Alzheimer

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Alzheimer's before and after Alzheimer

Rafael Euba, Consultant Old Age Psychiatrist, Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London SE18 3RZ.

Abstract

The concept of dementia in old age has been known throughout the centuries. “Senile dementia” was one of the main diagnoses used on the admission records to mental asylums. Alois Alzheimer identified a pre-senile disorder that was in fact indistinguishable from late-onset dementia. Initially, Alzheimer’s disease had very little impact on the academic world.

Alzheimer

Alois Alzheimer

Introduction

Alois Alzheimer, a Bavarian psychiatrist and researcher, described in 1907 the case of a woman from Frankfurt, who had developed dementia at the age of 51. Her name was Auguste Deter and she had an early-onset dementia with secondary psychotic features, which progressed to the point when she had to be admitted to a mental institution, where she eventually died.
Alzheimer carried out his research at Munich University, where he worked in a department lead by none other than Emil Kraepelin. It was Kraepelin who coined the term “Alzheimer’s Disease” in the eighth edition of his Textbook of Psychiatry, in which he included a description of Auguste Deter’s disorder. It has been suggested that Kraepelin would have felt motivated to present his colleague’s clinical case as a newly discovered illness in order to increase the prestige of his department1.

The concept of dementia in antiquity and pre-industrial times
Obviously, dementia is not a new disease. We know that a significant proportion of old and very old people are likely to suffer from dementia at any given time, so it is safe to assume that human communities have always been familiar with the concept of dementia2. Life expectancy has increased considerably over the last century in developed countries, but some individuals would have reached old age even in pre-industrial times, at least in settled agricultural societies.
Some authors have suggested that old age in antiquity was invariably regarded in a negative light and that dementia was seen as an inescapable aspect of the decay that accompanies old age3. Pythagoras described the apparently inevitable decline in mental power witnessed in old age, while Galen, the renowned Roman physician, coined the term “morosis” to depict the obliteration of knowledge and intellectual skills that affects the senium4. However, this negative view of old age was not universally shared during classical times5-6.

Some classical writings portray old age as a feature that accompanies wisdom, or even godliness. The righteous Methuselah, for instance, lived to the age of 969 years, according to Genesis, while Abraham reached a more modest 175 years. Cicero, the Roman thinker and statesman, related the positive aspects of old age in his De Senectute: ”… reflection, force of character, and judgement; in these qualities old age is [...] even richer.”7. Seneca wonders “is [old age] the clearest and purest part of all, provided only that the mind is unimpaired?”8. The very word “Senate” -the Roman legislative body- originates from the Latin term for “old man”. It follows that while the loss of mental faculties was clearly recognised as a risk associated with old age, this was not necessarily seen as inescapable. Dementia therefore must have been regarded as a disorder of the mind that afflicted only certain individuals in old age.
The 13th century Franciscan friar Roger Bacon wrote “Methods of Preventing the Appearance of Senility”, in which he identified the brain as the source of intellectual functions9. The concept of dementia, articulated through a variety of different terms, appeared in the works of some authors over the next centuries, such as Thomas Willis’ “Practice of Physick”4. However, the first modern definition of dementia in old age was postulated by the French reformer psychiatrist Jean Etienne Esquirol in his “Des Maladies Mentales”, published in 1838 : “a cerebral disease… characterised by an impairment of sensitiveness, intelligence and will”10. He also listed as possible causes of dementia factors such as masturbation11, which betrays the pre-empirical thinking of the period.

Dementia during the Asylum period

“Senile dementia” and “senility” were amongst the most frequent diagnostic labels used in the admission and discharge records in lunatic asylums during the 19th century12-14. The types and the causes of insanity were at times confused in the asylum records, in a period in which diagnostic rigor was less important than the expected curability of the disorder12.
Many types of dementia were first described during the 19th century: James Parkinson’s “Shaking Palsy”, George Huntington’s familial dementia, as well as Pick’s and Binswanger’s Diseases.

Alzheimer’s contemporaries

Kraepelin himself wrote about dementia, which he conceptualised as an intensification of the ordinary changes and deficits seen in old age15. He also observed that in this disorder there is a decline in creativity, judgement and speech.
Gheorghe Marinescu and Paul Blocq, while working in the Salpêtrière in Paris, described neuritic plaque deposits in the brain of an elderly patient with epilepsy in 1892. Solomon Carter Fuller, an African-American psychiatrist, reported in 1907 the existence of neurofibrils in dementia, although he recognised that Alzheimer was the first to describe the neurofibrillary tangle as a type of intracellular degeneration16. In the same year, Oskar Fischer reported neuritic plaques in 12 cases of late-onset dementia and their absence in the members of a control group4,17.

