Onset Insidious Clear cut, often acute
Course over 24 hours Insight Orientation Memory loss Responses to mistakes
Recent > remote Agitated
Worse in evening or night Worse in morning
Present Reasonable Recent = remote Gives up easily 'Don't know'
Slow and reluctant but understands words (if cooperative)
Response to cognitive testing Near miss!
It is vital to detect depression in the elderly as they are prone to suicide. 'Nothing to look back on with pride and nothing to look forward to.' The middle-aged and elderly may not complain of depression, which can be masked. They may present with somatic symptoms or delusions.
Dementia (chronic organic brain syndrome)
The incidence of dementia increases with age, affecting about 1 person in 10 over 65 years and 1 in 5 over 80 years. The important causes of dementia are:
• degenerative cerebral diseases including Alzheimer's disease (60%)
• alcohol excess 8
The characteristic feature is impairment of memory. Abstract thinking, judgment, verbal fluency and the ability to perform complex tasks also become impaired. Personality may change, impulse control may be lost and personal care deteriorates. 8
The DSM-III (R) criteria for dementia are presented in Table 8.2 and clinical clues suggesting dementia in Table
The many guises of dementia can be considered in terms of four major symptom groups. 6
1. Deficit presentations: due to loss of cognitive abilities, including o forgetfulness o confusion and restlessness o apathy (usually a late change) o self-neglect with no insight o poor powers of reasoning and understanding
2. Unsociable presentations: based on personality change, including o uninhibited behaviour o risk taking and impulsive behaviour o suspicious manner o withdrawn behaviour
3. Dysphoric presentations: based on disturbed mood and personal distress, including o depression (hopeless and helpless) o irritability with emotional outbursts o lack of co-operation insecurity
4. Disruptive presentations: causing distress and disturbance to others, including o aggressive, sometimes violent, behaviour o agitation with restlessness
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