f A COMPREHENSIVE REVIEW IF GERONTO-PSYCHIATRIC ITERATURE IN THE POSTWAR PERIOD NATIONAL CLEARINGHOUSE FOR MENTAL HEALTH INFORMATION ''''GERONTO-PSYCHIATRIC LITERATURE IN THE POSTWAR PERIOD A review of the literature to January 1, 1965 by L. Cıompi Translated from Fortschritte der Neurologie Psychiatrie und ihrer Grenzgebiete (Stüttgart), 34(2):49-159, 1966 Reprinted and distributed by The National Clearinghouse for Mental Health Information U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PußLic HEALTH SERVICE ® HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION National Institute of Mental Health Chevy Chase, Maryland 20015 ''Public Health Service Publication Number 1811 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price $1 ''FOREWORD In recent years, the literature on the problems associated with aging has greatly expanded. Much has been written about the nature of the aging process, the behavior of older people under various circumstances, the impact of established customs and institutions on the aged, and the ways society adapts to the needs of the growing number of senior citizens. Effective ways to close the gap between this body of knowledge and its application in social welfare, institutional care programs, housing, health, and community planning still must be found. This monograph has been translated in order to make available to researchers and program planners in this country an extensive review of the world literature on human aging. The bibliography contains 2747 citations, many of which are foreign, and which will therefore alert readers in the United States to the impressive efforts in other countries. The review also reflects the interdisciplinary approach to the study of human problems that is actively followed by the National Institute of Mental Health. References are made to many of the social and cultural aspects of aging which must be understood before a total approach can be implemented to solve this growing problem. This report is a comprehensive review of current thinking about aging. It is especially valuable to those who design research and programs to help solve the problems of the senior citizens in this country and through- out the world. Director National Institute of Mental Health iii 049 ''AUTHOR'S ACKNOWLEDGMENTS This study was prepared as part of a large geronto-psychiatric research program, subsidized by the Schweizerische Nationalfond fur wissenschaft- liche Forschung (Swiss National Fund for Scientific Research). The pre- liminary work for this study was carried out by my colleagues, Dr. A. Calanca, Dr. de Perrot and Dr. G. P. Lai, under the direction of Professor C. Muller. The secretarial work was performed by Mrs. J. Cristen, Mrs. A. Francioli, Miss M. Giroud and Miss R. Waidyasekera. I should like to express my thanks to the Swiss National Fund for Scientific Research and all of those involved, without whose constant support the execution of this work would have been impossible. —L. Crompi Chief of research in geriatric psychiatry University Psychiatric Clinic Cery Prilly/Lausanne, Switzerland The National Institute of Mental Health expresses its appreciation to Dr. L. Ciompi and to Georg Thieme Verlag, publisher of Fortschritte der Neurologie Psychiatrie und ihrer Grenzgebiete, for their permission to translate and distribute this article. iv ''CONTENTS Forewörd su... ce man a EER BB nennt EEE NRE nn nn ill Author’s Acknowledgements .........--. 0c ee eee eee eee een nenn iv A. Introduction. ........-=@ss@wa@ 5s eee es cee eee nem e nen l B. The History of Geronto-Psychiatry .........22eeeeeereeene l ©. Normal Aging ...... 00008 cewews seer ewe ete wes remnant nn 2 I. Demography of Aging ........... 005 eee eee reece eee ees 2 Demographic age distribution of the population - relationships in Switzerland — causes - future population movements II. Sociology of Aging ........... 6. cece eect tenet nn 3 Reviews, summarizing presentations, literature surveys — general con- siderations - comparison with pre-industrial cultures — family struc- ture — possible occupations — retirement — economic and financial problems III. Psychology of Aging .......... 0. eee e ee eee eects 4 Reviews and summarizing presentations - normal, regular phenomena of aging - individual psychic functions — testing methods — behavior research — personality structure - productivity — the old age of great personalities - extremely aged persons — clinical psychology - contributions of psychoanalysis D. Psychopathology ............. cece eee eee eee eee ees 9 I. General Considerations ......... 0.0.0.0 cece eee eee teens 9 Summarizing reports, works with general content, discussions of the literature - morbidity and mortality — picture of psychopathological phenomena - etiology and pathogenesis-course — classification II. Predominantly Psychogenic Psychic Disturbances ............-- 13 General considerations — neuroses and psychoreactive disturbances - psychosomatic disturbances — sexuality — delinquency of the elderly - suicide and suicide attempts — alcoholism III. Predominantly Endogenous and Involutional Psychoses of Old ICE nice cmsiawe duns CHEE RR ER EER EIS EHEM Em men nme 17 General considerations — presenile dementias — senile and arterioscle- hallucinatory psychoses of old age IV. Predominantly Organic Disturbances ..........---..00 0000555 20 General considerations — presenile demetias — senile and arterioscle- rotic dementia — additional organic brain disturbances (progressive paralysis — Parkinson’s disease — brain trauma - brain tumors) - epilepsy V. Predominantly Congenital and Constitutional Disturbances .... 26 Psychopathies — oligophrenias E. Therapy and Prophylaxis .............-. cee eee eee eens 27 I. Somatic Therapy ......... 0.0.00 cece eects 27 General medical treatment; so-called youth cures - states of con- fusion - rehabilitation IL. Psychiatric Therapy «ais sessves carer uw ren enews en nme ann 28 Summarizing presentations — psychiatric pharmacotherapy — electro- shock treatment — psychotherapy — therapeutic environments, occu- pations and leisure activities v ''III. Hospital Organization and General Old-Age Nursing .......... 30 General considerations—geriatric and geronto-psychiatric treatment centers — daytime in-patients — homes for the aged IV. Psychic Hygiene ......... 0... cece cc tenn eee 32 General considerations — “basic needs” — questions of residence — leisure time and possibilities for occupation — interests — education for old age F. Concluding Remarks ............ 00000. e eee tenes 33 Summary — methodological questions of old age research Gy, References 2. wie mens cmrmeemew sus mem OREM s Ee ews sam CHEN EM 35 vi ''A. Introduction Geronto-psychiatry is a concept which, at least in our clinic—in analogy to “pedo- psychiatry”’—is preferred above all other similar designations when it comes to this newest spe- cial branch of our, profession dedicated to advanced age. It still frequently represents a step- child of psychiatry, neglected in its clinical as- pects and in research. Nevertheless, in the past 20 years, with the general demographic and sociological development of geriatrics, the in- terest in geronto-psychiatric questions has sud- denly picked up on all sides. Without fanfare, then, a very comprehensive special literature, which becomes increasingly difficult to survey, has arisen in this special area. The present review represents an attempt to facilitate access to this group of reference works, which has been growing like an ava- lanche. Our primary sources included the com- prehensive geriatric inventory of references by Shock [2302, 2303, 2304] as well as standard works such as the Handbook of Aging and the Individual [298] and the Handbook of Social Gerontology [2462], the substantial German- language reference handbook of Ruffin [2172] published in 1960, periodicals such as the Zentralblatt für die gesamte Neurologie und Psychiatrie and Excerpta Medica, as well as additional collections of references [1037, 2024, 375, 2300, 2144, 1021, 376, 377, 2301, 706, 379, 2138, 511, 2506, 91, 381, 2501, 2509, 383, 2597, 384, 1815, 678, 385, 386, 2041, 288, 2318, 387, 1218, 681, 2512] and a multitude of individual author’s references scattered throughout the entire literature. Basically, we limited ourselves to clinical geronto-psychiatry and its ancillary areas. Large and important territories of basic research, such as the biology and histology of aging, were not touched; however, the latter is surveyed in detail in the work mentioned by Ruffin [2172]. We have not set precise limits in time or space for ourselves. For easily imaginable _ practical reasons, the “center point” of the material which we used clearly lies in the Western Euro- pean and Anglo-Saxon literature of the postwar period. Where it seemed necessary to us for reasons of continuity, we occasionally went back to older works. Finally, we must mention that the presentation is generally chronological, when a number of authors are quoted concern- ing a certain question. Completeness could not be attempted; lacunae and at times a degree of arbitrariness in the selection of articles for discussion could not be avoided, as frequently we could not obtain certain publications, or could examine the re- ports only in summarizing references. However, we have at least mentioned most of the mate- rial which was known and accessible to us, except for articles in a limited number of ancillary areas such as sociology and psychology; but in these cases, we were able to mention a few re- cent surveys. The 2747 reports presented repre- sent a selection from about 4500 titles which we originally assembled. B. The History of Geronto-Psychiatry There is a large number of publications con- cerning the history of gerontology and geriatrics in general such as, in recent years, the fine reports of Burstein [454, 455, 457, 458] and Grmek [1040, 1041, 1042] and in addition, [2386, 2174, 1057, 28, 2586, 1978, 536, 2418, 288, 1009, 1893]. However, the history of geronto- psychiatry in particular is covered in only a few summarizing presentations. One of these comes from H. Sjoegren [2333] and represents the introduction to a well-known and important study concerning the psychic diseases of old age. In this report, Sjoegren sketches the development of geronto-psychiatry from the time of his precursor Canstatt [515] in 1839, who was the first to analyze the psychic questions of old age; through the reports de- lineated by Griesinger, Wernicke, later Kraepelin and a number of other investigators; through the concepts of the 19th and the beginning of the 20th century, which were predominantly oriented toward the organic characteristics of the brain; up to the modern multidimensional thinking of the present. A copious work by Rosen [2125] extends back as far as antiquity and the Middle Ages. Birren [300] divides the ''2 historical development of the psychology of aging into three phases. The first, at the end of the 19th century and the beginning of the 20th century, saw the introduction of quantitative methods by Quetelet [2048, 2049], Galton [922, 923], in addition to Wundt and Pavlov. A second phase, the beginning of the systematic studies, was distinguished by names such as Hall [1088], Koga and Morant [1393], Tachi- bana [2429], Miles [1753, 1754], and Frenkel- Brunswik [893], and followed between the two world wars. The third phase, from 1946 to the present, was characterized by a tremendous ex- pansion in the field (under the leadership of investigators such as Pressey, Bartlett, Shock, Birren, Donahue, Bourliere, Riegel, Havighurst, Post and others), whose magnitude is indicated GERONTO-PSYCHIATRIC LITERATURE by the fact that between 1950 and 1959 more was published concerning the psychology of aging than during the previous 115 years! In addition, there are historical introductions to reports concerning special problems, indi- vidual diseases and the like, which we will not report in greater detail at this point. However, we would just like to mention Dedieu-Anglade [674], who saw the beginning of extensive research on the psychic diseases of old age in the treatise of the Swiss investigator Wille [2656] in 1873 concerning the psychoses of the elderly; in addition to Herbeuval and Lorcan [1148], who reviewed a few earlier reports from the Nancy school; and finally Vallieri [2522], who described the contribution of Charcot [551] to gerontology. C. Normal Aging I. Demography of Aging Almost every report discussing old age con- tains an introductory note on the striking in- crease in the older segments of the population. According to Martin [1165], this development can be summarized in the statement that since the beginning of the 20th century, the average life span has increased by about twenty years [also see 270, 963, 1357]. An excellent survey based on the 1950 census outlining the demographic age distribution of the population in 32 countries can be found in the tables at the end of the book Aging in Western Societies [448]. In addition, the figures for 8 Western countries were ob- tained by Hauser and Vargas [1112], who com- pared the mortality and the life expectancy in 72 countries around the year 1950 on the basis of statements in the demographic yearbook of the United Nations. With the exception of New Zealand, all of the countries with populations notably elevated in age are in Western Europe. Among these, France takes first place with 11.79 percent of its population over 65, West Germany (9.98 percent) the seventh [also see 722] and Switzerland (9.57 percent) the tenth place [also see 1111, 776, 727, 2499, 1015, 162, 1590, 238, 1910, 1391, 2123, 2032, 64, 2347, 2288, 130, 1911, 369, 722, 886, 2033, 1912]. Information concerning the proportions in Switzerland, where between 1900 and 1960 the population over 65 increased from 5.2 to 9.4 percent, or in absolute figures, from 173,721 to 554,240, can also be found [2251, 2263, 117, 2262, 2264, 897, 1402, 1899, 1322, 2265, 2266]. A large number of authors studied the causes of this development, which in all highly civi- lized countries is principally related to the de- crease in fertility, linked with a pronounced regression of mortality in the past 30 years [1324; also see 51, 513, 895, 776, 171, 896, 2629, 2473, 1809, 2270, 297, 162, 257, 1644, 592, 1710, 593, 1962, 1019, 1112, 1323, 1322, 1375, 2359]. In the USA, the mortality for the age groups between 65 and 84 