Alzheimer’s are more likely to have an APOE4 gene; however, many people with Alzheimer’s do not have it. There is concern that a genetic test for this gene could lead to excessive anxiety. This is particularly true of individuals whose parents have suffered from the disease. A study of such individuals tested for the APOE gene did not find any serious anxiety in those who tested positive, but none suffered from anxiety or depression prior to the test. In addition, they were given counselling and followed up for a year. A surprising feature of the gene is that those who have it are more intelligent.
There is no cure for Alzheimer’s, but a few drugs such as Aricept can improve memory a bit, and have general benefits including improving alertness and motivation for those in the early stages. It may take some months for there to be a noticeable improvement or slowing down of memory loss. Claims that the anti-histamine drug Dimedon had positive effects have now been shown to be wrong. Non-drug treatments include reality orientation with clocks, boards and newspapers; reminiscence therapy recalling past events like marriage; cognitive stimulation therapy like physical and mental games; and music therapy. There is evidence that exercise and a diet rich in fruit and vegetables lowers the risk of getting Alzheimer’s. A good education also lowers the risk.
Dementia with Lewy bodies, which are abnormal aggregates of protein that develop inside nerve cells, is thought to be second only to Alzheimer’s disease as a cause of dementia. It is similar in some ways to both the dementia resulting from Alzheimer’s disease and the movement problems of Parkinson’s disease. While Alzheimer’s disease usually begins quite gradually, dementia with Lewy bodies often has a rapid or acute onset. Typically there are recurrent visual hallucinations, and Parkinsonian motor symptoms such as rigidity and the loss of spontaneous movement. These patients will often have a sleep behaviour disorder that involves acting out dreams, including thrashing or kicking during sleep. Patients may also suffer from depression. As with all forms of dementia, it is more prevalent in people over the age of 65. It gets is name from the protein clumps that develop in nerve cells and damage them and it overlaps clinically with both Alzheimer’s disease and Parkinson’s disease, but is more associated with the latter. The overlap in the presenting symptoms—cognitive, emotional, and motor—can make an accurate differential diagnosis difficult.
Other forms of dementia may be caused by the reduced blood flow to the brain which occurs with ageing. Vascular dementia is a result of damage to the brain caused by problems with the arteries feeding the brain or heart. Symptoms begin suddenly, often after a stroke, and may occur in people with high blood pressure or previous strokes or heart attacks. As well as delivering oxygen and nutrients to the brain, the blood flow removes waste products in the fluid surrounding the brain, and these may include tau proteins and amyloid which are linked to Alzheimer’s. Patients with dementia have evidence of reduced blood flow. A dramatic possibility to increase blood flow involves trepanation, making a hole in the skull which could alter the flow of fluids round the brain in a positive manner. It remains to be seen whether such a procedure can treat Alzheimer’s, and whether it is acceptable.
Creutzfeldt-Jakob disease, which has been called mad cow disease, is another dementia. This is a rare and fatal brain disorder; most patients die within a year, and it usually occurs sporadically in people with no known risk factors. However, a few cases are hereditary or may caused by eating meat that has been infected. Signs and symptoms usually appear around the age of 60 and initially include problems with coordination, personality changes and impaired memory, judgement, thinking and vision. Mental impairment becomes severe as the illness progresses, and it often leads to blindness. Pneumonia and other infections are also common.
Mental illnesses with some similarities to Alzheimer’s include Down’s syndrome, which is due to an extra chromosome 21 in the sufferer’s cells; patients have only two thirds of normal lifespan. HIV-associated dementia is not age-related, and results from infection with the human immunodeficiency virus, which causes AIDS, and leads to widespread destruction of brain matter which results in impaired memory, apathy, social withdrawal and difficulty concentrating. Often problems with movement also occur.
Parkinson’s disease is the second most common neurodegenerative disorder usually occurring late in life and affects 120,000 people in the UK. It is due to the death of nerve cells that signal by the neurotransmitter dopamine, which activates cells in our brains that let us move, for reasons that remain unknown. It is characterised by debilitating symptoms of tremor, rigidity, and slowed ability to start and continue movements. Seventy-five per cent of all cases of Parkinson’s disease begin after 60, and incidence increases each decade after that up to about 80 years of age.
Depression—which is characterised by negative thoughts, low self-esteem, lack of pleasure, and often physical symptoms—affects three times as many older people as dementia. It varies from mild to severe and affects 10–15 per cent of people over 65 living at home in the United Kingdom. However, the most common age for depression is around 45. There are twice as many depressed women as men. More than 2 million older people over the age of 65 in England have symptoms of depression‚ but the majority are not getting any help‚ according to a report by Age Concern. In the USA severe depression is present in 20 per cent of those over 85, and older people are, in fact, more likely to have mild depression than any other age group. This is not because older age is inherently depressing, but because depression is often a side effect of physical illness. It is the commonest and the most reversible mental health problem in old age.
The reasons for depression in old age may be different to those for younger age groups but usually involve a loss of some sort. Depression in old age can develop as a result of the complicated and hard events in life—the loss of relatives, loneliness, a change of lifestyle because of retirement, or the appearance of illnesses. Depression is the major cause of suicide. Four out of five suicides in older adults are men. Among men over 75, the suicide rate is around 15 per 100,000 and is similar to younger age groups. Depression can be treated with cognitive therapy and antidepressants. These treatments helped with my own severe depression, which occurred when I was 65. One of the causes for my depression was fear of retirement, but the main cause was anxiety about a heart problem.
Psychoanalysis is not helpful with respect to depression or dementias in old age, and this was even Freud’s view. In 1905, showing a notably dismissive attitude to the old, he wrote: ‘Psychotherapy is not possible near or above the age of 50, the elasticity of the mental processes, on which treatment depends, is as a rule lacking—old people are not educable—and, on the other hand, the mass of material to be dealt with would prolong the duration of the treatment indefinitely.’
Age alone does not cause sleep problems. Disturbed sleep, waking up tired every day, and other symptoms of insomnia are not a normal part of ageing, but pain and health issues are often obstacles to sleep for old people. A frequent need to go to the bathroom, arthritis, asthma, diabetes, osteoporosis, night time heartburn, menopause, and Alzheimer’s can cause frequent awakenings.
Are there any mental gains that come with ageing? Wisdom can be one, along with the advantages of accumulated experience. Older adults are better at comprehension of questions, and detection of absurdities. They are able to give attention to quite complex tasks, including events requiring focused attention, and also when a task requires divided attention. But if things become very complex, they may do less well than the young. There is some evidence that discourse skills improve with age, and the elderly are capable of complex narratives. In spite of the declines mentioned earlier, older adults do very well performing their jobs. Knowledge about the job increases with age and is maintained. Many tasks become almost automatic. Computer skills are significantly less than those of the young, but brain scans have shown that using the internet boosts brain activity of the elderly more than reading, and this could help prevent dementia.
I talked recently with Dr Martin Blanchard, a geriatric psychiatrist, and asked how he got involved in old age psychiatry:
I became interested in geriatric medicine when I was a student as it involved many disciplines, and I had a very good experience working in old-age psychiatry, the patients were so grateful. One of our problems in medicine is that we do not think enough about the quality of life, we prolong it. The main problem with our patients is not dementia but depression. There is no real treatment for dementia but rather there is management of the patients lives.
Did many of his patients actually want to die?
That is in fact quite rare unless they have a severe depression. Even when frail and with problems they want to go on living. Few of our patients actually remain in hospital for more than several weeks. The number of patients we have to deal with has not increased over recent years, but the number of referrals we get from different GPs varies a great deal as they handle their patients in different ways.
