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Treatable Brain Diseases in the Elderly

National Institutes of Health
Consensus Development Conference Statement
July 10-11, 1978

This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/.

This statement was originally published as: Treatable Brain Diseases in the Elderly. NIH Consens Statement 1978 Jul 10-11;1(5):23-26.

For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Treatable Brain Diseases in the Elderly. NIH Consens Statement Online 1978 Jul 10-11 [cited year month day];1(5):23-26.


Introduction

Old age is often viewed as a time when mental prowess begins an inevitable and irreversible decline. In the not too distant past, this mistakenly conceived notion of the typical elderly person was shared by many of those physicians responsible for the medical treatment of the elderly population. Now, faced with a growing number of geriatric patients, physicians are becoming more aware of the danger of accepting such stereotypes and more concerned with providing effective treatment for the special problems of the aged.

On July 10 and 11, 1978, the National Institute on Aging (NIA) and the Fogarty International Center (FIC) brought together experts in the fields of internal medicine, neurology, psychiatry, epidemiology, radiology, psychology, geriatric medicine, and general medicine for a consensus development conference on treatable brain diseases in the elderly. With this meeting, the NIA continued its work towards the development of a concise, authoritative statement that will help physicians determine the cause of cognitive dysfunction in their elderly patients. Consensus development at the National Institutes of Health brings together authorities in many specialized fields to critically assess current knowledge and to reach agreement on the efficacy and safety of diagnostic and treatment approaches.

Throughout the course of the two-day conference, discussion focused on several basic questions:

  1. What is dementia?
  2. How common are treatable brain diseases which cause cognitive impairments?
  3. What information should physicians have to obtain the most comprehensive and useful history of impaired patients?
  4. What is the best kind of physical examination to carry out on impaired patients?
  5. What is the role and value of the mental status examination in the detection, diagnosis, and evaluation of brain disease?
  6. What is the role and value of the CT scan (computerized axial tomography) in the detection, diagnosis, and evaluation of brain disease?
  7. Given a diagnosis of Alzheimer's disease or multi-infarct dementia, what is the physician's responsibility to both the patient and the family?

 

Consensus was not reached on the terminology of cognitive impairment in the elderly. The participants cited the vast number of currently used terms, including dementia, brain syndrome, brain failure, and senile psychosis; the multiplicity of qualifying adjectives such as organic, functional, acute, chronic, irreversible and reversible; and the additional confusion presented by such phrases as pseudo-senility and pseudo-dementia. While many of these are subject to criticism, the majority of the participants felt that a new system would not help practitioners. It was suggested that an appropriate terminology could be selected from the existing terms and that these terms should be clear of any negative connotations. The participants also agreed that, regardless of the terminology employed, the main import of a consensus document is to aid physicians in distinguishing between those disorders which can be successfully treated and reversed and the so-called "irreversible" disorders--most notably Alzheimer's disease and multi-infarct dementia. Dr. Richard Besdine of the Hebrew Rehabilitation Center for Aged, Roslindale, Massachusetts, and Assistant Professor of Medicine, Harvard Medical School, presented a long list of disorders which are detrimental to normal brain functioning in the elderly. This list included adverse drug reactions, depression, infectious diseases, heart diseases, stroke, metabolic disorders such as kidney failure or thyroid disease, anemia, and a number of other physical and emotional problems. Of these, it was generally agreed that depression, drug toxicity, and endocrine-metabolic disorders are the most prevalent reversible causes of mental deterioration in elderly patients.

While the elderly constitute 11% of the U.S. population, it is currently estimated that they consume 25% of all drugs sold in this country. Because of the frequent occurrence of multiple diseases in old age, it is not uncommon to find one patient simultaneously taking five or six different drugs. In addition, physiological impairment of the heart, blood vessels, kidneys, digestive tract, and nervous system can seriously alter the body's ability to metabolize drugs. It was the opinion of the participants that psychotropic drugs should be administered to elderly patients with extreme caution although judicious use of these drugs can be valuable in treatment of depression. It was also suggested that the physician can solve many problems of elderly patients by establishing what and how much medication those patients are taking.

Depression as a cause of cognitive impairment in the elderly is frequently overlooked by physicians despite growing evidence that depression is a common response to crises occurring in late life. This may be because physicians do not look for depression in their elderly patients; it may also be because stereotyped images of age-related mental decline effectively mask this curable disorder. According to Dr. Lissy Jarvik of the UCLA Department of Psychiatry, depression may go unnoticed because it presents differently in elderly persons. Dr. Jarvik offered the following rule of thumb to the consensus group: while depression in elderly patients shows itself as loss of appetite, insomnia, withdrawal, anxiety, and other emotional and somatic complaints, typical symptoms of depression such as loss of self-esteem, guilty feelings, and self-pity are frequently absent. She further emphasized that short-term treatment can prove effective for such disorders and that elderly patients are frequently responsive to the benefits of psychotherapy.

One of the underlying themes of the consensus meeting was that a patient with intellectual impairment is as deserving of a comprehensive work-up as a patient with any other complaint. This includes a thorough history to determine the extent and tempo of the decline as well as the effect of stressful life events. It also includes a thorough physical examination.