has decreased considerably [1739]. In contrast, a study by Freudenberg [897] remarkably showed that contrary to popu- lar opinion, the mortality for the more elevated ages has changed very little in the past hundred years; and in the eighth decade, in Germany and Switzerland, for example, it even increased somewhat [see also 776, 2558], which probably indicates that the progress of medicine and hy- giene has affected the elderly substantially less than we think. Gould [1015], who attempted to predict the future population movements in England based on the developments up to this time, came to the view that the increase in the elderly segment of the population will reach an approximate limit- ing value in the next 50 years, in contrast to Kaufmann [1324], who believed that this limit- ing value of 16 to 17 percent over 65 will be reached as early as 1980-85 in the European countries [also see 364, 365, 2287]. ''IN THE POSTWAR PERIOD Il, Sociology of Aging The increasing attention paid to social factors is one of the most prominent traits of recent geronto-psychiatric thinking. Aging is recognized as a social problem to such an extent that, for example, Post [2017; also see 210, 2463, 1201] considers geronto-psychiatry and sociology as almost synonymous. Particularly in the Anglo- Saxon countries, but also in other places, an immense amount of literature has been pro- duced concerning the social questions of aging, which we cannot report on individually, al- though we attempt to give a rough overall view. In the past few years, these questions have been set forth in a number of comprehensive, even handbook-size surveying reports [1128, 734, 2462, 448, 2663, 2466] and in additional sum- marizing presentations and literature surveys (2024, 781, 2624, 2017, 2172, 1507]. Of the innumerable publications with general content, which vary widely in importance, we can only present a small selection here [441, 1114, 966, 443, 668, 2291, 1414, 53, 1119, 61, 445, 1924, 176, 2099, 1112, 362, 645, 939, 1302, 1710, 345, 1704, 1559, 2625, 1523, 1745, 2687, 1822, 1768, 462, 1136, 363, 2437, 1312, 1447, 2721, 57, 1304, 1467, 330, 332, 2173, 450, 1447, 1005, 1914, 2002, 2465, 1074, 931, 2438, 1404, 1352, 149, 731]. The thoughts which are expressed over and over again in these publications can be con- cisely summarized approximately as follows: with the evolution of the farming and hand- working society into an industrial society, from sessile to mobile populations, from rural to urban social intercourse, from the extended to the presently limited families, the social posi- tion of the elderly has changed basically. They have lost their previous solid status in the family and society to a certain extent, they are isolated and little noticed, they often seem superfluous and do not know what to do with their endless amount of leisure and free time, which “stretches out before them like an eternal Sunday afternoon” [2277, 2391]. In many re- spects, their situation and mentality are similar to those of typical minority groups [191]. Under these conditions, comparisons with earlier or contemporary pre-industrial cultures were frequently undertaken with a certain nos- talgia [2255, 1728, 2125], particularly compari- sons with the well-known privileged position of the aged in the ancient Chinese extended family [781, 546]. According to a study by Lin [1554], however, the senile psychoses in the 3 Formosan Chinese were no less frequent than, for example, among the Thuringers of Germany! Lips [1570], who described the role of the aged in such different primitive races as the Eskimos, the Indians and the primitive Australian tribes, found huge differences be- tween individual tribes and warned against false generalizations. According to Margaret Mead [cited in 2093; also see 1709], age counts for little in bellicose cultures, where a great deal of emphasis is placed on physical strength and aggressiveness; but it counted for a great deal, on the other hand, where conditions were peaceful and experience and wisdom were held in great respect [also see 2355, 2315, 2535, 2422, 2591, 2717, 2316, 1134, 1787, 1878]. A large number of extensive statistical and social-medical study series concerning the rela- tionships between social status and physical health in our modern technical and industrial society has been published, such as those of Sheldon [2289], Cavan [534], Havighurst et al. [1128], Donahue et al. [749], Pressey [2034], Roth et al. [2154], Riegel et al. [2095], Cesa- Bianchi et al. [542, 543, 540; also 1038, 2038, 1454, 2731, 937, 2440, 1431]. In general, these studies confirm what Cavan determined [531] in the most imposing of these studies on 2988 test subjects: the physical equilibrium in old age (in the Anglo-Saxon countries, the concept of “adjustment” is frequently used [see for ex- ample 1123, 2480, 544]), is strongly dependent upon social factors and is most likely to be guaranteed in those cases where the possibilities for sufficient social contacts and meaningful activity, as well as a certain social security and a satisfactory condition of bodily health, are maintained. Out of the entire complex of social questions concerning age, two themes, which have been intensively studied in many special reports, can be selected as central and particularly prob- lematic under today’s conditions: on the one hand, the structure of the modern family (also see Schelsky [2219]), the relationships between the generations and the increasingly precarious position of the aged in a milieu in which fa- milial ties are endangered [see 219, 2054, 444, 1023, 54, 55, 56, 1401, 1691, 1557, 447, 230, 1018, 2296, 330, 918, 421, 1735, 1560, 449, 2130, 2111, 1843, 213, 58, 526, 2231, 254, 2438, 1404]; on the other hand, the question of occupational possi- bilities in a society where there is less and less work for the elderly [1159, 2363, 52, 575, 227, 2325, 146, 2189, 2366, 1374, 1973, 2514, 2683, ''4 225, 1523, 733, 1150, 1503, 899, 1124, 1790, 522, 831, 1496, 1734, 2479, 351, 1908, 1764, 1235, 1217, 1990, 2685, 964, 2292, 881, 281, 2684, 509]. Paradigmatically, so to speak, not infre- quently the social problems and perhaps even the entire psychic problems of the aged come together in the “storm front” of a situation of immediate urgency [2241], that is, retirement. As is known, Stauder [2362] coined the term “retirement bankruptcy” for this phenomenon, and the large number of reports which are specially concerned with the question of pen- sioners stems from the human problem complex which is often linked to this recent social institution [see, for example, 1129, 547, 1694, 2455, 1746, 646, 374, 1130, 1941, 1810, 901, 2595, 71, 2596, 2461, 1366, 1577, 2087, 1942, 2414, 1268, 1953, 267, 1568, 782, 2081, 254, 1898, 1569, 1646, 194, 780]. It is possible that the replace- ment of the strict retirement age by a more flexible system, which has already been accom- plished in a few places, would offer significant advantages, even though it is not the final answer [1095, 239, 782, 2196, 1888, 800, 2205, 2707]. For the rest, the attempt is made to com- bat intensively the emptiness and passivity fol- lowing retirement by means of such opportu- nities as clubs, homes, leisure time organizations, etc. [1300, 1197, 1879, 1528; also see page 32]. If we now think of the difficult economic and financial problems which age imposes upon both the individual concerned and his entire com- munity, then the second half of life may seem to be only a period of immense social difhculties [see 1532, 499, 453, 574, 724, 2164, 84, 21, 8, 599, 830, 1909, 1698, 1690, 805, 804, 2526, 2503, 603, 1715, 1474, 806]. Although these difficulties justly deserve our utmost attention, they do not by any stretch of the imagination represent the complete and only reality, as has been clearly demonstrated by studies of elderly individuals who did not undergo psychiatric treatment; among the al- most 3,000 test subjects of Cavan [534], only 10 percent of the men and 13 percent of the women stated that they were less happy in their old age than earlier. Other investigators have also demonstrated that the much-abused retire- ment does not lead to psychic decompensation in the great majority of cases and that only a small percentage of the retirees really desires to work any more [see 1941, 2017, 2282]. Final- ly, we must indicate that social factors are surely of significant importance, but that in addition, there are also decisive factors which GERONTO-PSYCHIATRIC LITERATURE depend upon the entire personality structure and particularly upon the internal possibilities for compensation and adaptation to the psychic situation of age. These factors shape and in- fluence the social milieu [see 321, 472, 2173]. Il. Psychology of Aging A myriad of studies, differing greatly in methodology, can be found under this title in the literature concerning the theme of psychic aging. These range from the most meticulous psychometric and experimental determinations of the decline in individual psychic functions as a result of age; through the more inclusive study of certain behavior patterns; up to com- prehensive conceptual studies from the view- points of clinical psychology, psychoanalysis, anthropology, philosophy of life, and religion. Scientific psychology itself represents an ex- tremely extensive and highly specialized area within this theme, which on one hand extends far over the boundaries of clinical psychiatry, and on the other nevertheless exhibits so many points of contact with clinical psychiatry that it seems absolutely necessary for us to undertake at least an overall orientation. For detailed studies, we must refer the reader to a series of review and summarizing presentations, the first of which is the Handbook of Aging and the Individual [298] edited by Birren, as well as the distinguished review by Riegel [2092] which surveys 465 titles and the handbook article by Ruffin [2172; also see 2008, 738, 1020, 2317, 1452, 1021, 741, 2301, 1309, 1859, 1937, 1456, 1453, 1904, 2138, 1542, 193, 68, 253, 102, 2377, 583, 2037, 297, 2597, 2567, 263, 301, 1959, 579, 1175, 470, 304, 469, 1922, 337, 304, 307, 306]. One of the central problems, which is equally significant for psychology and clinical psy- chiatry, is unquestionably that of the norm. Another is the question of whether regular phenomena of aging are to be classified as in the psychic region or not [see, for example, 1727]. This question was answered with a “yes” by most authors, including Birren [302], on the basis of recent studies as well as the funda- mental reports of Miles [1753, 1754], Jones and Conrad [1264], and Wechsler [2598, 2599, 2601, 2602]. On the other hand, we find con- troversial interpretations of the question whether pathological psychic breakdown phe- nomena in old age, such as those which are found in senile dementia, represent merely a quantitative increase in “normal” involutional ''IN THE POSTWAR PERIOD processes or something qualitatively different. Dorken, for example [753] represented the latter viewpoint on the basis of factor-analysis studies, in contrast to Wechsler [also see 242, 367, 1834]. As concerns the individual psychic functions, in contrast to earlier concepts, intelligence is primarily interpreted as causing the psychic phenomena of aging in persons with high intellectual levels to be attenuated and delayed in their appearance. However, experience, habit and numerous social factors are also influential [85, 1860, 1902, 2458, 1894, 1196, 1724, 302]. “ In addition, not only have very great in- dividual differences been confirmed, but also the differences (which have been known for a long time) between the premature and the normally-appearing decline in sensory and psy- chomotor capabilities; and the much greater stability in the verbal and vocabulary areas also has been corroborated [979, 1236, 2214, 1092, 2091, 1891, 584, 285, 302, 1770, 2079, 541]. As one of the most constant phenomena of aging, largely independent of other factors, a general tendency to slowing down of all psychomotor reactions has been noted—a phe- nomenon which has been studied in particularly great detail by Birren, Botwinnick, Welford, Riegel, and Pacaud [1901, 2617, 2618, 308, 1903, 309, 295, 296, 2620, 2622, 2621, 2623, 302, 1906, 361, 312, 311, 310, 2628, 2627]. Ruffin [2172], in considering the various psycho-physical phe- nomena of aging, decided on an _ increasing “weakening of the basic vital force” as the most pervasive general phenomenon of aging. As Jones [1265], Conrad [611], Gilbert [960] and other authors have precisely con- firmed, this weakening also becomes evident in the area of the mnemonic functions and the learning processes, a theory of which recently was presented by Kay [1338] among others [also see 2619, 2092, 1209, 1254, 2674, 1219, 580, 495, 180, 226, 795]. The question of whether intelligence as such plays a role in preserving the intellect was answered “no” by many authors [1214, 2284, 1608]. According to Kral et al., who analyzed the memory problems of old age with particular intensity [1419, 1421, 1433, 1435, 2612, 1428; also see 2741, 1961, 2602, 1215, 407, 215, 1152, 2089, 494], the relationships between the intellect and the general health condition are very close, so that the intellectual function can often be considered as a prognostic in- dicator of vitality [1426, 1428]. In addition, the decrease in the learning capacity in the first 5 two decades is more frequently linked to lack of use and an incorrect mental attitude than to age itself [2357, 2460]. The utilization of suitable testing methods for measuring psychic productivity among the elderly once more presents very difficult prob- lems because of the lack of a definite normal standard, the huge individual differences, and the fact that most of the tests which are used have only been standardized for young ex- perimental subjects. Calanca [496] from our clinic reported this briefly [also see 1934, 1574, 865, 539, 2640, 2452, 701, 240, 200, 1799, 1211, 2549). For practical purposes, a series of widely known and well studied tests are available. We cannot go into the extraordinarily comprehen- sive special literature concerning the Wechsler- Bellevue test series. We must only point to the reports of Wechsler himself [2598, 2601, 2600] and the summarizing presentation of Riegel [2092]. Of particular interest for the psychi- atrist is a series of reports concerned with the