Alzheimer’s after Alzheimer

Emil Kraepelin himself was not certain that Alzheimer’s “senium praecox” was nosologically an entirely separate entity from late-onset dementia. Moreover, it has

been claimed that Gaetano Perusini remarked that Alzheimer, with whom he worked, regarded the cases he had described simply as an atypical form of senile dementia1. Many have argued that there were insufficient reasons to categorise Alzheimer’s disease as a particular type of neuropsychiatric disorder. In fact, for entire decades the academic and the lay media showed little interest in this new disease. In time, it became synonymous with old-age dementia because of its similarity to the much more prevalent late-onset variety of the disorder. An increase in life expectancy, together with improvements in health care, have brought Alzheimer’s disease to the forefront of public awareness. It is interesting to note however that only 42 papers on Alzheimer’s Disease could be found in the Medline database in 197511. Alzheimer received his first ever mention in The Times in a short science report in 1981 and the second two months later, stating that Rita Hayworth, the famous American actress, had contracted the disease, “described as a quickly deteriorating form of senility”18.

Conclusions

Our ancestors, even in distant historical times, were familiar with the concept of dementia in old age. Esquirol wrote a detailed clinical description of the disorder and “senile dementia” was one of the main diagnoses used on the admission records to mental asylums. Alois Alzheimer identified a pre-senile disorder characterised by a cognitive decline and histological changes that were in fact indistinguishable from those found in late-onset dementia. Alzheimer’s disease had relatively little impact on the academic world and hardly featured at all in the lay media until very recently. The raising of its profile is likely to be due to the progressive identification of Alzheimer’s disease with the concept of dementia in old age and the increasing health and social demands that dementia poses on our aging population.

References

1. Berrios G. E. (2004). The history of 'Alzheimer's disease'. The Human Genome. http://genome.wellcome.ac.uk/doc_WTD020951.html Accessed August 2010.
2. Karenberg A, Förstl H. Dementia in the Greco-Roman world. J Neurol Sci 2006; 244: 5-9.
3. Brannon WL. Alois Alzheimer (1864-1915) II. Dementia before and after Alzheimer: a brief history. J S C Med Assoc 1994; 90: 402-3.
4. Berchtold NC, Cotman CW. Evolution in the conceptualization of dementia and Alzheimer's disease: Greco-Roman period to the 1960s. Neurobiol Aging 1998; 19: 173-89.
5. Schäfer D. 'That Senescence Itself is an Illness': A Transitional Medical Concept of Age and Ageing in the Eighteenth Century. Med Hist 2002; 46: 525-548.
6. Gilleard C. Old Age in Ancient Greece: Narratives of desire, narratives of disgust. Journal of Aging Studies 2007; 21:81-92.
7. Achenbaum A. Ageing and Changing: International Historical Perspectives on Ageing. In: Johnson ML, (Ed.), The Cambridge handbook of age and ageing (p. 22). Cambridge: Cambridge University Press; 2005.
8. Troyansky T. Growing older with Cicero (and others).The Gerontologist 2004; 44:279-282.
9. Román GC. Historical Evolution of the Concept of Dementia: A Systematic Review from 2000 BC to AD 2000. In: Nawab Qizilbash (Ed), Evidence-based Dementia Practice, Oxford: Blackwell Science; 2002.
10. Esquirol J. Des Maladies mentales. Paris: Baillière; 1838.
11. Boller F & Forbes MM. History of dementia and dementia in history: an overview. J Neurol Sci 1998; 158: 125-33.
12. Dwyer E. Homes for the mad. Life inside two nineteenth century asylums. Rutgers University Press. New Brunswick and London; 1987.
13. Crammer J. Asylum history: Buckinghamshire County Pauper Lunatic Asylum - St John's, London: Gaskell, Royal College of Psychiatrists; 1990.
14. Shorter E. A History of Psychiatry. From the era of the asylum to the age of Prozac. New York: John Wiley and Sons; 1997.
15. Stam FC. Senile Dementia and Senile Involution in the Brain. In: Frederiks J.A.M. (Ed) Handbook of Clinical Neurology Vol. 2 (46). Neurobehavioural disorders. Amsterdam: Elsevier Science Publishers B.V.; 1985.
16. Goedert M & Ghetti B. Alois Alzheimer: his life and times. Brain Pathol 2007; 17: 57-62.
17. Goedert M. Oskar Fischer and the study of dementia. Brain 2009; 132: 1102-1111.
18. The Times 1981, 4th June, p. 7. The Times Digital Archive, accessed August 2010.

First Published February 2012

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