Senile Dementias

Senile dementia is one of the major health problems confronting mankind in this century. To some extent the problem has, of course, always existed. The condition was sufficiently troubling to classical philosophers and jurists to have apparently provoked comments by Solon in approximately 500 B. C. and Plato in the fourth century B. C. (Plutarch 1967 translation; Plato 1921 translation). Medical recognition can be traced at least as far back as the second century A. D. (Adams 1861). However, several factors have converged in this century to extend the absolute dimensions of the problem of senile dementia and to increase societal, medical, and scientific recogni tion of the magnitude of the condition. Perhaps the most important factor relating to the present importance of senile dementia is demographic. Although the human population has been increasing since the mid-eighteenth century, it has only been since the advent of the twentieth century that a decrease in mortality has been noted for those over the age of 45 (McKeown 1976). Consequently, the absolute number of aged persons and the proportion of increasingly aged persons in the populations of the world's industrial nations have been steadily increasing. For example, in the United States, 4% ofthe population was over the age of 65 in 1900. In the 1970 census, this proportion had grown to 10%.

The concept of dementia has itself been the subject of increasing refinement and precision in definition and diagnosis. Two important sub-types have been identified: Alzheimer's disease and multiple-infarct dementia. Alzheimer's disease or Senile Dementia of the Alzheimer Type (SDA T), arises out of changes in the brain which are as yet poorly understood and identifiable with certainty only at post mortem examination. This type of dementia has been named after Alois Alzheimer, who first identified these changes, in the earliest years of this century. Alzheimer's is the commonest type of identified dementia. The second commonest type is multi-infarct dementia (MID), which follows a stroke or strokes affecting the relevant part of the brain. Like SDA T, it can be diagnosed with certainty only after death, although Jorm (1987, Ch. 8) reviews progress in using various types of tests which can suggest, if not confirm, its presence during the sufferer's lifetime. As will be shown in Chapter 2, some populations appear to reverse the general picture and exhibit more MID than SDAT. Many dementia sufferers cannot, even after a post-mortem examination, be neatly categorized as one or the other of these sub-types. A considerable uncertain 'grey area' of dementia remains at present very poorly understood. Some elderly people develop dementia as a side-effect of known physical disease. Some of these conditions are curable. Care of the demented person has traditionally taken place in the community: hospitalization is a fairly recent innovation.

Society is showing increasing concern for disorders related to aging that lead to a loss of brain function. In view of the enormous proportion of elderly people in our society today, brain aging is more than ever subject to challenge to us all, not only politicians and health authorities, but every individual who is confronted with the difficult situation of watching the mental powers of apparently healthy elderly friends, neighbours, or relatives fail, often with alarming rapidity. This challenge is directed especially toward us scientists. As one of our colleagues succinctly put it 2 years ago at the close of our First International Symposium on Brain Aging: "Do something. We are not dealing here with just another disease; we are concerned with human dignity. " More than any statistics, these words convinced me that Tropon's decision to leave the field of classic CNS pharmacology and move into the field of gerontopsychopharmacology was the right one, even though we knew that success would be uncertain and that, even if it finally comes it will be many years hence. At this point, let me add a personal comment: each one of us is judged by his or her own success. We live in a competitive society where success counts. This applies not only to the businessman, but also to the scientist, in particular, to those in industry.

There are currently about 21 million people over 6S years in the United States and over a million of them suffer from a severe degree of mental impairment. This number will undoubtedly increase as more and more people attain their full lifespan. The Veterans Administration is acutely aware of this problem in the population it serves. Currently, there are about 31 million veterans in the United States. About 13 percent of these veterans are over 6S years of age and the number is expected to increase to 40 percent by the turn of the century. In recognition of the pressing need to address this problem, eight Geriatric Research, Educational and Clinical Centers (GRECC) have been established under the auspices of the Veterans Administration and the guiding spirit of Dr. Paul Haber, Assistant Chief Medical Director for Professional Services, Veterans Administration. The purpose of these centers is to develop a better understanding of the complex biomedical and socio-economic problems of the aged in general and to enhance the quality of life of the older veterans in particular o Gerontologists working towards a better understanding of the aging process and better care of the aged have made major progress in the biomedical field in the last decade. Among the efforts made by the Veterans Administration, the department of Extended Care and Academic Affairs have sponsored a number of symposia in the field of Gerontology.

Published in 1993. The Increasing numbers of very elderly people in the population and the decreased use of long-stay hospitals are leading to pressure for services in the community for people with dementia. Residential care plays an important role in the care of such people, and developing new, innovative services and monitoring the quality of care in existing institutions are important policy issues. The book describes an investigation into the relationship between the residential care environment and the welfare of residents with senile dementia. Unlike many studies of residential care, the study included aspects of both the physical and social environment and examined the impact on residents over time. The study used some innovative approaches to assessing the impact of the environment of residents and the book describes a model using quantitative techniques to analyse outcomes for residents. The policy issues and provide pointers for specifying standards for the care of residents with senile dementia. The potential for innovative schemes building on the results of the study is discussed, and the concept of ‘informal care homes’ is introduced.