possible diagnostic application of this test among the elderly [see 2677, 1314, 1075, 359, 2679, 229, 847, 2698]. Many authors [such as 1214, 2284] have sug- gested the Bender-Gestalt Test as the best method for discovering manifestations of or- ganic breakdown [also see 1934, 1471, 635, 2283, 1213, 1702, 1434]. Perron [1959] reported on a graphometric method, which in particular is supposed to permit the recording of organic deficiencies taking into consideration the level of education and intelligence. In the area of the projective personality test, the Rorschach test remains the most fre- quently used. In this case, also, only a few reports can be mentioned out of the immense special literature [2105, 2106, 1135, 1073, 2107, 497, 1464, 1388, 98, 2117, 594, 1553, 99, 1892, 96, 97, 794, 1358, 1434, 139, 1359]. In summarizing the results concerning Rorschach findings in the elderly, Riegel [2092] stated a general slowing down, falling off of the intellectual, productive and creative capabilities, diminution of the emotional responsiveness, the social contacts and sense of reality, as well as a tendency to nar- rowing and stereotyping of the thought content and interests. Many authors have used the human figure- drawing test of Goodenough and Machover [2397, 1470, 1472, 1585, 1473, 971], the frustra- tion test of Rosenzweig [2133, 845, 542], graph- ological [2005, 2354, 214] and other methods ''6 [1221, 1703, 501, 1882, 1536, 1409] on the el- derly. Inspired by the methods of behavior research, in the past 10 to 15 years, particularly in the USA, scientific psychology has more and more turned away from the isolated psychometric study of individual psychic functions in favor of a comprehensive study of the entire psychic manner of behavior and its correlation with a multitude of somatic, social and psychological variables [see, for example, 1210]. The results and problems of this research direction are sum- marized primarily in the Handbook of Aging and the Individual [298] as well as in others [706, 2119, 160, 318]. As Birren [299] wrote in 1960 in a summarizing report, we are neverthe- less far from a universal behavior theory for the aged. Up to the present time, certain partial aspects such as learning theories [1254, 1338], perception [803, 2607], the study of psy- chomotor activity [2623], in which the differ- ences resulting from age are particularly clear, have been primarily subjected to intensive be- havioristic psychological research [also see 1382, 1261, 103, 1905, 2213, 1093, 914, 2636, 303, 1212]. At this point, we cannot go into detail concerning the extraordinary complexity of this huge area of research. However, as a practical example of behavioristic psychological research, we would like to mention the very basic study, which appeared in the book Human Aging [305], of 45 old men who were chosen as being particularly healthy by a 22-man research team under the direction of Birren. During a two- week stay in a clinic, detailed somatic, physio- logical, biological, psychological, and psy- chopathological characteristics, in addition to the influence of certain environmental factors, daily manner of living, etc., were studied and observed. Out of the plethora of data which were assembled, it is particularly interesting for the psychiatrist that certain abnormal psychic findings were obtained in about two- thirds of the cases; 28 percent suffered neurotic disturbances. The following factors proved to be pertinent to the altered behavior in old age: the personality structure, the capacity for in- trospection and adaptation, the factors of ar- teriosclerosis, psychomotor retardation, social relationships, state of bodily health [also see 486; as well as 1907, 2278, 451, 1436]. In addition, modern studies concerning the interaction between personality structure and age are strongly influenced by the methods of behavioristic psychology [see 30, 660, 78, 378, GERONTO-PSYCHIATRIC LITERATURE 112, 110, 424, 2136, 2, 2468, 2062, 787, 2080, 484, 2738, 2324, 1318, 3]. A comprehensive presenta- tion of the most important early and recent personality theories, such as those of Kret- schmer, Sheldon, Freud, Adler and his adher- ents, the Gestalt psychologists, and modern behavioristic investigators and sociologists was given by Riegel [2093]. He undertook a critical comparison of these theories with each other, studied them with respect to their contribution to the questions of aging and came to the con- clusion that up to the present time no satis- factorily comprehensive theory of personality and its relation to age exists. His demand for a cautious limitation to sharply delineated, but all the more clearly conceptualized sections for re- search is in close agreement with earlier sharp criticism of the personality research up to the present time, such as that formulated by Watson [2592] in 1954. Now we will turn to the interesting study of the relationships between productivity and period of life, for which Charlotte Buhler laid the foundations in her biographical study [431, 432, 434]. She evaluated, among others, 256 life histories of famous personalities in a systematic manner, compared them with the life courses of 50 average elderly men and showed that the high point of work and life was further and further shifted with respect to the biological high point, the more the corresponding achieve- ments depended upon general knowledge and experience [cited from 2092]. More recently, Revesz [2076, 2077], Lehman [1510, 1511, 1512, 1513, 1514, 1515, 1516, 1517], and Dennis [707, 711, 709, 708, 710] systematically studied the periods of greatest creative productivity of the most prominent personalities in different areas of creative effort. According to them, musicians, mathematicians and scientists achieved their highest accomplishments as early as the second and third decades, writers in middle age, and philosophers at later ages [also see 1153, 62, 2446, 2711, 1187, 393, 961, 2447, 2132, 2215, 1649, 410, 1767, 479, 100, 2057, 351]. The old age of famous persons and its influ- ence on their work has fascinated the students of aging for a long time. Brinckmann [404] as early as 1925 published a study concerning the late work of great painters, who remained fully productive in their old age, but whose style showed a tendency toward introspection, clarifi- cation, and universality. A similar evolution was demonstrated by Vischer [2551, 2555], whose writings represent a treasure chest of facts ''IN THE POSTWAR PERIOD concerning the old age of important personal- ities [also see 1367, 2047, 2031, 399, 1603]. In this connection, the problem of the ex- tremely aged is also of interest. Obrecht [1863] in 1949 studied the 12 persons more than 100 years old living in Switzerland at the time. He found predominantly lively, active characters, often treated roughly by fate but happily ad- justed to elevated age. Constitutional factors most likely play an important role in the often astounding psycho-physical resistance of the ex- tremely aged [also see 206, 2561, 2256, 2172, 348, 289]. Considerations concerning psychic aging from the viewpoint of a sympathetic clinical psy- chology were primarily instituted by European investigators of aging. In addition to the actual psychic regression phenomena, they paid in- creased attention to equalizing and compen- sating forces [F. A. Kehrer, 1339, 1340, 1341; J. H. Schultz, 2252, 2253] which can lead to a new psychic equilibrium in the basically altered situation of old age. J. H. Schultz [2252] spoke of a metamorphosis of the internal environ- ment, which resulted from the interaction be- tween decreased psychic capacities on the one hand and the change in the entire psychic situa- tion on the other hand—a situation which is primarily characterized by the problem of the finality and nearness of death. Authors such as Dublineau [772, 771, 773], Minkowski [1759, 1760], and Schulte [2243, 2244, 2246] showed that these changes provide possibilities for new development and creativity, for “spiritualiza- tion” and the wisdom of age. A similar line of thought is also taken in the reports concerning the psychology of old age by Vischer [2531, 2553, 2555, 2560], by Stoll [2394, 2395], and in the symposium lectures, edited by Wittgenstein [2681] concerning aging and the abilities of the aged [also see 1737, 1413, 1187, 1938, 1367, 382, 2242, 1458, 271, 2728, 293, 2271, 2406, 1064, 548, 2578, 1446, 766, 672, 2413, 1063, 1606, 1802, 294, 1282, 783]. As Vischer [2555, 2560] has also often em- phasized, it is nevertheless extraordinarily difh- cult to preserve true objectivity in our opinions concerning old age in general and concerning the psychic phenomena of aging in particular [also see 2548, 142]. Moreover, in the USA, the mostly instinctive avoidance reaction and the negative general attitude with relation to age forms the subject matter of systematic studies particularly by Tuckman, Lorge [2488, 2481, 2489, 2494, 2492, 2490, 2485, 2493], Kogan et 7 al. [1394, 1395, 1396, 1379; as well as 1115, 1455, 1116, 521, 967, 833, 1103, 2659, 143, 796, 168, 2170]. Also, the subjective attitude of old people toward themselves and toward age, which is naturally closely related to the entire manner in which age is experienced and mastered, has been systematically studied many times in these correlations with the other circumstances of life [1666, 1667, 433, 475, 329, 2639, 1249, 669]. Indubitably, the changes in feelings toward time and life and the problem of death assume a central place among all the psychic problems of age. Such questions were particularly studied by Vischer [2551, 2553, 2555, 2560], J. H. Schultz [2252, 2253], Blum [331], Kafka [1279], Kahn [1281], Minkowski [1760], and Stern [2375, 2377]. Vischer and Minkowski have provided imposing descriptions of the manner in which the basic feelings and attitude toward age change from that of childhood and youth, in which the world is full of new sensations and whose future lies before him endless, indefinite and full of hope, so that a year seems infinitely long and actually makes up a proportionately large part of his life; up to the old man, for whom a year represents only one-seventieth or one-eightieth of his life, so that he conceives the time of the year as being shorter and shorter, who experiences only a little that is new and is drawn irresistibly forward toward death. L. de Nouy [1506] attempted to explain the frequent subjective feeling of an acceleration of time in old age by means of changes in physiological rhythm, but nevertheless this in- evitable feeling of acceleration was primarily understood to result from the peculiar psy- chological situation in old age [see Gschwind, 1061]. Stern [2377] emphasized the relationship between activity and the feeling of acceleration on the one hand, passivity and the feeling of slowing down (boredom) on the other. There- fore, in old age it is particularly the active people who would experience the sensation of accelerated time, which may also have to do with the impression that the time which remains is no longer sufficient for that which must be completed [also see 530, 335, 778, 1048, 853, 836, 857, 2608, 2063, 1501, 2575, 435, 1317, 1706, 2129, 2486]. Also, van der Horst [1186] concerned himself with the situation of proceeding toward death from an anthropological and existential view- point, and Vetter [2539] considered it in a more philosophical and religious aspect [also see 659, 1415, 1524, 86, 322]. In a series of Anglo-Saxon ''reports, the relationship to death in connection with many other psychic and social facts was studied using the methods of behavioristic psychology, testing and psychometry, and the fear of death was found to be greatly increased where there were no religious connections [835, 2424, 1250], when neurotic features were present [2294, 2979] and where social and affec- tive adjustment [2307] was poor. A.E. Christ [569] remarked that the problem of death is today often surrounded by a taboo similar to that which surrounded sexuality in the 19th century [also see 834, 63, 2308, 1230, 1270, 634, 2426, 2103, 2427, 1251, 570, 1140, 12, 1615]. A new American theory concerning psychic aging, in which both thoughts of death and death itself have a place, is the “disengagement theory” represented by such authors as Cunning, Henry and McCoffrey [1142, 642, 643; also see 672, 2430, 1614]. This theory starts from the usual observation that elderly people par- ticipate less in life and in their world than younger people. Thus, a “disengagement” nat- urally comes about at elevated ages. This dis- engagement consists of a withdrawal of in- terests from the external world, which expresses itself as increased introversion, egocentricity, passivity and indifference and which leads to a new internal equilibrium corresponding to the situation of old age and detachment from the world. Such considerations concerning affectivity in old age can serve to carıy us over to psychoanalytic contributions. First we must note that psychodynamic evolution in advanced years has been studied very little in comparison with childhood and early adulthood. Grin- stein’s [1039] comprehensive index of the psy- choanalytic literature, for example, contains only 50 psychoanalytic reports concerning elevated age, out of almost 50,000. Abraham [14, 15] was one of the first to make the attempt, as early as 1919, to push forward analytically in the area of the second half of life, despite Freud’s warnings. The reports of Atkin [163] and Kaufmann [1326], which ap- peared in the 1940’s, contained the first attempt to fit the psychodynamic aging processes systematically into the system of instruction of psychoanalysis. In these reports, for example, the rigidity and immobility of elderly people were interpreted as a defense mechanism against menacing disturbances of the libidinal equilib- rium, and the many other types of regressions into methods of satisfaction characteristic of GERONTO-PSYCHIATRIC LITERATURE early childhood were enumerated [also see 712, 2195, 1049, 2206, 1184, 1991, 2297, 29, 938]. Also interesting are the observations of Kauf- mann [1326] concerning psychodynamic mech- anisms in senile dementia cases and concerning the deeper reasons for the troublesome and ambivalent general attitude toward the aged. Schilder [2223] published a study inspired by the viewpoints of Melanie Klein, in which he showed that the fundamental