Several participants suggested that a simple mental status examination is the most useful instrument for taking a patient's history. This led to a somewhat unresolved discussion of the value of psychological testing. Although the group expressed the need to include specific examples of structured mental status exams in their recommendations, the Goldstein-Scheerer tests, the Goldfarb-Kahn scale, and several other frequently used tests were all considered lacking in some respect. It was suggested that these concentrate too heavily on measurement of disorientation--a late sign of cognitive impairment--while excluding a formal means for measurement of impaired judgement. Dr. Leslie S. Libow, Chief of Geriatric Medicine at the Long Island Jewish-Hillside Medical Center and Medical Director of the Jewish Institute for Geriatric Care, briefly explained the strategy currently in use at these institutions which measures social function, reasoning ability, orientation, memory (immediate, recent, and remote), arithmetic and calculation, judgement, and emotional state.

Dr. Monica Blumenthal, Western Psychiatric Institute, Pittsburgh, Pennsylvania, suggested that in taking a patient's history the physician should make every attempt to determine the patient's social and environmental situation. She emphasized the fact that labels of cognitive impairment are frequently attached to older persons in deprived social circumstances and that persons in institutions with diagnoses of brain syndrome are most likely to be poor, isolated, widowed, and suffering from some sensory deprivation. She recommended that the physician recognize the value of home visits, attach labels with extreme caution, and approach diagnosis and treatment in a positive way in order to avoid exacerbating cognitive loss.

There was general agreement that a comprehensive physical examination would include a rectal, pelvic, genital, and neurological examination, as well as routine laboratory evaluation--CBC, sedimentation rate, stool for occult blood, thyroid functions, electrolytes, BUN, calcium, phosphorus, urinalysis and culture, B-12, liver functions, blood sugar, syphilis serology, chest x-ray, and EKG.

What was expected to be the most heated discussion during the meeting--that on the role of the CT scan (computerized axial tomography)--was relatively tame with the experts agreeing such a technique could be valuable in ruling out certain treatable causes of dementia but could not give a definitive diagnosis of Alzheimer's disease or multi-farct dementia. It has also agreed that when used with elderly patients, the CT scan cannot differentiate between pathological brain atrophy and "normal" brain atrophy. In addition, Dr. Robert Katzman of the Albert Einstein College of Medicine, New York, and Dr. Ernest Gruenberg of Johns Hopkins University, both argued that there is no direct correlation between cerebral atrophy and cognitive dysfunction. Dr. Gruenberg noted that autopsied brains of severely demented persons sometimes show little atrophy and vice versa. Dr. Katzman pointed out that the hallmark of senile dementia of the Alzheimer's type is pathological change in the neurons, not atrophy of the brain.

There was considerable discussion about the role of the CT scan in relation to other radiological tests. Dr. Juan Taveras of the Massachusetts General Hospital argued that the CT scan is the most sensitive instrument for detection of cerebrovascular accident, subdural hematomas, epidural hematomas, intracerebral hemorrhage, abscess, subdural empyema, hydrocephalus, and brain tumor, and should be performed early in the work-up to rule out these disorders before skull x-rays and brain scans are performed. Some participants favored this idea.

Although the main focus of the NIA/FIC consensus meeting was treatable brain disorders, the participants agreed that the so-called irreversible disorders are by no means hopeless and that this point deserves recognition in any communication directed at the physician. Dr. Gruenberg noted that the term irreversible refers to the damage done to the brain rather than to cognitive impairment and that physicians continue to be responsible to their patients and their patients families when there is a diagnosis of one of these disorders. Much can be done in terms of general care for the patient to lessen discomfort, to slow and sometimes arrest deterioration, and to help the patient make use of residual strengths.

The consensus development conference on treatable brain disease in the elderly concluded with a list of unresolved issues. The following needs were cited by the group as deserving of further exploration:

  1. The need to give careful consideration to terminology;
  2. The need to consider the importance of diagnosis in terms of third-party payment programs;
  3. The need to determine the prevalence of reversible disorders;
  4. The need to develop a geriatric drug formulary;
  5. The need to clarify what--if any--memory loss is "normal" in old age; and
  6. The need to refine an easily administered mental status examination for physicians and to identify or develop a more sensitive and reliable form of psychological testing than those currently available.

In addition, several issues have been raised as a result of the conference that require the attention of the consensus group. For example, in the presence of aphasia--a common impairment of elderly stroke victims--it is difficult to evaluate cognitive impairment. Many persons who have aphasia are not demented, but their ability to communicate is seriously impaired.

Although the experts agree that the prevalence of potentially reversible brain disorders is large enough to warrant the careful attention of the health care practitioners, it may be several months before final consensus is reached on all of the issues discussed during the two-day conference. Once tentative agreement is reached, a draft document will be circulated through a number of professional medical organizations, and finally published and given the widest possible dissemination. It is hoped that this exercise will eventually result in a statement that will help physicians detect, diagnose, and evaluate specific treatable disorders that now result in unnecessary physical, emotional, and economic hardship for many older persons.  

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