Diagnosing Aspergers syndrome in the elderly: a series of case presentations

Evaluation of p21 expression and related autism-like behavior in Bisphenol-A exposed offspring of Wistar albino rats

BACKGROUND

Bisphenol A (BPA), an endocrine disruptor, may be involved in the etiology of autism spectrum disorders (ASD); however, the mechanism of neuronal and astrocytic damage remains ambiguous. A possible role of altered expression of p21 in autistic-like behavior in rat offspring was examined with prenatal and postnatal BPA exposure.

METHODS

Wistar albino dams were exposed to BPA (5 mg/kg) intraperitoneally throughout pregnancy and until the third postnatal day (PND). Pups were examined on 21st PND for behavioral test. Blood samples were collected for serum lactate levels and pups were sacrificed. Right frontal cortices were dissected out and processed for H&E, immunohistochemical analysis, and gene expression.

RESULTS

Anxiety like behavior and thigmotaxis along with reduction in serum lactate concentrations were observed in pups exposed to BPA. Decline in neuronal number and decreased astrocytic population with reduced dendritic spines were revealed by H&E and immunohistochemical analysis, respectively, in right frontal cortices. Over expression of p21 was also detected in BPA-exposed offspring.

CONCLUSIONS

Over expression of p21 may be associated with autistic behavior. Further studies are recommended to explore the structural alterations in other white matter pathways in frontal cortices.

Behaviors Characteristic of Autism Spectrum Disorder in a Geriatric Cohort With Mild Cognitive Impairment or Early Dementia

INTRODUCTION

Autism spectrum disorder (ASD) represents a heterogenous cluster of clinical phenotypes that are classically diagnosed by the time of adolescence. The possibility of late-life emergence of ASD has been poorly explored.

METHODS

To more fully characterize the possibility of late-life emergence of behaviors characteristic of ASD in mild cognitive impairment and AD, we surveyed caregivers of 142 older persons with cognitive impairment from the University of Kentucky Alzheimer's Disease Center Longitudinal Cohort using the Gilliam Autism Rating Scale-2.

RESULTS

Participants with high autism index ratings (autism "possible/very likely," n=23) reported significantly (statistically and clinically) younger age at the onset of cognitive impairment than those who scored in the autism "unlikely" range (n=119): 71.14±10.9 vs. 76.65±8.25 (P=0.034). In addition, those in the autism "possible/very likely" group demonstrated advanced severity of cognitive impairment, indicated by the Clinical Dementia Rating Scale Sum of Boxes scores.

DISCUSSION

Data demonstrate that ASD behaviors may seem de novo of degenerative dementia and such behaviors are more prevalent in those with early onset dementia. Further work elucidating a connection between ASD and dementia could shed light on subclinical forms of ASD, identify areas of shared neuroanatomic involvement between ASD and dementias, and provide valuable insights that might hasten the development of therapeutic strategies.

Aging and Autism: Understanding, Intervention and Proposals to Improve Quality of Life

BACKGROUND

The population with autism spectrum disorder (ASD) has been increasing and is currently estimated to be 1 in 58 births. The increased prevalence of ASD together with the lack of knowledge on the processes of aging in this population, the support needed at this stage of life, and the associated risk factors, have led to an urgent need for further research.

METHODS

This study provides a review of the literature on social- and health-related conditions that may appear when persons with ASD grow old.

RESULTS

In addition to the autism-related conditions, different neurological, genetic, and environmental factors may be involved in the process of aging. In this complex setting, this study provides proposals that may guide the development of support services that may improve the quality of life for aging people with ASD.

CONCLUSION

Aging in ASD is emerging as a growing problem, which requires immediate planning and targetted treatment development.