schizo-paranoid and depressive Kleinian states with their manifold projection and introjection mech- anisms are also manifest in old age. Gillespie [962] described the manner in which the projec- tion mechanism in senile persons represents the first line of defense against the anxiety concern- ing death [also see 2272]. Psychoanalysis has frequently attempted to recognize in the psychodynamic evolution of the second half of life a regularity similar to that observed in childhood, which would lead to the formation of cohesive theories of psychological development extending into old age. Thus, for example, Banham [181] explained the lack of adaptability in the age with a “genetic theory of the emotions.” Hamilton [1094] primarily con- sidered the evolutionary course of the libido, Linden [1564, 1556, 1562] that of the aggres- sive feeling, while Repond [2074] emphasized the influence of “epigenetic” organizational factors, which seek to create a specific psycho- physical state of equilibrium in each phase of life. Starting from the conceptions of Linden, Leeds [1509] set up six stages of increasing “recession,” from a mere intensification of reminiscence to a helpless condition correspond- ing to that of a small child or even a fetus. Finally, in the light of modern psychoanalytic knowledge concerning psychoses, Rouart [2159] briefly discussed the question of why psychotic regressions occur more easily in certain seg- ments of life, including the period of involu- tion, than in others. None of these theories seems to have achieved general recognition. In 1961, following intensive study of the psychoanalytical literature concern- ing aging, Dedieu-Anglade [674] came to the conclusion that the problem of libidinal involu- tion remained incompletely studied. However, most authors are agreed [see 507, 1668, 2545] concerning the predominant importance of the many compensation and defense mechanisms with respect to the phenomena of aging, and particularly with respect to the increasingly menacing loss of self-esteem. Canestrari and ''IN THE POSTWAR PERIOD Manganotti [514], for example, studied 93 elderly people and found the following com- pensation mechanisms to be particularly fre- quent and characteristic: euphoric denial, de- 9 pression and self-denial, aggressiveness, flight, and most frequently regression [also see 1049, 1939, 1669, 2381, 471, 324, 1716, 2093, 2065, 2380, 556, 1561, 247, 1325, 1535, 485, 349, 135, 161}. D. Psychopathology I. General Considerations A number of extensive summarizing presenta- tions concerning questions of the general psychopathology of aging have appeared in recent years. This includes those of Sjoegren [2333], Ruffin [2172], Bronisch [416, 418], Busse [463], Goldfarb [999], Bernard et al. [263, 258], Bisio [314], in addition to a very large number of reports with general content, literature discussions, etc. [93, 2328, 929, 1021, 1621, 2010, 887, 1622, 1623, 2110, 391, 2276, 2669, 969, 983, 1079, 1692, 37, 1774, 2146, 1080, 2405, 2665, 426, 2104, 119, 1526, 2609, 2016, 89, 670, 1962, 2388, 664, 2151, 320, 465, 2594, 2502, 2096, 2528, 203, 2569, 702, 705, 1320, 1343, 666, 1742, 124, 2202, 761, 679, 487, 680, 1855, 492, 483, 685, 880, 748, 2692, 1652, 919, 2150, 2566]. Next we will turn to the question of psy- chiatric morbidity and mortality. Parallel to the growth of the elderly population segment, all of the western countries have reported a marked increase in the frequency of hospitalization for psychiatric disturbances of old age, whereas according to Mayer-Gross [1683], in India, where the average life expectancy is only 35 years, these disturbances are quite rare [also see 2422]. According to the very meticulous statistical studies of Malzbert [1635, 1641, 1642, 1639, 1644], the admission of elderly people is increasing more rapidly percentage-wise than that of the younger age groups, which is primarily attributable to a pronounced increase in involutive, senile and arteriosclerotic ill- nesses [also see 1549, 888, 1034, 1054, 2298, 276, 1931, 461, 2001, 1993, 1921, 624, 1830, 1578, 2651, 953, 1786, 1811, 2416]. Weiss et al. [2609] reported on a three times higher hospitalization rate in the American age group over 65 years in comparison to the popu- lation average. In England, according to Post [2018], the psychiatric illness risk in 75-year-olds is five to six times higher than for 25-year-olds. The Swedish relationships were analyzed by Sjoegren and Larsson [2335]. Pisani et al. [1988] assembled statistics on a group of 186 patients out of a total of 2240 cases which re- flected the frequency, diagnostic distribution, beginning of illness and the progress of psy- chiatric disturbances of old age in an Italian province [also see 1998, 1835, 1027, 1847, 846, 344]. From Switzerland, Junod [1277] briefly reported that the total number of admissions per year at the psychiatric university clinic of Genf doubled between 1920 and 1960, whereas the admissions of patients over 65 increased by four times during that period. In evaluating these developments, we must obviously consider not only an actual increase in psychiatric diseases of old age, but also numerous other factors such as the changing family structure, possibilities for nursing care, etc. [2172, 1091]. Malamud [1621] stated that some figures are available which reflect the more severe and therefore the hospitalized psychic disturbances of old age. In recent years, a larger number of more inclusive studies has been undertaken with the goal in mind of drawing conclusions con- cerning the frequency of psychic disturbances of old age in the average population. However, quite different figures resulted from these stud- ies; and particularly because of the different‘ diagnostic criteria, they could not always be , compared with each other. Post [2018] calcu- lated that 11 percent of the elderly population was dependent upon others and in need of hel on account of psychic disturbances. Busse [467 found, out of 222 old people, only 89 who ex- hibited no psychic symptoms; in the cases Kral [1422] there were only 19 out of 21 whereas Roth and Kay [2154] studied 297 randomly selected persons over 65 years of age, who lived with their families, and discovered psychic disturbances in 30 percent, of which 10 percent were designated as severe [also see 1329]. Nielsen [1838] studied the necessity for psychic treatment over a period of five years in a farm population on the Danish island of Samso. Here, 8 percent of the population over 65 years of age required psychiatric help durin this period [also see 1933, 2697, 2416, 105]. Mortality among the inmates of psychiatric ''10 hospitals is substantially higher among the aged than in the average population, and in this figure a greater suicide frequency among the de- pressives, an elevated mortality from tubercu- losis among the schizophrenics [2250], occasion- ally malnutrition [1870], but primarily the fre- quency of senile and arteriosclerotic illnesses [1271, 1870, 1638, 2652, 2474, 2508, 2719, 2720] play an important role. Kay [1327] conducted a catamnestic study concerning the long-term fate of 236 patients who were hospitalized at ages of 60 or greater. In the case of organic dementia, he found a five times higher mortality than in the average population; in the case of paranoid conditions, on the other hand, almost no difference; and in the case of affective illnesses, only slight differences [also see 1637, 2387, 2009, 2547, 406, 2720, 624, 649, 2631]. Concerning the psychopathological manifesta- tion pattern of psychic disturbances in old age, out of the immense number of publications [such as 456, 2328, 553, 1889, 73, 2571, 879, 2138, 1844, 2451, 2664, 1955, 2405, 976, 1725, 2096, 1337, 1940, 142, 1650, 2725, 2611, 662], we would primarily like to select a few reports which have aimed their sights directly at the psychopathological phenomena which are typi- cal of old age. This path was taken by Bostroem [356], in that he-to be sure, only according to clinical impressions—compared the typical manifestations of a series of psychic diseases in youth, middle age and old age with each other. He found, particularly in the case of cli- macteric and involutional disturbances, an ex- ceptional tendency toward the development of anxiety, delusional suspicions, hypochondria, rigidity and withdrawal, but also observed that old age had mitigating effects on illnesses of an affective type. This finding was later confirmed, for example, by the studies of C. Müller con- cerning compulsive diseases [1794, 1797; also see 398] and concerning schizophrenia in old age [1796], which we will mention in greater detail later. Basic tendencies similar to those of Bostroem were also described by Bronisch [418], who emphasized the following features as particularly typical for old age: intensification of behavior patterns, normal in themselves, to a pathological point; tendency to delusional interpretation of sensory stimulation; as well as paranoid, depressive and anxiety reactions, fre- quently peculiar solidification of the psycho- pathological picture; certain abnormal behavior patterns in the areas of sexuality and criminal- ity; increased tendency to suicide. Busse GERONTO-PSYCHIATRIC LITERATURE [461, 467] underlined the paramount impor- tance of the increased tendency to hypochon- dria, to depressive mood changes, to insomnia, to nocturnal agitation and to general restless- ness [also see Gruhle 1055, Zeh 2733, 2734; as well as 69, 292, 552, 2320, 1726]. As concerns etiology and pathogenesis, in the earlier presentations the peculiarities of the elderly were primarily viewed from the angle of increasing organic breakdown phenomena of the brain, possibly associated with constitutional factors. Depressive or paranoid pictures, for ex- ample, appeared to Lange [1482] in 1934 as merely “ancillary manifestations of senile idiocy, which attach themselves as accessory symptoms onto the nucleus of dementia!” In contrast to such concepts, in recent times a multidimensional type of thought has prevailed, which considers a multitude of closely inter- laced factors for the origin of psychic diseases of old age. Among these factors, in addition to organic breakdown, we must particularly men- tion the climacterium and the later involution period, the general state of health, hereditary and constitutional factors, the premorbid per- sonality, and finally a whole complex of ever more closely noted biographical, psychogenic, and sociogenic aspects [see 417, for example]. The modern multifactorial manner of think- ing is well exemplified by the “premature failure conditions” of Beringer and Mallison [252], who showed how atrophic processes of the brain in collusion with physical or psychic noxae and psychoreactive mechanisms can lead to decompensation phenomena in the presenile age [also see Zeh 2732, Bronisch 414]. As an individual factor, for example, the effect of the climacterium in the woman [1065, 2210, 851, 2137, 925, 2139, 1067, 2358, 7, 184, 2211, 1628, 1651, 1555, 1895, 2532, 2634, 2000, 1885, 1928, 2532, 721, 1370, 2361, 1459] and a possible “male climacterium” in the man [1141, 209, 2637, 2638, 1477, 1722, 286, 1565] have been heavily debated. Kehrer [1339] as early as 1939 denied the male climacterium and argued strongly against a suggestive overrating of the change of life as a direct agent of illness and continued to hold this point of view as late as 1959 [1342]. According to Bickenbach [283], the climacterium is passed through with- out incident by 50 to 70 percent of women. Weill-Halle [2604], on the other hand, found that climacteric disturbances were almost en- tirely absent among 2000 African women, who had little contact with civilization [also see ''IN THE POSTWAR PERIOD 2483, 204, 1634, 1500]. Neither M. Bleuler [328] nor Benedetti [234] believed in a direct causal relationship between endocrine events and severe psychic disturbances in the climacter- ium, aside from possible manifestations within the framework of a general endocrine psy- chosyndrome. Today, most authors clearly place the greatest emphasis on psychogenic factors, which are related to the peculiar psychic load situation during the transition into the second half of life [see, for example, 1326, 549, 1712, 774, 1680, 1671, 1502, 610, 1342]. The significance of the involutional period is interpreted with almost as much controversy. To some authors [such as Kehrer, 1339] it is nothing more than an additive factor which can bestow a certain amount of contrast and color to the picture of a disease which is not specific to involution. Other authors [such as Malamud, 1625] attribute a far greater weight to this period in regard to the origin of certain disease pictures, which they conceive as being specif- ically involutive. Naturally, these authors at the same time assume extreme positions concerning the formulations of the many possible inter- mediate forms and combinations [also see 2070, 1992, 658; as well as page 18]. In connection with the involutional processes, in addition, close relationships between the gen- eral state of bodily health and the psyche have been indicated [for example, 1189, 1888, 2345, 2152, 1193, 1582, 665, 1335, 1220, 1194]. The importance of physical diseases in precipitating senile psychoses was also recently reconfirmed by Loeffler-Schnebli [1592; also see 1670]. Stone- cypher [2396, also see 2267] reported on post- operative psychoses in old age. Here we must also mention a few studies concerning changes in sleep due to age (lighter sleep, changes in the sleep rhythm, electroencephalographic findings, etc.) and their relationship to psychic disturb- ances [2043, 2044, 585, 183, 13, 2540, 292]. A study by Hirschmann and Klages [1170; also compare 1377 and 775] showed which posi- tion constitutional factors assumed within such a multidimensional diagnostic system. These authors discussed a series of psychic illnesses of old age from this viewpoint and analyzed the interaction between cyclothymic features of the disposition, schizothymic partial tendencies and sociological components as well as aspects of the life history. The hereditary factors which are related to the constitution were studied in par- ticularly great detail by Kallmann and his co- workers using the method of research on twins ll [1295, 1293, 837, 1289, 1291, 1245, 1292, 823, 1288, 1246, 1243, 1244; also see 2251, 1740, 537]. In his summarizing