, and sphincteric incontinence developed subsequently. A diagnosis of progressive supranuclear palsy was made. He died four years after the initial assessment. Neuropathological examination revealed changes characteristic of progressive supranuclear palsy, and suggestive of Alzheimer's disease. Globose tangles, granulovacuolar bodies and gliosis were present in the midbrain, the pons, the dentate nucleus of the cerebellum, and the globus pallidus. Senile plaques and occasional neurofibrillary tangles and granulovacuolar bodies were found in the hippocampus, amygdala, and temporal cortex. The coexistence of two disease processes resulting in dementia is discussed.

Cerebral amyloid angiopathy: incidence and complications in the aging brain. II. The distribution of amyloid vascular changes

Ten histologic sections were sampled from similar cortical regions in each of 84 autopsy brains removed from patients aged 60 to 97 years. The sections were stained by the Congo-red method and examined under polarized light for the presence of cortical (parenchymal) cerebral amyloid angiopathy (CAA). Some degree of CAA was found in 36% of all brains examined, with a higher proportion of patients affected in each successive decade of life. Angiopathy was seen most frequently and was of greater severity in the parietal and occipital gray matter. Overall, it was often a patchy and asymmetric lesion. There was sparing of subcortical white matter and the hippocampi. CAA was most severe in cases of Alzheimer's disease, but occurred in the absence of this condition.

Sleep apnea: relationship to age, sex, and Alzheimer's dementia

The relationship of sleep apnea to age, sex, and Alzheimer's dementia was investigated in 45 elderly subjects and 10 young males, all nonobese, normotensive, nonsmoking, with no sleep complaints and no medical problems other than Alzheimer's disease. Mean apnea/hypopnea index [(AH)I] was significantly greater in elderly males than in young males or elderly females. Mean (AH)I and percentage of subjects with an (AH)I greater than 5 in the Alzheimer groups were not significantly different from age and sex-matched controls. Results were similar when the apnea index was substituted for (AH)I. The data from this preliminary study indicate that healthy, elderly males with no sleep complaints and elderly males with Alzheimer's disease experience a significant, subclinical ventilatory impairment during sleep. Data from the 10 elderly females and 10 young males indicated no such impairment. The physiological significance of this degree of sleep apnea in otherwise healthy elderly males is unclear at present.

A case of combined Pick's disease and Alzheimer's disease

The diagnosis of combined Pick's and Alzheimer's disease is rare, and over the years different authors have used different criteria to arrive at such a diagnosis. A case is reported of presenile dementia in which the histological changes of Pick's disease and Alzheimer's disease were mingled. The brain showed no focal atrophy, but the Pick changes were most numerous in the hippocampus and in the temporal lobe. An antibody against the 155 kilodalton component of neurofilaments demonstrated not only neurofibrillary tangles and components of senile plaques, but also Pick's inclusions.

Confrontation naming impairment in dementia

The effects of dementia etiology and severity on the confrontation naming ability of individuals with Alzheimer's, Huntington's, and Parkinson's diseases and multi-infarct dementia are investigated. Although naming impairment is reported as a consequence of dementing illness, confrontation naming is not found to be significantly impaired in mildly involved patients. Further, although moderate Huntington's and Parkinson's patients made more naming errors than normals, only moderate Alzheimer's disease patients are found to be significantly different. Regardless of etiology, most misnamings are found to be semantically related or semantically and visually related to the stimulus. Results challenge the theory that misnamings of dementia patients result primarily from misperception.

Enhancement of memory processes in Alzheimer's disease with multiple-dose intravenous physostigmine

Physostigmine (.125 mg, .25 mg, or .50 mg) or placebo was administered intravenously to 10 neuroleptic-free patients with Alzheimer's disease over a 30-minute period. All patients performed better on a recognition memory task while receiving physostigmine. When placebo or the dose of physostigmine previously associated with an improvement in memory was readministered, physostigmine again enhanced performance on a recognition memory task. These results indicate that the acute augmentation of cholinergic activity in some patients with Alzheimer's disease can partially reverse the memory deficit of that disorder and may provide an approach to the eventual therapy of this condition.

Dementia: the search for treatable causes

Of 100 consecutive cases of dementia, 23 were found to be of treatable or reversible causes. Many of these patients had been labeled as having "senile dementia" and some were en route to chronic care facilities. The implications of overlooking a treatable cause of dementia are obvious but cannot be overemphasized. An evaluation of dementia with emphasis on the potentially correctable causes is outlined.

Alzheimer's disease and senile dementia of Alzheimer type. A comparative study

Clinical and neuropsychological findings, EEG, and several blood and CSF parameters were investigated in 36 patients with Alzheimer's disease (AD) and 35 patients with senile dementia of Alzheimer type (SDAT). There were more women among senile patients and more familial cases among presenile patients. The average duration of the symptoms was longer in presenile patients (6.1 years) than in senile patients (3.9 years). This could be due to the lower resistance to the disease process in the senile group. Extrapyramidal signs, especially rigidity, were found in over 60% of all patients and in practically all patients with advanced dementia. Tremor was found in three patients only. Four presenile (11%) and two senile (6%) patients had epileptic seizures. All patients had abnormal EEG recordings, mainly in form of diffuse slowing. A positive correlation was found between the EEG abnormality and the severity of dementia in AD but not in SDAT. However, the difference between the correlation coefficients in AD and SDAT was insignificant. Between EEG and the duration of the disease there was no correlation. EEG was not more abnormal in very severe dementia than in severe dementia. Other findings were similar in AD and SDAT. It is concluded that it is artificial to separate AD and SDAT at the age of 65 and that they clinically compose a single entity. This entity could well be called Alzheimer's disease.