Older Adults with Autism Spectrum Disorders in Sweden: A Register Study of Diagnoses, Psychiatric Care Utilization and Psychotropic Medication of 601 Individuals

In a Swedish sample of persons eligible for disability services and aged 55 years or older in 2012, persons (n = 601) with autism spectrum disorder diagnoses registered in specialist care were identified. Register data concerning diagnoses of other psychiatric disorders, psychiatric care, and psychiatric medication were reviewed. More than 60% had been in contact with psychiatric care. The majority had no intellectual disability (ID) diagnosis recorded during the study period. Apart from ID, affective disorders, anxiety and psychotic disorders were most commonly registered; alcohol/substance abuse disorders were uncommon. Psychotropic drug prescriptions were very common, especially in the ID group. Professionals need awareness of this vulnerable group; studies concerning their life circumstances and service requirements should be conducted.

Screening of Autism Spectrum Disorders in Geriatric Psychiatry

Autism spectrum disorders (ASD) are difficult to detect in old age. This study examined if ASD symptoms in older adults (age > 60) can be detected with the Dutch informant personality questionnaire, (Hetero-Anamnestische Persoonlijkheidsvragenlijst, HAP) in a mental health setting. Patients with ASD (N = 40) were compared to patients with a different psychiatric diagnosis (N = 43; personality disorders excluded). The ASD group had significant higher scores on the scales 'Socially avoidant behavior', 'Rigid behavior' and 'Unpredictable and impulsive behavior'. These scales were able to discriminate between individuals with or without ASD. The HAP can thus be used as a screening instrument for ASD symptoms in elderly patients. Further research is needed to clarify what items have the best predictive validity for ASD symptoms.

Gray Matter Characteristics in Mid and Old Aged Adults with ASD

It is widely acknowledged that the brain anatomy of children and adolescents with autism spectrum disorder (ASD) shows a different developmental pattern then typical age-matched peers. There is however, a paucity of studies examining gray matter in mid and late adulthood in ASD. In this cross-sectional neuroimaging study, we, performed vertex-wise whole-brain and region-of-interest analyses of cortical volume, thickness, surface area, and gyrification index in 51 adults with and 49 without ASD, between 30 and 75 years. There was significant age-related volume loss and cortical thinning, but there were no group differences. The lack of significant anatomical differences between intellectual able individuals with and without ASD, suggests that ASD is not (strongly) related to gray matter morphology in mid and late adulthood.

Executive function and functional and structural brain differences in middle-age adults with autism spectrum disorder

There is a rapidly growing group of aging adults with autism spectrum disorder (ASD) who may have unique needs, yet cognitive and brain function in older adults with ASD is understudied. We combined functional and structural neuroimaging and neuropsychological tests to examine differences between middle-aged men with ASD and matched neurotypical (NT) men. Participants (ASD, n = 16; NT, n = 17) aged 40-64 years were well-matched according to age, IQ (range: 83-131), and education (range: 9-20 years). Middle-age adults with ASD made more errors on an executive function task (Wisconsin Card Sorting Test) but performed similarly to NT adults on tests of delayed verbal memory (Rey Auditory Verbal Learning Test) and local visual search (Embedded Figures Task). Independent component analysis of a functional MRI working memory task (n-back) completed by most participants (ASD = 14, NT = 17) showed decreased engagement of a cortico-striatal-thalamic-cortical neural network in older adults with ASD. Structurally, older adults with ASD had reduced bilateral hippocampal volumes, as measured by FreeSurfer. Findings expand our understanding of ASD as a lifelong condition with persistent cognitive and functional and structural brain differences evident at middle-age. Autism Res 2017, 10: 1945-1959. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

We compared cognitive abilities and brain measures between 16 middle-age men with high-functioning autism spectrum disorder (ASD) and 17 typical middle-age men to better understand how aging affects an older group of adults with ASD. Men with ASD made more errors on a test involving flexible thinking, had less activity in a flexible thinking brain network, and had smaller volume of a brain structure related to memory than typical men. We will follow these older adults over time to determine if aging changes are greater for individuals with ASD.