presentation, published in 1961, Kallmann stated that the role of the hereditary factors with respect to life ex- pectancy had been proved [also see 113, 1234, 1294, 586, 2071, 1036]. In addition to various genetic theories concerning age, he also discussed the significance of heredity in the case of Pick’s disease (lobar atrophy) and Alzheimer’s disease (presenile dementia) , arteriosclerosis, schizo- phrenia and manic-depressive psychoses. In the case of senile dementia, he theorized a dom- inant genetic factor of limited penetrance. In addition, Sjoegren and his colleagues [2336, 2331, 2333] also provided important research contributions concerning the inheritance of senile and particularly presenile maladies [also see pages 23, 24]. Inherited and acquired psychic characteristics contribute to the premorbid personality struc- ture, whose importance for the type and form of the psychic disturbances of old age has been given a prominent status by many authors over and over again [see 1625, 2138, 2394, 472, 2395, 2096]. In a comparative study between healthy patients and patients who first became decom- pensated in old age, Vispo [2562] demonstrated in the case of the latter that pronounced neu- rotic features were definitely present in their pre- morbid personality. One of the most interesting recent works on this theme may be the immense study of Cahn [491], who followed up the re- lationships between premorbid personality and psychic maladies of old age on 1000 hospital patients over 65 years of age, and also included the social circumstances, psychic traumas, etc., in his studies. He found clearly abnormal pre- morbid characteristics in about 25 percent of the men and about 20 percent of the women, and of these, he was able to distinguish three different types with varying sensitivities for cer- tain social or psychic stress situations. Biographical and psychogenic factors are being more and more clearly explained in terms of their effect on psychic disturbances of all kinds in old age, whether it be in the contrast- heightening force on the premorbid personality, or in connection with the situation of becoming and being old in itself. Busse et al. [472] con- ducted a lengthy series of studies and primarily found preexistent neurotic features as well as losses of self-esteem, whether caused by internal or external forces, to be responsible for a poor psychic adaptation in old age. The manner in ''12 which such preexisting neurotic tendencies can become virulent in the manifold frustration situations of old age is shown, for example, by Bergler [250], Linden [1556], Cameron [507], Smirnoff [2341], and Klages [1377]. In addition, Vischer [2559] described how a “nega- tive life balance” ‘can serve as the nutrient medium for psychic breakdown in old age. In a lecture collection edited by Zwingmann [274] concerning the psychology of life crises, the difficulties associated with the turning point of life and elevated age in a series of reference reports are discussed in great detail. According to Hoff [1174], disturbances which cause crises primarily operate in these three central and es- sential divisions: place of residence, activity, and intimate relationships [also see 65, 972, 66, 114, 1070, 2225, 2028, 390, 1226, 2364, 1731, 993, 517, 1695, 315, 2562, 1957; further literature is also indicated on page 13 ff.]. Finally, under the influence of Anglo-Saxon investigators the entire external environment has been implicated in the causal chain of psychic disturbances of old age. Thus, socio- logical viewpoints also play an important part in the recent summarizing presentations on the psychopathology of age [see 461, 1310, 1171, 2663] and have been clearly expressed in many additional surveys or individual reports [such as 2191, 1021, 559, 2314, 1053, 2138, 507, 1624, 427, 1611, 2013, 2240, 2017, 2296, 1335, 1227, 869, 2743, 1786, 704, 1996, 147, 1589, 1507, 748, 1431]. Malamud [1625, 1626] was primarily able to demonstrate their significance in the case of involution psychoses, when they were coupled with an unfavorable personality struc- ture; and Sjoegren [2331] believed that for his group of “Insufficient praesenilis’ (plus reactive states with hypochondriac, dysphoric or sensitive tinges), familial conflicts, the death of close relatives, job difficulties, and somatic ill- nesses were important in 90 percent of the cases [also see 2172]. Likewise, Post [2017] confirmed the effect of social factors, primarily in the case of functional psychic disturbances of old age, but on the other hand he also showed that, as in the case of senile dementia, these factors were far from playing the role which is sometimes attributed to them. It is even true that individuals with senile dementia had more numerous and better social contacts available to them than a control group which led relatively isolated lives, but remained healthy! The progress and prognosis of psychic dis- GERONTO-PSYCHIATRIC LITERATURE eases of old age were previously interpreted pessimistically in general, with emphasis on the unfavorable and protractedly worsening evolu- tionary tendencies. According to Kidd [1365], the prognosis for elderly people is much more favorable today than previously, and he believes that the progress in dealing with affective dis- turbances is responsible. Kay et al. [1330] came to the conclusion, after studying the progress of 229 patients, that the following points should be evaluated as prognostically unfavorable: male sex; existence of organic disturbances of the central nervous system; absence of affec- tive, paranoid, or neurotic defense reactions; social isolation; absence of earlier psychic decompensations followed by remission [also see 1328]. In the case of the involutional psy- choses studied by Malamud et al. [1625], the age, the intellectual level, the sexual and family adaptation, the time which has passed between the change of life and the appearance of the psychosis, and most important of all, the pre- morbid personality are considered to be the most significant factors for prognostic purposes. A subsequent catamnestic study of the same material also showed the decisive importance of social milieu in which the patient found him- self following release from the hospital [1626}. According to Lhoas and C. Müller [1546], out of 203 individuals over 65 years of age hos- pitalized during a period of one year, primarily the patients with old-age depressions and acute delusional or confused states could be released from the hospital after a relatively brief stay. Roth [2145; also see 1336] studied 450 patients and determined clear differences between the progress of affective psychoses, paraphrenias, and states of confusion on the one hand, and senile and arteriosclerotic psychoses on the other hand. He suggested a corresponding new classi- fication of the psychoses of old age [also see 2009, 2216, 1180, 620, 1160, 1331, 2435, 2612, 1579, 2021, 2399, 1673]. The entire question of the classification of psychic disturbances of old age, which is ex- ceedingly complex because of the interweaving of a unique multiplicity of etiologic factors and an almost equally huge variety of mani- festations, was also discussed in great detail in 1954 and 1956 by Sjoegren [2331, 2333], in 1960 by Ruffin [2172], in 1962 by Bronisch [418], and in 1963 by Janzarik [1241]. The two last-named authors depended primarily on the classification scheme of K. Schneider, whereas Sjoegren [2333] suggested ''IN THE POSTWAR PERIOD a new classification scheme based on the analysis of 1000 cases which along general lines includes the subdivisions into “Insufficientia praesenilis, Atrophia cerebri, Insania senilis, Insania cum arteriosclerosi cerebri, Insania endogenica, and Insania praesenilis symptomatica” [also see 2155, 2145, 2565, 1927, 273, 770]. In addition, questions of classification have been included in many publications, frequency dedicated to more general problems of the psychopathology of age [such as 1339, 2175, 2584, 2395, 2014, 1896, 1229, 123]. If in the following we divide our material along general lines into the groups of pre- dominantly psychogenic, endogenous, and or- ganic as well as constitutional and congenital psychic disturbances, this is not supposed to represent a new attempt at classification by any stretch of the imagination, but is merely supposed to make possible a certain rough orientation to the material which is found in the literature. The fact that sharp borderlines exist even less in old age than otherwise, and also that many types of omissions and other types of inaccuracies are inherent in the subject itself, probably does not need to be further emphasized. II. Predominantly Psychogenic Psychic Disturbances General. A clear grouping and representation of the literature which falls within the range of psychic old age disturbances presents con- siderable difficulties, since massive confusion concerning terminology reigns in this domain. Designations such as affective, psychoreactive, functional, neurotic, and even psychopathic disturbances have different meanings according to each author; they are often poorly de- lineated, and overlap each other without includ- ing each other. It is probably for this reason that the summarizing presentations of recent years have mostly coined new inclusive concepts such as the “‘insufficientia praesenilis” of Sjoegren [2332], the “minor maladjustment” of Goldfarb [995], the “psychoneurotics” of Kehrer [1342], or the “troubles psychiques mineurs” of Bourliere and Dedieu-Anglade [371, 368]. We do not even find unanimity concerning the rough question of the maximum or mini- mum frequency of these maladies. A few studies seem to show that the frequency of psychoreactive diseases drops off with increasing age [2293, 2498, 1142, 1744, 206]. On the other 13 hand, the precarious affective situation of the aging and the aged, and their increased suscepti- bility to many types of psychogenic disturbances have been repeatedly mentioned [see 250, 1132, 972, 114, 1070, 1556, 507, 2376, 425, 390, 2341, 2364, 476, 90, 827, 1389, 927, 993, 994, 1695, 192, 1277, 314, 1708]. In many cases, such discrepancies can be attributed, over and above diagnostic and conceptual differences, to differences in the selection of initial material: a decreasing frequency at elevated ages is usu- ally determined on the basis of hospitalization frequency in psychiatric clinics, whereas a sur- prising number of disturbances designated as neurotic or reactive can be found among the non-hospitalized “normals” or patients of poly- clinics. Busse [473, 474, 476] found 56 out of 222, Kral [1422] 91 out of 210, Roth and Kay [2154] 17 percent out of 297, Nielsen [1838] 5 out of 73 and Birren [305] 28 percent out of 47 elderly individuals who suffered from psychogenic affections of this type [also see 136]. In a summarizing report concerning the neuroses of later life, Cameron [507] followed up the biological-somatic, sociological, and per- sonality-specific formation conditions of affec- tive disturbances individually [also see 590, 827, 1731, 136]. Like other authors [such as 995, 27], he emphasized that the reaction of aged persons to many types of failure, uncertainty and dependency situations are not basically much different from those of younger people, even though these factors become evident in different ways [908] or are set off by different causes such as retirement, heavy losses, changes of residence, illness, operations, etc. [also see Klages 1378; as well as 2201, 2291, 2454, 2152, 1573, 1287, 1259, 2470, 321, 2398, 517, 673, 940, 468, 905]. The symptomatology of psychogenic disturb- ances of old age is likewise largely unspecific, except for the fact that depressive and hypo- chondriac pictures are particularly prominent [2379, 467, 2122]. We are becoming increasingly aware of the fact that decompensation phenomena of old age, which at first appear to be of purely organic origin, are often primarily determined by emotional factors and therefore may be reversible [1612, 118, 1330, 266, 1674, 1852, 572, 2477]. Williams and Jaco [2666] gave an over- all view concerning the question of such “func- tional” psychoses, whose frequency is often underestimated. They primarily incriminated ''14 the effect of socio-environmental factors. S. Müller [1800] was once more able to demon- strate the important role of the premorbid personality structure, as well as the possible significance of psychic traumas which were experienced earlier, in 30 cases of this type [also see 2562]. Del Carlo and Giannini [518] studied 1,279 affective psychoses of old age and came to the conclusion on the basis of this study that quite common situations of doubt and loss of higher existential values played a decisive role in precipitating such psychoses. In the area of neuroses and psychoreactive disturbances, which often cannot be clearly distinguished from each other, according to Clow and Allen [590], who spoke of a “diffuse neurotic reaction” in old age, “pure” forms are quite rare. Far more important are mixed conditions, such as those in the cases of Kral [1422], where neurasthenic mixed forms clearly stood in the foreground, with pictures of con- tinuous depression with weakness, fatigability, irritability, insomnia, and many physical com- plaints which could not be objectively sub- stantiated. Sarteschi and Muratorio [2200] studied 170 elderly psychoneurotics, and in 127 cases they found neurasthenic syndromes, in 12 cases anxiety syndromes, in 13 cases hysteric syndromes, and in 9 cases marked anxiety or compulsive syndromes. Actual neuroses with splitting off of com- plexes approximately in the sense of Binder [287], whose psychoanalytic aspects will be dis- cussed later see pp. 8 ff. and 31 ff.), very rarely appear for the first time in old age [see 2060, for example]. It is far more likely that earlier neurotic conflicts, perhaps successfully sup- pressed and compensated for a long time, can be reactivated and exacerbated under the pe- culiar stresses of old age; or, if the neurotic affection had never completely disappeared, it can be gradually transformed [507]. Ernst [809], in particular, followed up such develop- ments very carefully in catamnestic investiga- tions. In those case histories in which, for ex- ample, a regression of acute and massive, perhaps hysteric neurotic symptoms took place in favor of more uniform, more strongly somatic and chronic pictures, and