Faculty Bibliography

Despite the enormous medical and psychiatric importance of mental illness among the elderly, clinicians generally are not trained in the phenomenology and presentation of the major mental disorders that occur primarily in this age group. The authors describe the presenting symptoms and course of four conditions--senescent forgetfulness, primary degenerative dementia (considered as the confusional phase and dementia phase), geriatric depression, and multi-infarct dementia--with emphasis on differential diagnosis. The clinical examination of the patient is the most important feature of any diagnostic and assessment program; because of the wide prevalence and in many ways unique aspects of mental illness among the elderly, all but the smallest psychiatric programs should have at least one clinician who specializes in assessment of geriatric problems

Piracetam (Nootropil, 2-oxopyrrolidone acetamide) has been extensively investigated for the treatment of cognitive impairment. Initial studies on normal subjects and patients with mild or moderate cognitive decline have been somewhat encouraging. A further evaluation of the effects of piracetam was conducted in the treatment of elderly outpatients 60-85 yr of age with mild to moderate memory impairment consistent with a diagnosis of Primary Degenerative Dementia (PDD). The effects of piracetam in 20 patients were examined. All patients received 7.2 g of piracetam and placebo for 4 wk in accordance with a double-blind, randomized treatment order, crossover design with 1-wk washout periods prior to each crossover period. The total study period for each patient was 10 wk (1-4-1-4). An analysis of 43 psychometric measures revealed significant improvement (P < 0.05) in only 3 measures, all favoring the treatment conjunction with cholinergic precursors in patients with cognitive decline. In a 2nd study, a 1-wk open trial of 1.6 g of piracetam t.i.d. [3 times a day] in conjunction with 3 g of choline chloride t.i.d. was conducted in 15 patients. Four patients were rated as clinically improved. These responders were all subjects with moderate cognitive impairment. The responders showed much higher RBC [red blood cell] choline levels than the nonresponders, both at baseline and during treatment. The effects of piracetam treatment alone in elderly outpatients with mild to moderate cognitive decline are subtle and not of proven clinical significance. Studies of longer duration and of piracetam in combination with other agents may eventually show genuine clinical utility

The most widely known substances that have been investigated for treating cognitive deterioration in the aged are cerebral vasodilators, Gerovital H3, psychostimulants, 'nootropics,' neuropeptides, and neurotransmitters. The rationale for the choice of specific agents has shifted as our conceptions regarding the origins of cognitive decline have changed; we now know that most cognitive deterioration occurs independently of arteriosclerotic vascular changes. Substances currently being investigated because of their effects on brain electrophysiology, on neurohumoral processes, or on central neurotransmitters show promise