Executive Functions in Older Adults With Autism Spectrum Disorder: Objective Performance and Subjective Complaints

Although deficits in Executive Functioning (EF) are reported frequently in young individuals with Autism Spectrum Disorders (ASD), they remain relatively unexplored later in life (>50 years). We studied objective performance on EF measures (Tower of London, Zoo map, phonetic/semantic fluency) as well as subjective complaints (self- and proxy reported BRIEF) in 36 ASD and 36 typically developed individuals (n = 72). High functioning older adults with ASD reported EF-impairments in metacognition, but did not deviate in EF task performance, except for a longer execution time of the Tower of London. The need for additional time to complete daily tasks may contribute to impairments in daily life and may be correlated to a higher level of experienced EF-difficulties in ASD.

Aging with autism spectrum disorder: an emerging public health problem

From 1943, when Leo Kanner originally described autism, and to the first objective criteria for "infantile autism" in DSM-III and the inclusion of Asperger's disorder in DSM-IV, the subsequent classification scheme for autistic disorders has led to a substantial change with the 2013 issuance of the DSM-5 by including subcategories into one umbrella diagnosis of autism spectrum disorder (ASD) (Baker, 2013). ASD is a lifelong neurodevelopmental disorder, characterized by social and communication impairments and restricted, stereotypical patterns of behavior (Baker, 2013). It is currently expected that most, or all of the actual cases of ASD, are identified in a timely way (i.e. in early childhood). However, there are many undiagnosed older adults who may have met the current diagnostic criteria for ASD as children, but never received such a diagnosis due to the fact it had yet to be established. In addition, some patients with relatively less impairing phenotypes may escape formal diagnosis in childhood, only to later be diagnosed in adulthood. Nevertheless, the first generation of diagnosed patients with ASD is now in old age. Many such ASD patients have needed family and institutional support for their lives subsequent to childhood diagnosis. Due to aging and death of their parents and other supportive figures leading to a loss of social structures, there is no better time than now for the medical community to act.

"What is Life Like in the Twilight Years?" A Letter About the Scant Amount of Literature on the Elderly with Autism Spectrum Disorders

The purpose of this letter is to show the lack of published literature on elderly adults with Autism Spectrum Disorders.

Can Bayesian Theories of Autism Spectrum Disorder Help Improve Clinical Practice?

Diagnosis and individualized treatment of autism spectrum disorder (ASD) represent major problems for contemporary psychiatry. Tackling these problems requires guidance by a pathophysiological theory. In this paper, we consider recent theories that re-conceptualize ASD from a "Bayesian brain" perspective, which posit that the core abnormality of ASD resides in perceptual aberrations due to a disbalance in the precision of prediction errors (sensory noise) relative to the precision of predictions (prior beliefs). This results in percepts that are dominated by sensory inputs and less guided by top-down regularization and shifts the perceptual focus to detailed aspects of the environment with difficulties in extracting meaning. While these Bayesian theories have inspired ongoing empirical studies, their clinical implications have not yet been carved out. Here, we consider how this Bayesian perspective on disease mechanisms in ASD might contribute to improving clinical care for affected individuals. Specifically, we describe a computational strategy, based on generative (e.g., hierarchical Bayesian) models of behavioral and functional neuroimaging data, for establishing diagnostic tests. These tests could provide estimates of specific cognitive processes underlying ASD and delineate pathophysiological mechanisms with concrete treatment targets. Written with a clinical audience in mind, this article outlines how the development of computational diagnostics applicable to behavioral and functional neuroimaging data in routine clinical practice could not only fundamentally alter our concept of ASD but eventually also transform the clinical management of this disorder.

Self-reported social skills impairment explains elevated autistic traits in individuals with generalized social anxiety disorder

Screening for autism in individuals with generalized social anxiety disorder (GSAD) is complicated by symptom overlap between GSAD and autism spectrum disorder (ASD). We examined the prevalence of self-reported autistic traits within a sample of participants with a diagnosis of GSAD (n=37) compared to individuals without a GSAD diagnosis (NOSAD; n=26). Of the GSAD sample participants, 70.84% self-reported autistic traits above a cut-off of 65 on the Autism Quotient-Short (AQ-S) and reported significantly more autistic traits on 3 of 5 AQ-S subscales compared to the NOSAD group. Diagnosis uniquely predicted variation in the social skills subscale above and beyond the other subscales and other predictors. Furthermore, variation in the social skills subscale largely explained group differences on the other subscales. Our results suggest caution in utilizing measures like the AQ-S with clinical populations characterized by social difficulties such as individuals with a GSAD diagnosis.