thus a devel- opment “from cradle to the grave” was evident, Ernst was able to develop prognostic rules similar to those for endogenous psychoses. For disclosing the evolution of neuroses in old age, in addition, his concept of the “residual neurotic state” [810] can be fruitful. This GERONTO-PSYCHIATRIC LITERATURE residual neurotic state appears to go along with such central symptoms as a reduction in per- sonal potential and reduction of motivation within the more extensive framework of a “gen- eral residual psychosyndrome.” Reda and Vella [2060] studied 1,327 hos- pitalized patients and 100 patients living in a home for the aged, who were over 65 years of age, with respect to the “senile psychoneuroses’ and found that authentic neuroses which ap- peared for the first time in old age were ex- tremely rare. However, they did find many neurotic disturbances which appeared for the first time and which were related symtomat- ically or prodromatically with involutional, senile and somatic illnesses. They also observed that preexistent neuroses often became ex- acerbated in old age, or that their symptoms changed. They found it necessary to distinguish between neuroses and a series of reactive dis- turbances of adaptation, which could be at- tributed, for example, to bodily diseases, family and social difficulties. Another huge work concerning the “involu- tional neuroses” we owe to Dedieu-Anglade [674], who undertook a comprehensive progress report on the related literature and also noted the primary importance of the premorbid per- sonality structure on the basis of 19 of his own cases with obsessive, phobic, and hysteric symp- toms. In 11 cases, preexistent neurotic features could be clearly demonstrated; the more care- fully the anamnesis was studied, the more evident it became that such disturbances for the most part extended far back into the past [also see 1575, 842]. In the case of compulsive illnesses, the pene- trating investigations of C. Miiller [1794, 1793, 1795, 1799] showed that in many patients— more than half of his 57 cases—old age could have a pacifying, soothing, even satisfying ef- fect, even if symptoms were externally evident, a phenomenon similar to that which frequently can be observed following leukotomy (pre- frontal lobotomy) [also see 392, as well as 2029, 1487, 33]. On the other hand, it is well known that under certain circumstances, which have been reported in the literature [1184, 2224; also ‚see 674], it is possible for compulsive manifes- tations to appear for the first time in old age, perhaps only episodically, with or without psycho-organic components. Similar developments have likewise been re- ported for neurotic anxiety symptoms: on one hand, the attacks of anxiety which followed a ''IN THE POSTWAR PERIOD phased pattern are often less frequent and less intense in old age [1862, 2643, 809]; on the other hand, the second half of life in general carries an increased readiness for anxiety [2030, 1556, 2668, 1699, 1678, 2036, 2142, 1349, 490, 232, 1398, 2675]. For the rest, the effect of old age on pre- existent neuroses is little known, which is not very remarkable considering the extensive dif- ferences in the spontaneous development of such affections [see, for example, 822, 2293, 2564, 2389, 250, 809, 636, 936, 2552, 550]. The relationship between psychosomatic disturbances and old age has been but little studied as far as we know, perhaps because such affections only infrequently appear for the first time in old age: out of 1,019 cases of Erfmann [807], 84 percent of the cases first became evident before the age of 40. Only 6 cases first appeared between the ages of 60 and 70. In a bird’s-eye view of psychosomatic diseases, which may have a particularly close relationship to elevated age, Mittelmann [1765] suggested as the essential factors: (a) reaction to the gen- eral slowing down and weakening process; (b) reaction to menopause in the case of women [also see 2139, 1854, 2712, 148], and less fre- quently to impotence among men; (c) disturb- ances in the cardiovascular system with hyper- tension and disturbances of the coronary or cerebral blood perfusion; (d) disturbances in the area of the auditory system [also see 388, 801, 423, 558, 1332, 651, 1109, 1381, 88, 2481, 1011, 1283, 1994, 1769, 461]. In almost every report concerning psychogenic compensation and defense mechanisms, feelings of frustration and losses of self-esteem in old age, the particular problem of sexuality is discussed, which Mikorey [1750], among others, treated in a penetrating study [also see 163, 1326, 2223, 1502, 507, 2377, 27, 1169]. However, confirmed documentations concerning actual sexual relationships at elevated ages are quite rare. In the study of Kinsey et al. [1371, 1372], which was based on the questioning of several thousand younger individuals, only 99 men and 56 women over 60 years of age were included. Naturally, these numbers permit no statistical evaluation, but nevertheless they do permit us to make the important general statement that the overall sexual activity drops off gradually with increasing age. Even in the change-of-life years, on the average no critical or sudden drop 15 in the sexual activity is observed. A few in- dividuals carry on regular sexual intercourse until they are quite elderly, but at 70 years, one- fourth of the men are impotent; and at 80 years, three-fourths. Parallel to the delayed re- sponsiveness of the female sexuality, the full sexual activity is maintained more frequently by women than by men into the fiftieth and six- tieth years—a determination which was not con- firmed by other authors, such as Stern [2377], who usually observed a pronounced decrease in female sexuality following the climacterium. Additional data are presented by a number of more recent studies, although because of their peculiar methods of selecting their test sub- jects, they can likewise not be considered as statistically representative. Destrem [717], for example, based his very interesting findings on observation of “more than 500 patients studied in private practice or in consultantship,” and he found, without giving precise figures from one age class to another, a continuous decrease in overall sexual activity and finally transforma- tion into a playful, rudimentary, more or less pathological type of activity. Newman et al. [1824] obtained the study material from 250 persons over 60 years of age, and found that of the single and widowed persons, only 7 percent had regular sexual relations at least one time per month, but 54 percent of the married people did. From the 75th year on, this author, too, detected a pronounced decrease in all sexual activity. Similar findings were presented by Finkle et al. on the basis of 101 patients [8587]. A relationship between sexual potency in old age and the extent of earlier sexual activities was confirmed by Freeman [890] on 74 test subjects, but denied by Braadbaart [389] on the basis of 147 test subjects [also see 237, 578, 1525, 2210, 2392, 233, 1541, 380, 2358, 101, 697, 1944, 1465, 799, 2163, 892, 2576]. Sexuality also plays an important role in the case of old-age delinquency, of which moral delinquents are known to make up the greater part. They are usually explained by means of an organic-involutional ego weakness, possibly by way of increased sexual fantasy activity and appetite [2670, 956, 2680, 1915]. In addition, aggressive feelings can also play a role as a reac- tion to repeated failures, according to Schulte [2245], who discussed the various aspects and the dynamics of this typical “criminality as the result of weakness” in a detailed study [2247] presented in 1960. Hirschmann [1169] noted a ''16 split between sexuality and eroticism as the basis of pedophilic acts of previously blameless old men. According to Wyrsch [2715], criminality in general decreases with age, as Pakesch [1915] recently confirmed. However, First [915] deter- mined an absolute and also a relative increase in the delinquency of old age on the basis of 112 cases from Zurich in the past few years. In addition to moral delinquency, which was ex- clusively encountered in men, other crimes varying from robbery through assault and bat- tery and even including murder and arson were found. Ponti [2004] designated sexual crimes, verbal aggression and the less serious forms of assault and battery as typical of old-age delinquency. In a statistical study involving many cases, Burger-Prinz and Lewrenz [440] subdivided the criminality of the elderly, which in contrast to late criminality appeared for the first time after sixty years of age, into crimes against property, crimes against life and sexual crimes. They noted the peculiar biological and socio- logical conditions of old age delinquency and presented for discussion the thought of a spe- cial criminal court for the elderly parallel with the criminal court for younger people [also see 1587, 1766, 2404, 18, 2724, 1457, 2160, 2727, 25, 2234, 1466, 2188, 2699, 1082]. Closely related to the peculiar psychic stress situation of old age, the question of suicide and suicide attempts must follow. The frequency of such incidents once more increases in ele- vated years, as Burgess [449], for example, demonstrated in a comparative table for a num- ber of countries [also see 1738, 715, 1143, 534, / 208, 1543, 653, 1142, 1816, 165, 1741, 2067, 1948, 911, 931]. This rule fails to apply only in China and Japan, a fact which probably is related to the especially privileged social status of the elderly in those countries [2182]. Accord- \ ing to Mayer-Gross et al. [cited from 461], in \ England, suicide among women is most fre- quent between 45 and 64, whereas among men, it reaches its peak after sixty-five. The serious- ness of the danger of suicide in old age is made clear by the fact that radical methods of sui- cide, such as hanging, shooting, and jumping into water are preferred [1738, 1373, 208, 165], and that successful attempts are relatively more frequent in old age than unsuccessful ones [2182]. Among the many other statistical correlations GERONTO-PSYCHIATRIC LITERATURE between suicide and social status, religious af- filiation, social milieu, etc. [see, for example, 1738, 208, 461, 449] it is of particular impor- tance that family suicide is also more frequent in old age [1740]. In addition, Gruhle [1056] showed that the psychoses play a much less sig- nificant role with respect to suicide than the social and psychic factors, and that among these a poor psychic adaptation to intense physi- cal pain is important [see also 1373]. Sainsbury [2182] likewise emphasized severe physical ill- nesses as a suicide motive and also suggested the importance of isolation, retirement and the generalized loss of social status and prestige. In 50 to 60 percent of the successful suicide attempts in old age, he found depressive dis- turbances in the anamnesis; 10 to 20 percent exhibited signs of senile dementia. Batchelor and Napier [208] found familial stress with psychic disturbances in 65 percent of 200 suicide attempts. More than half had been psychically ill earlier, and an abnormal premorbid per- sonality structure could be demonstrated in 75 percent. Social and economic forces seem to these authors to be of relatively limited signifi- cance. In a large statistical study of Gardner et al. [931; also 930], schizophrenics and neu- rotics attempted to end their lives in old age particularly frequently. However, relationships with particular situations of socio-psychological stress were also evident in this study [also see 207, 1884, 2059, 699, 222, 941, 2181, 1874, 2495, 1876, 2183, 639, 1875, 931]. The peculiar problem of old age in relation to alcoholism has been the subject of very few systematic studies, which probably reflects the fact that the abuse of alcohol appears far more frequently as a social problem among forty- year-olds [1728]. However, observations concerning the in- creased frequency of hospitalization for alco- holics over forty years of age are found in an earlier report of Gruhle [1055] concerning the effect of age on psychic disturbances. He also noted the psychogenic factors in alcoholism, the clinical manifestations and the decreased toler- ance for alcohol in old age. Simon and Neal [2320] reported an increased danger from alcohol in the second half of life: among 530 patients hospitalized for the first time after 60 years of age, they found 107, or 20 percent, in whom the abuse of alcohol and particularly “problem drinking” played an im- portant role. Frequently, it was a matter of ''IN THE POSTWAR PERIOD chronic drinkers for many years whose pre- dilection to drink became more severe in old age. In particular, women and certain earlier social drinkers actually became alcoholics in old age. On the other hand, old age can also have a positive affect on alcoholism, as Favre and de Meuron [828] determined. Although they only studied 25 patients in their sixties, catamnestic studies showed surprisingly good results of treat- ment—18 were completely abstinent two years later and only two had actually fallen back into their old habits. They related this fact to the beneficial effect of increasing anxiety concern- ing injury to their health, and death [also see 502, 529, 530, 1775, 2497, 1571, 1508, 1610, 1272, 1104, 1714, 1462, 726, 1267]. Ill. Predominantly Endogenous and Involutional Psychoses of Old Age General considerations. At this point, we wish to discuss the group of old-age psychoses, at whose center the nucleus group of endogenous and involutional psychoses is found. ‘These assume a relatively unstable middle ground between the predominantly organic and the pre- dominantly psychogenic affections, and perhaps exactly for this reason they represent one of the most complex areas of all geronto-psychiatry. Certain recent summarizing studies concern- ing this subject are available, such as those of Malamud et al. [1625, 1626], Hirschmann [1168], Lechler [1504], Sjoegren [2333], Davidoff [658], Bronisch [417], Hoff [1174], de Giacoma [950, 949; also see 1613, 925, 1992, 1999, 1315, 2665, 2365, 1683, 2666, 1926, 1551, 1582, 1410, 1897, 953, 1416, 2202, 2153, 164, 518, 2383, 1719, 167, 338, 1917]. The difficulties which are repeatedly discussed in these reports primarily fall within the area of etiology and thus of classification [also see page 12]. For this reason, numerous attempts at reclassification have been made