Presbyophrenia: clinical aspects

Spontaneous confabulations in amnestic-mild cognitive impairment due to Alzheimer's disease: a new (yet old) atypical variant?

Confabulation may be present in Alzheimer's disease (AD), but usually it is not a primary feature of either its typical or atypical variants. In this report, we describe the case of an AD patient who showed an unusual and enduring neuropsychiatric phenotype characterized by early and prominent spontaneous confabulation. Surprisingly, such atypical AD presentation bears a striking resemblance to presbyophrenia, a subtype of dementia which was described at the beginning of the twentieth century and then sank into oblivion. In discussion, we speculate on the "return" of presbyophrenia as an unrecognized neuropsychiatric variant of AD and its possible neuroanatomical substrates.

Presbyophrenia: a possible subtype of dementia

Presbyophrenia is characterized by memory impairment, disorientation, confabulation, hypomanic features, and a preserved social facade. These occur in the absence of prior history of alcoholism or affective illness. We present three cases with presbyophrenia and suggest that the syndrome is a recognizable subtype of dementia, possibly related to disruption of aminergic pathways in frontal and subcortical structures.

The meaning of insight in clinical psychiatry

Insight can be defined not only in terms of people's understanding of their illness, but also in terms of understanding how the illness affects individuals' interactions with the world. The term 'insight' encompasses a complex concept which should not be considered as an isolated symptom which is present or absent. Instead, it may be more appropriate to think of insight as a continuum of thinking and feeling, affected by numerous internal and external variables. Different psychiatric disorders involve different mechanisms in the process of impairment of insight; this may influence the ways in which insight should be assessed in clinical practice.

Psychiatric phenomena in dementia of the Alzheimer type

Psychiatric symptoms and behavioral disturbances are of importance in dementia of the Alzheimer type (DAT) but have been relatively neglected by researchers. The main psychiatric symptoms are disorders of thought content (delusions and paranoid ideation), disorders of perception (hallucinations and misidentifications) and disorders of affect (depressed and elevated mood). They occur commonly in DAT, and there is evidence that they may indicate subtypes of the disorder in view of their demographic, structural, and prognostic correlates. Personality changes are very common, and these may be the earliest manifestation of dementia. Behavioral disturbances tend to be associated with advanced dementia and are particularly disruptive to caregivers. Structural correlates suggest that some behaviors are a direct result of brain damage. Psychiatric and behavioral features in DAT are important, as they may serve as a model for symptomatology in functional psychiatric disorders.

Extrapyramidal signs, primitive reflexes and frontal lobe function in senile dementia of the Alzheimer type

Of 146 elderly subjects suffering from Alzheimer-type dementia, 44% were found to have significant extrapyramidal signs. Although extrapyramidal signs were more common in those who had taken neuroleptic drugs in the preceding six months, 22 subjects (15%) who were drug free also had extrapyramidal signs. Scores for cognitive function and for 'frontal lobe' signs (verbal fluency, evidence of perseveration, and primitive reflexes) were found to correlate well with scores for extrapyramidal signs, suggesting that they reflect changes in a common substratum. It is tentatively suggested that this might be an abnormality in the dopamine system.

Assessing dementia. Part II: Clinical, functional, neuropsychological and social issues

Comprehensive assessment of the dementing person entails looking beyond syndromal diagnosis to broader aspects of the individual's functioning and circumstances. Systematic attempts are being made to conceptualize the stage, severity and sub-type of dementia and these may prove useful in daily practice. Clinical aspects of a broader assessment include attention to possible coexisting psychiatric syndromes and the disruptive behavioural changes common in dementia. In addition, alternative perspectives to the medical model can contribute valuable information for future planning. Functional assessment can delineate lost abilities that limit the person's adaptive capacity and indicate retained skills necessary for independent living. The neuropsychological approach can identify spared abilities and specific impairments, as well as quantifying changes over time. Attention to social issues can clarify the strengths and deficiencies of the support network and define the burdens of caring. A general approach, which emphasises the need for dementia assessment to be comprehensive, multidisciplinary, naturalistic, intervention oriented, practical and longitudinal, is proposed. This assessment approach is closely linked to the most important role of the clinician, that of continuing care and management.

Presbyophrenia: the rise and fall of a concept

The history of the concept of presbyophrenia is traced from its inception in 1863 to the present day. Early in the twentieth century it was used to refer to a subtype of dementia characterized by confabulations, marked memory impairment, hyperactivity, disorientation, elevated mood and preserved social graces. At the time it was considered to be either a form of Korsakoff's psychosis or a subtype of senile dementia. The decline of the concept started in the 1920s and was precipitated by the redefinition of dementia in terms of impaired cognition, cortical symptomatology and specific neuropathological changes. Three explanations for the curious combination of symptoms characterizing presbyophrenia were then suggested: toxic-delirious states, manic illness in late life, or a combination of cerebrovascular disease and senile dementia. It is suggested that the dismissal of presbyophrenia could have been premature as it may capture a behavioural phenocopy of relevance to clinical practice.

Delusions and the psychopathology of the elderly with dementia

Thirty-seven, out of a sample of 100 elderly subjects, all suffering from dementia, were found to have delusions. The delusions were more common in women, in patients with a history of psychiatric illness, and amongst those with higher information subscores (Blessed Scale); and were less common in patients suffering from apraxia or severe psychosocial incompetence. Amongst the deluded patients the simultaneous presence of disorientation, hallucinations and hyperactivity often signified the diagnosis of delirium, but on follow up it was not correlated with death within 18 months. The same symptoms in the non-deluded patients were correlated with severe social incompetence and death within 18 months. It is concluded that the presence of delusions in subjects over 75 years old suffering from dementia is related, to certain extent, to previous or concomitant psychiatric illness, and that it reflects a relative preservation of mental function amongst those without such history.