Autism Characteristics in Older Adults with Depressive Disorders

OBJECTIVE

To study the prevalence of autism spectrum disorder (ASD) characteristics in older adults with and without depressive disorders and the social network and past negative life events in those with a high number of ASD characteristics and those without a large number of these characteristics.

METHODS

This large, multisite, naturalistic, prospective cohort study used data from the Netherlands Study of Depression in Older persons (aged 60-90 years) with (N = 259) and without (N = 114) a depressive disorder according to DSM-IV criteria. ASD characteristics were measured with the abbreviated Autism Spectrum Quotient with a cutoff score of 70. Additional measures were the Composite International Diagnostic Interview, the Inventory of Depressive Symptomatology, the Becks Anxiety Inventory, the Close Person Inventory, and the life events questionnaire.

RESULTS

Of the older adults with a depressive disorder, 31% showed elevated ASD characteristics, which is much higher than the observed 6% in the comparison group. High ASD characteristics were associated with elevated depression and anxiety symptoms and more comorbid anxiety disorders. Those with a high number of ASD characteristics did not differ in the size of their social network or the number of negative life events as compared with those with less ASD characteristics.

CONCLUSION

ASD might be overlooked in older adults, especially within geriatric psychiatry. When diagnosing and treating depression and anxiety in older patients, one should be attentive to ASD.

Age-related differences in cognition across the adult lifespan in autism spectrum disorder

It is largely unknown how age impacts cognition in autism spectrum disorder (ASD). We investigated whether age-related cognitive differences are similar, reduced or increased across the adult lifespan, examined cognitive strengths and weaknesses, and explored whether objective test performance is related to subjective cognitive challenges. Neuropsychological tests assessing visual and verbal memory, generativity, and theory of mind (ToM), and a self-report measure assessing cognitive failures were administered to 236 matched participants with and without ASD, aged 20-79 years (IQ > 80). Group comparisons revealed that individuals with ASD had higher scores on visual memory, lower scores on generativity and ToM, and similar performance on verbal memory. However, ToM impairments were no longer present in older (50+ years) adults with ASD. Across adulthood, individuals with ASD demonstrated similar age-related effects on verbal memory, generativity, and ToM, while age-related differences were reduced on visual memory. Although adults with ASD reported many cognitive failures, those were not associated with neuropsychological test performance. Hence, while some cognitive abilities (visual and verbal memory) and difficulties (generativity and semantic memory) persist across adulthood in ASD, others become less apparent in old age (ToM). Age-related differences characteristic of typical aging are reduced or parallel, but not increased in individuals with ASD, suggesting that ASD may partially protect against an age-related decrease in cognitive functioning. Despite these findings, adults with ASD experience many cognitive daily challenges, which highlights the need for adequate social support and the importance of further research into this topic, including longitudinal studies. Autism Res 2016, 9: 666-676. © 2015 International Society for Autism Research, Wiley Periodicals, Inc.

Functional behavioral analysis and social scripting for the older patient with schizophrenia: a staff development program

Executive functioning is the ability to plan, strategize, organize, and focus on details. Impaired executive functioning plays a significant role in behavior disturbances. Lack of inhibition, impaired abstract reasoning, thought perseverance, rigidity in routine, and lack of insight disrupt social skills and daily life. Autism and schizophrenia present some similar behaviors, including impaired executive functioning, often resulting in pharmacological management as many healthcare professionals receive limited training in executive functioning. Non-pharmacological tools used in autism for behavior management include functional behavioral analysis and social scripting, which help to identify causes of behavior and teach more appropriate behavioral responses. Described here is an educational program for healthcare workers in a long-term care skilled nursing facility, to help them understand the basis for behaviors in individuals with impaired executive function, to use these same tools for behavioral modification techniques, and to help patients learn more appropriate social skills. Program evaluation suggested the educational program was successful in increasing the staff's knowledge and comfort level in addressing the behavioral issues that arise with this population and staff also reported less use of medication as first-line treatment for behavioral issues.