recently [such as 658, 2333], in which distinction of a particu- lar group of involutional psychoses is sometimes advocated [see 1625, 2432], and sometimes proscribed [see 2428], or sometimes one of the many etiological factors is given particular preeminence. We would also like to mention the suggestion of Roth, Kay, Hopkins, Osterman et al., who had good reason for differentiating only between affective and senile-arterosclerotic old-age psychoses [1336, 2145, 1896]. Once more, the necessity for a multidimensional type 17 of thinking is emphasized by everyone con- cerned. Bronisch [417], for example, spoke of the somatic, reactive, and endogenous compo- nents as well as the predisposing readiness for illness, preexistent physical diseases, and addi- tional irritative and disease-potentiating noxae, which must be considered in every case. How differently such psychoses can be inter- preted by various investigators is demonstrated by a report of Swierczek [2428], who re- examined 164 cases diagnosed as involutional psychoses: he discredited about one-third of these diagnoses and considered the rest as doubt- ful. The fact that the actual predictive value of the commonly applied diagnostic differentia- tions is often limited is also supported by a factor-analysis study of Wittenborn and Bailey [2678]. In the symptomatology, according to Bronisch [417], a tendency toward the atypical is quite characteristic. However, along general lines, the two spheres of depressive manifestations on the one hand, and delusional-hallucinatory psy- choses on the other hand, can be differentiated. We would like to discuss these conditions separately now. The old-age depressions of various origins were recently considered more thoroughly by, among others, Kielholz [1368], Alsen and Eckmann [79, 81], Weitbrecht [2614], Stenback [2369], Leonhard and Briewig [1527] and Becker [221; also see 589, 1772, 1484, 2385, 997, 2644, 1072, 2156, 2311, 1851, 1598, 2122, 2072, 2384]. Ftiologically, although the interaction of a multiplicity of factors was emphasized, some- times more consideration was given to the reac- tive and social [2177, 2379, 1475, 1368, 2666, 321, 2398, 900, 2671, 1534, 2023], neurotic [507, 1259, 588, 883, 467], and existential as- pects [1085, 518]; and sometimes more to the specific climacteric [851, 721, 1369], involu- tional [1625, 2432, 1772, 1928, 2374, 1598, 212], endogenous [1527; also see above] or organic and general somatic [11, 1928, 953, 2207, 1605, 2441, 2536] aspects. The sociogenic and psychogenic “motivation groups” described as etiologic factors by Kiel- holz [1368] on the basis of 157 severe involu- tion depressions are most instructive. He par- ticularly noted isolation, inactivity, a feeling of not being needed and additional psychic traumas. In connection with the relationship of depressive syndromes to organic cerebral proc- esses, a report of Lechler [1504] must be men- ''18 tioned, which represents the viewpoint that the organic decomposition of old age can precipi- tate or reveal an endogenous psychosis. In addi- tion, the study of Weitbrecht [2613] concern- ing the relationship between cyclothymic syndromes and organic cerebral processes, and that of Alsen [79], who described eight possibilities for a coincidence between depres- sive symptomatology and organic cerebral decomposition, must be mentioned. According to Petrilowitsch [1965], the rare “solidifying retrogressive depression” in the sense of Medow [1713], represents a special form of cyclo- thymia, which may be modified by involutional processes [also see 1527]. As we must expect, considering the immense differences in the diagnostic classifications, the statements concerning the frequency of various forms of depressive illness differ markedly from each other. Alsen and Eckmann [81], for example, primarily diagnosed mixed forms be- tween the two poles of organic and endogenous disease, and out of 86 elderly depressive patients, they recognized only 3 as definitely endogenous; while Leonhard and Briewig [1527] determined the diagnosis of an endog- enous psychosis in a third of their 30 cases. However, it has generally been determined that all types of depressive states constitute the numerically most important group of non- organic old-age psychoses [see, for example, 1625, 1504, 2333, 2428, 953]. The unique tint given to depressive states by old age was particularly studied by Zeh [2734], who analyzed the age-related differences in the severity and duration of endogenous depressive phases, in addition to the frequent interference manifestations with organic decomposition symptoms, and noted a tendency towards the atypical, toward monotonic depression, toward anxiety, excitement and paranoid changes in elevated years. In addition, this author was also concerned with the manifestation picture of mania which is characteristic of old age. In comparison to the “pure and complete picture” of middle age, mania is characterized during the involutional period by a tendency toward rest- lessness, exultation and moodiness; and in old age by rigidity, vacancy and increasing organic features [2722]. The report of Becker [221] turned the question around a bit, and particu- larly emphasized the frequent agitation and a purportedly organic dysphoria, possible chang- ing to a “solidifying involutional depression” in the depressive symptomatology of old age. He GERONTO-PSYCHIATRIC LITERATURE also brought out the importance of altered social and cultural factors as well as the addi- tional affect of senile character changes and the increased anxiety concerning illness and death. Alarcon [43] was particularly concerned with the symptoms of hypochondria, which he found in about two-thirds of 152 cases of old-age depressions [also see 883, 1519]. According to Cameron et al. [508], the course and prognosis of involutional depressions are the more favorable, the more similar the mani- festation picture is to the classical endogenous depression, the better the social contacts which are available to the patient, and the less any earlier disturbances of objective relationships are still active. In a catamnestic investigation of Post [2021], in which he was able to follow 61 elderly depressive patients over a period of eight years, 18 percent remained continuously ill and showed a marked decrease in social com- petence, while the rest more or less recovered or were at least able to maintain their social rela- tionships. As a whole, Post did not receive the impression that the course of depression in old age was substantially different from that in younger years. Many psychodynamic investigations have also been concerned with depressions of old age. For example, Schilder [2223] described depres- sive projection and introjection mechanisms. According to Gillespie [962], these mechanisms primarily serve as defenses against the anxiety concerning death. Fessler [851] attempted to interpret climacteric depression psychoanalyt- ically as regression to the phallus-wish of early childhood; while Stern et al. [2381], in observ- ing reactions to grief, saw the minimum of ex- pression, the frequent lack of guilt feelings, the tendency to somatization and isolation, the idealization of the lost object and the projec- tion of aggressiveness to substitute objects as defense and compensation mechanisms against the loss which was suffered [also see 1755, 321). The problem of delusional and hallucinatory psychoses of old age primarily revolves around the endogenous-schizophrenic picture, and here we must distinguish between psychogenic affec- tions on one hand and organic affections on the other, as well as paranoid pictures and depres- sions [see 863, for example]; and again, ac- cording to some authors, a paranoid or hal- lucinatory, true involutional psychosis [for example 1625, 2061, 925, 658]. Thus, in prin- ciple, we encounter the same etiological and classification problems as in the case of depres- ''IN THE POSTWAR PERIOD sion and the overall psychoses of old age. Two aspects must be considered among the problems of old-age schizophrenias: first, the question of late schizophrenias which first appear in old age; and second, the question of the specific influence of old age on preexisting schizophrenic illnesses. The special problem of late schizophrenia was the particular concern of M. Bleuler [326], who devoted a study to this affection in 1943, which has since become a classic; and in more recent times, Knoll [1392], Janzarik [1240], Hirschmann and Klages [1170], Kay and Roth [1333, 1334] among others [also see 1629, 1481, 821, 500, 1796, 860, 278, 189, 129, 913]. Knoll [1392] became convinced of the im- portance of genealogical family relationships during the study of 114 delusional psychoses in the second half of life, for which he most frequently suggested the diagnosis of late schizophrenia. He also frequently found a cyclic element in the constitution and sympto- matology of his test subjects, and he ascribed to its effect the late appearance of the schizo- phrenic psychosis. Similar findings were also brought out by Hirschmann and Klages [1170] as well as Janzarik [1240], who once more analyzed the questions of differential diagnosis, premorbid personality, and the potentiating psychic tendencies on the basis of 50 late schizophrenias [also see 189]. Janzarik inter- preted a clear predominance of acute delu- sional, paranoid-hallucinative, and purely hallucinative pictures in contrast to chronically delusional and catathymic syndromes in elevated age, as the typical evolutionary direction from delusion to hallucinations [also see 44]. In studying the social forces, premorbid personalities and hereditary relationships of 99 patients who became ill with paranoid-hallu- cinative disturbances in the second half of life, Kay and Roth applied the concept of late paraphrenia—a form of the illness with par- ticularly well preserved affective and intellec- tual personality structure—which they con- sidered to be typical for old-age schizophrenia. However, other authors [such as Fish 863, 869] were doubtful about the usefulness of the paraphrenia concept [also see 1841]. The influence of old age on preexisting schizophrenia forms the main subject of a monograph by C. Müller [176; also see 1798], published in 1959. In the introductory literature survey, he mentioned the earlier report of this theme by Riemer [2198]. Riemer reported that 19 out of 100 elderly schizophrenics, he found no actual cases of psycho-organic disturbance, and thus he suggested a _ protective effect of schizophrenia with respect to senile dementia. Bychowsky [489] treated psychodynamic ques- tions and differentiated a group unchanged in old age, a group with slight organic damage, and a group changed in the syntonic sense. Deshaies et al. [716] made some particularly interesting observations on the healing processes beginning with the material from 530 institutional pa- tients. Müller also mentioned the very basic studies of Barucii [198; also see 199], who studied 80 schizophrenics over 70 years of age and often found a tendency toward stabiliza- tion and resocialization, but occasionally a new formation of symptoms, and also found clear psycho-organic decomposition symptoms in 20 percent, which argues against a decreased susceptibility of schizophrenics for — senile dementia [also see 1055, 2733, 1970, 1139]. Here we would like to mention a study by Hanfmann [1100], who studied 46 chronic, hospitalized mentally ill patients mostly between 40 and 60 years of age (two-thirds were schizophrenics) in relation to their subjective complaints. He found 52 percent to be satisfied and accommodated to their condition; 13 per- cent resigned but not satisfied; and 35 percent suffered greatly from their condition, which may frequently be related to the social condi- tions of institutional life. Also, among 25 elderly inmates of a home for the aged, who were previously schizophrenic, Wenger [2663] followed up their cases and found quite mild symptoms in about half of the cases. Most of the test subjects led a life which differed but little from that of a normal comparison group, which likewise seemed to support the idea of a healing action of old age on schizophrenia, although in a favorable milieu. C. Müller [1796] himself observed, in the case of 101 schizophrenics who had been hospitalized an average of 25 years, that old age did not simply represent a final condition, but exhibited its own dynamics. These dynamics can lead to an impairment of status in certain patients, particularly late schizophrenics, by way of pronounced regressive tendencies, encapsulation and delusional development; but in more than half, it can lead to a general attenuation and syntonization; and by way of tranquil resigna- tion and accommodation, it leads at least to a social improvement. Entirely in opposition to Riemer [2198], psycho-organic decomposition ''20 symptoms could frequently be discovered, which affected the overall state favorably as often as unfavorably. At 10-20 percent, senile dementia in the group supposedly was as frequent as in the average population. Somewhat similar observations were made by Wachsmuth [2570], although in a substantially less detailed study, who confirmed the fre- quently mollifying effect of old age on the basis of 100 chronic schizophrenics; for about 60 percent, the psychotic symptoms which still existed became increasingly bearable or in- significant, while about 96 percent were capable of performing supervised work, even though some loss of productivity was evident in a cer- tain percentage. The determinations of Gamna et al. [924] were somewhat less favorable. These authors observed, in the case of 119 chronic schizophrenic women over 70 years of age, that there was indeed a remission of the most strik- ing psychotic manifestations in old age. How- ever, in about one-fourth of the patients they did find a progressive intellectual decline as a result of the basic illness, and in another one- fourth as a result of senile evolution; whereas about one-third showed an almost completely unaltered clinical picture. Only in about 10 percent was the schizophrenic illness gradually resolved in old age. A series of more recent reports have pri- marily been dedicated to the special problem of delusion in old age, which is known to present particularly difficult questions in the areas of diagnosis and etiology. Whereas de- lusional