Lifetime autism spectrum features in a patient with a psychotic mixed episode who attempted suicide

We present a case report of a young man who attempted suicide during a mixed episode with psychotic symptoms. The patient's history revealed the lifetime presence of signs and features belonging to the autism spectrum realm that had been completely overlooked. We believe that this case is representative of an important and barely researched topic: what happens to children with nondiagnosed and nontreated subthreshold forms of autism when they grow old. The issue of early recognition of autism spectrum signs and symptoms is discussed, raising questions on the diagnostic boundaries between autism and childhood onset psychotic spectrums among patients who subsequently develop a full-blown psychotic disorder.

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in adult psychiatry. A 20-year register study

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are increasingly recognized in adults. This study aimed to assess trends in diagnostic practice, diagnostic delay and comorbidity regarding ADHD and ASD in adult psychiatric patients.

METHODS

Individuals with diagnosed ADHD or ASD were identified in an adult psychiatry register comprising 56,462 patients.

RESULTS

ADHD was diagnosed in up to 2.7% and ASD in 1.3% of the patients. Most cases were diagnosed within 2 years of first contact with adult psychiatry, but some patients were treated for 10 years or more before being diagnosed with ADHD or ASD. Seventy per cent of ADHD and 56% of ASD patients were treated as outpatients only. Other psychiatric diagnoses were registered in about 60%. Affective disorders were common in patients with ADHD. Psychoses and intellectual disability were more common in ASD patients. Psychoactive substance use-related disorders were considerably more common in those with ADHD. Concomitant ADHD and ASD were seldom diagnosed in this clinical material.

CONCLUSION

ADHD and ASD were probably much underdiagnosed in the studied group of psychiatric patients. Other psychiatric diagnoses were common, but not ADHD with concomitant ASD.

Into the unknown: aging with autism spectrum disorders

Research investigation of older adults with autism spectrum disorders (ASD) noticeably lags behind studies of children and younger adults with ASD. This article reviews the current literature regarding a range of quality of life outcomes of aging adults with ASD. Studies that have addressed life expectancy, comorbid physical and mental health issues, ASD symptomatology, and social, residential, and vocational outcomes are reviewed. Research challenges in identifying older cohorts of adults with ASD are also discussed, and notable areas of concern are highlighted. Overall, aging with ASD does present challenges, but there is also evidence that positive outcomes are attainable. The article concludes with brief recommendations on how to optimize the aging process for individuals with ASD.

Screening of autism spectrum disorders in the elderly: a contribution to a psychometric approach

Autism spectrum disorders (ASDs) in older adults have been neglected for a long time. As far as we know only five papers have been published. No empirical research in this area was found. Four papers were case studies of men diagnosed with an ASD (James et al., 2006; Naidu et al., 2006; van Alphen and Heijnen-Kohl, 2009; van Niekerk et al., 2011), and the fifth one was an opinion paper concerning the diagnosis of ASD in the elderly and the difficulties arising in this (Heijnen-Kohl and van Alphen, 2009).

Elderly with autism: executive functions and memory

Cognitive autism research is mainly focusing on children and young adults even though we know that autism is a life-long disorder and that healthy aging already has a strong impact on cognitive functioning. We compared the neuropsychological profile of 23 individuals with autism and 23 healthy controls (age range 51-83 years). Deficits were observed in attention, working memory, and fluency. Aging had a smaller impact on fluency in the high functioning autism (HFA) group than in the control group, while aging had a more profound effect on visual memory performance in the HFA group. Hence, we provide novel evidence that elderly with HFA have subtle neuropsychological deficits and that the developmental trajectories differ between elderly with and without HFA in particular cognitive domains.

Ageing in people with autistic spectrum disorder

BACKGROUND

Although autism in children and in adults attracts attention with respect to clinical and research needs, autism in the older individuals has not been considered to any degree. We review the evidence for urgently addressing the question of ageing in people with autistic spectrum disorder (ASD), focusing on those with disability.

METHODS

Perspectives are reviewed in relation to demographics, experiences of relatives or carers, anticipated residential care needs, requirement for specifically designed cognitive assessment tools and importance of initiating new brain ageing research initiatives in this area.

RESULTS

With escalating numbers of ASD individuals with disability reaching old age, provision of care is the paramount issue that is only beginning to be addressed in a few European communities and in the USA. How ageing affects cognition in such individuals as they reach an age no longer consistent with parental care is unknown, lacking any published evidence, and there is a clear need to design cognitive and behavioural assessment tools appropriate to ageing in ASD individuals with disability, as was the case with respect to dementia as a whole. Although there is a growing body of evidence on pathological, imaging, neuropharmacological and other key brain abnormalities in ASD, these are, to date, confined to children and young (only rarely to middle aged) adults.

CONCLUSIONS

The need for new initiatives in research into ageing in ASD is urgent. Apart from a growing care crisis, the prospect of understanding brain ageing in this population may bring potential rewards beyond immediate clinical need given the precedent of Down syndrome.

Diogenes syndrome and autistic spectrum disorder

Diogenes syndrome or senile squalor syndrome has been described in the psychiatric literature with an associated mental illness in between one half and two thirds of the cases cited. The occurrence of the syndrome in the absence of a psychiatric disorder has received much attention with many hypotheses proposed. We present the case of a 72-year-old man living for many years in domestic squalor whose presentation, neuropsychological profile and history suggest an underlying autistic spectrum disorder. We are not aware of any similar case in an older adult reported in the medical literature. The co-occurrence of these two conditions is an intriguing one as certain key features of autistic spectrum disorder may predispose to Diogenes syndrome.

Aging in autism spectrum disorders: a mini-review

This article addresses an important and barely researched topic: what happens to children with autism spectrum disorders when they grow old. We review the small published literature on aging in autism. We then consider the relevance of research on 'neurotypical' aging in core domains of autistic impairment: social cognition, executive function, cognitive style and memory. Research themes from the study of normal aging, including cognitive reserve, compensation, quality of life, loneliness and physical health are of relevance for future research on autism. Studies of aging in autism will be important not only to plan appropriate services, but also to shed light on the full developmental trajectory of this neurodevelopmental condition, and perhaps provide clues to neuropathology and etiology.

Diagnosing autism spectrum disorders in elderly people

BACKGROUND

As autism spectrum disorders (ASD) have largely been neglected in old-age psychiatry, the objective of the present paper is to describe the diagnostic process in elderly patients.

METHODS

A systematic review of the literature on ASD in older age was undertaken and illustrated by a case series of three elderly patients first diagnosed with ASD in later life by a tertiary mental health clinic.

RESULTS

The search of the literature only yielded three papers on late-life ASD, while the review of the available diagnostic procedures among adults suggests some relevance for screening instruments (Autism Questionnaire), diagnostic instruments (Module 4, Autism Diagnostic Observation Schedule), and neuropsychological examination to profile impairments. Nonetheless, the case reports clearly showed that taking a thorough history with the patient, corroborated and supplemented by a close relative or caregiver who has known the patient for at least ten years, still remains the most important diagnostic tool.

CONCLUSION

The three case studies show that in clinical practice ASD can easily be missed in elderly individuals presenting with comorbid psychiatric disorders, potentially causing iatrogenic damage. Although further research on phenotyping and diagnosing ASD in older people is warranted, the most important step at this point is to create a greater awareness of the possibility of ASD in old age among health-care professionals working with people in this age group.