affections of old age were mostly diagnosed as paranoid schizophrenics by Knoll in his publication which was already mentioned [1392] and by Kay and Roth [1333] as late paraphrenics, Fish [863] found, among 42 patients hospitalized within one year for para- noid conditions, 16 schizophrenias, 7 paranoid depressions, 16 organic psychoses, and 3 psychogenic reactions. Lange and Poppe [1480] in the case of 100 elderly women described a correlation between delusional illnesses and insufficient intelligence, general physical and neurological changes, mark- edly defective vision, as well as manifold social and family difficulties. Demonstrable hereditary factors were absent in 79 percent. In relation to the progress of chronic delu- sional affections of old age, Gregoretti and Pis- seri [1031] emphasized the very different evolutionary tendencies resulting from the pres- ence of systematic-paranoid, imaginative-fan- GERONTO-PSYCHIATRIC LITERATURE tastic (paraphrenic) or paranoid-schizophrenic delusion structures. Funding [913] frequently observed an unfavorable evolution in the case of 148 predominantly psychogenic psychoses characterized by catathymic delusions beyond the 50th year of life, although the evolution sull was better than that of schizophrenia or senile dementia [also see 2061, 7, 2194, 500, 2295, 251, 912, 35, 189, 1033, 2286, 663]. Other interesting special psychopathological problems were treated by, for example, Ehren- teil and Jenny [792] who said that the elderly schizophrenic’s perception of time was such that he often identified his old age with the begin- ning of the psychosis. A related phenomenon is represented probably by the fact reported by de Simone [2322] from our clinic, that chronic schizophrenics often telescope the decades- long hospitalization period in describing the course of their lives. In addition, a special theme was studied by de Perrot [1960], in that he compared the attitudes of the families toward their ill relatives for elderly chronic schizophrenics and victims of senile dementia. It was found that the affective relationships with the schizophrenics often remained inten- sive and complex for decades, with anxiety and defense, attempts to make up, and imagi- nary fixation of the patient in his personality before the onset of illness; whereas the families of senile dementia patients rapidly became in- different and even rejecting and hostile toward them [also see 859, 1572]. Further reports con- cerning chronic schizophrenia in old age are concerned with the progress of remissive forms of the disease [2517], with psychological test methods [1242, 1182, 1028, 1685, 974], with motor activity [791], and with questions of mortality [1969, 2250; also 1638]. IV. Predominantly Organic Disturbances General considerations. Probably nowhere is the modern change in geronto-psychiatric con- cepts so clearly discernible as in the area of psycho-organic affections of old age. The most outstanding common feature in the recent sum- marizing presentations, literature reviews, etc., such as those of Post and Stengel [2024], Roth [2144], Ross [2138], Sjoegren [2331], Griithal [1059], Hoff [1172; also see 1177, 1776], Rothschild [2157], Ferraro [848]. Delay and Brion [692; also see 1620, 1681, 1801, 1190, 959, 2144, 1653, 2723, 1010, 1781, 1090, 397, 725, 415, ''IN THE POSTWAR PERIOD 723, 1076, 531, 625, 1258, 1596, 346] is an ex- tensive difference of opinion and a common ap- proach to the problem. The most important result brought to the fore by Weitbrecht [2615], is that the concept of dementia, which Zutt [2746] also treated recently in a pene- trating analysis, can no longer be considered in the former sense as an irreparable defect. In addition to the purely organic decomposi- tion processes, whose symptomatology, etiology, and pathoplastics Zeh [2732] discussed in par- ticularly great detail, in recent times additional etiological factors have been made known from all sides, in order to explain the fact that ap- parently unchanging dementia states may be at least partially reversible. Among these factors, we must first name a pronounced, experimen- tally demonstrable, and unspecific_stress-sensi- tivity of organically injured patients [see 1108, 350, 1173, 1430, 1016, 1425, 2653]. Particularly in states of conlusion and other decompensation phenomena which were at first thought to be purely organic, certain socio- logical and psychogenic factors [see 2658, 1350, 1351, for example], results of character changes, ability to hear, sexuality, sleep [292], biochemical disturbances, and other forms of sensory isolation have also proved to be sig- nificant. Primarily, however, according to a re- port of Roth [2149], in the large majority of cases, underlying somatic affections play the principal pathogenic role [also see 1701, 2011, 2114, 1849, 249, 874, 630; 629, 1968, 500, 2585, 875, 1321, 1850, 2695; as well as 228, 1592, 510, 2259; 945]. On the other hand, the importance of hered- itary factors in organic diseases of old age has been heavily emphasized recently. Thus, for example, Constantinidis, Garrone and Ajuria- guerra [618] reported on 814 patients, in whose families 188 (usually homologous) secondary cases were found. A dominant hereditary trans- mission is assumed for vascular dementias, but for atrophic-degenerative illnesses, on the other hand, a recessive hereditary transmission is assumed. In this connection, we would also like to mention at this point a comprehensive report by Larssen et al. [1490] on senile dementia which appeared in 1963, and which we will mention in greater detail later [see page 24; also see Kallmann, 1290, 1288; as well as 637, 370, 1652]. With reference to diagnostics, the question of the differentiation of affective from organic psychoses of old age, which was particularly 21 surveyed by Ehrentheil [789] and which H. E. Kehrer [1344] also concerned himself with {also see 1336, 2145] has probably achieved even greater practical significance than the also much-discussed differential diagnosis of the various organic affections among each other (2732, 2157, 2333, 1418, 1596, 947]. It is fre- quently difficult to differentiate these from endogenous psychoses [2613, 2346; also see 1441]. Alsen [80] described, for example, “endoformic” manifestations, that is, those which are reminiscent of endogenous psychoses, in the case of impaired cerebral blood perfu- sion; and Jakob [1229] reported an “inter- mediate syndrome,” which began with the mani- festations of an endogenous psychosis and then developed further into a typical, chronic or- ganic disease condition [also see 1713, 1965]. In addition, certain chronic hallucinatory and delusional states, such as the “chronic tactile hallucinoses” of Bers and Conrad [269], whose nosological position is much debated, can also contribute to diagnostic difficulties [also see 871, as well as 45, 1533, 1032]. Concerning methods of investigation which to some extent attempt to provide differential- diagnostic conclusions, a large number of psy- chological test procedures are available [see 2055, 360, 358, 218, 1986, 1788, 754, 196, 1580, 1890, 752, 2661, 2662, 1081, 2581, 2433, 854, 2467, 2221, 1799, 244; also see 1020, 755, 144, 197, 1857]. A full inventory of such testing possibilities for organic brain damage was pre- sented by Pflugfelder [1971]. Special test methods for the memory function, in addition, were extensively represented in the monograph of Haase [1081] concerning the anamnestic psychosyndrome in middle age and old age. The conclusions of Tramer and Bentovim [2478] are interesting: they shied away from the use of complicated test batteries, since for practical purposes they obtained more accurate reflections of the actual possibilities of their patients by using objective clinical tests of understanding and adaptivity in elementary problems from the daily environment of the patients. A similar path was followed by Allison [77; see also 76], who described a large number of clinical study methods for organic patients in his book “The Senile Brain” [also see Klein and Mayer-Gross 1386; also 1284, 1222]. With respect to the electroencephalogram, constant correlations between clinical state and cerebral current curves [for example, 1688] do not seem to be confirmed, as Turton [2496], ''22 for example, demonstrated on 670 dementia patients [also see 2587]. In their 1964 survey on the present-day status of EEG research on the elderly, G. and J. Verdaux [2530] discussed the difficulty in defining the “normal EEG of the elderly,” noted a general tendency to slowing down of the basal rhythm and emphasized the importance of longitudinal section studies. The EEG is supposed to have a prognostic value pri- marily in the case of certain vascular disturb- ances, even though in individual cases no paral- lelism between clinical, anatomical, and EEG findings can be determined [also see 1687, 1594, 177, 1296, 2313, 2606, 1237, 2423, 1783, 1547, 2533, 1866, 2222, 1238, 688, 1660, 1689, 2420, 1239, 2309, 2672, 1865, 1390, 1278, 2306, 1867, 1864, 477, 1529, 1762, 2540, 751]. In the pneumoencephalogram, for 535 patients with psycho-organic permanent damage, which he subdivided into four groups of de- fects, in 77 percent of the overall number Huber [1198] determined pathological findings similar to those of cerebral atrophy [also see 1631, 567, 1717, 1026]. In addition, we also have biochemical [898, 760, 1782, 436, 933, 732, 609, 2537, 1930, 1929, 768, 1733, 700, 935, 616, 613, 46, 619, 1873, 1872, 340, 1671, 614, 615, 1062, 1935, 617, 1945, 2519, 1817, 1431, 1206], histological [1808, 1029, 873, 1416, 947, 175, 2718, 516, 2655] and physiopathological [793, 437] methods available, but we will not discuss them in greater detail at this point. For the presenile dementia cases in particular, in the newer summarizing reports [for example T. and H. Sjoegren 2336; also see 2329, 2330; Jervis 1255; Delay and Brion 692; see also 695, 693; Ferraro 849; Bernard et al. 261; as well as 412, 1749, 290, 1376, 817, 1856, 1068, 74, 954, 1408, 4, 2279, 2218] we once more see the much-debated problems of differential diag- nosis, hereditary relationships and the noso- logical-pathogenetic relationship of these affec- tions to the aging process and to senile dementia in the foreground of interest. Concerning the clinical manifestations of these affections, unanimity prevails only along general lines; whereas if we look deeper, once more various symptoms or symptom complexes are suggested as particularly typical. Thus Sjoegren et al. [2336], who analyzed 80 cases of presenile dementia statistically, clinically and partly histologically in a very careful monograph, found for the first stage of Alzheimer’s disease, in contrast to reports in the GERONTO-PSYCHIATRIC LITERATURE literature, that aspontaneous-apathic reactions were more frequent than hyperreactive mani- festations. Progressive dementia, amnestic aphasia, agraphia, apraxia and dysarthria could usually be demonstrated. Delay and Brion [692], who based their findings on a very meticulous clinical and histological investiga- tion of 30 cases of Alzheimer’s disease and 9 cases of Pick’s disease, designated the triad of dementia, spatial disorientation and aphaso- apraxo-agnostic syndrome, which can be com- plicated by disturbances of consciousness, epileptic attacks, extrapyramidal symptoms, time disorientation, and psychotic pictures, as char- acteristic for Alzheimer’s disease. Jervis [1225] emphasized in the first stage the intellectual breakdown; later the appearance of changes in motivation with euphoric or depressive syn- dromes, disturbances of speech, possibly hallu- cinations and a neurological symptomatology; while the third phase led to a deep dementia with almost complete destruction of speech and frequently muscle contractions [also see 255, 1821, 1521, 2056, 2220, 661, 1297, 9, 2274, 1653, 1981, 1609, 1069, 2700, 2003, 2090; as well as 826, 1749, 325]. In the case of Pick’s disease, which was the special concern of Sjoegren et al. [2336], Delay et al. [694, 692] and Escourolle [812; also see 850, 401, 1110, 1980, 291], Mallison [1630] brought to the foreground the frequency of progressive dullness and early symptoms of changes in nature of a psychopathic type and temporary blocking of semiautomatic activities. Sjoegren et al. [2336] likewise often observed “ethical defects” at the beginning, as well as apathy or moria; and later, amnesic or sensory aphasia, but almost never disturbances of muscle tone. For Delay and Brion [692, also see 694] the monotonic progressive dementia, the frontal symptoms with euphoria and apragatism, stereotyping, bulimia, and amnestic aphasia as well as the absence of disturbances in spatial orientation, psychotic states, epileptic attacks, and particularly an aphaso-apraxo- agnostic syndrome as the characteristic features of Pick’s disease. Jervis [1255], on the other hand, characterized this affection by a slow, progressive organic dementia with focal symp- toms, among which he included aphasia, apraxia and also in this case, apathic or excited states which will finally change into a deep dementia, possibly accompanied by paralyses, muscle con- tractions and epileptic attacks. Munch [1803], who has studied the breakdown of speech [also ''IN THE POSTWAR PERIOD see 1601, 1376] during this affection in detail, represented the viewpoint that we are not dealing with true aphasia, but with deeper disturbances in the speech interpretation func- tion and particularly its intentional aspects [also see 850, 401, 1110, 10, 1980, 1233, 291]. Psychotic manifestations were observed by Lechler and Eiden [1505] in both Pick’s and Alzheimer’s disease in a considerable percentage of the cases. In the former, lack of inhibitions is the most prominent; in the latter, disturb- ances in orientation. In the case of Pick’s dis- ease, Klages [1376] determined increased damage to the higher intellectual functions, particularly those of speech; but in the case of Alzheimer’s disease, more frequently states of motor excitation and neurological breakdowns. The lack of agreement and to a certain extent the open contradiction in these various clinical descriptions are obvious. Under such conditions, the differential diagnosis, particularly of the two principal presenile dementias [see 2370, 1657, 1932, 10, 692 among others] becomes extremely problematic, although new criteria for differentiation are continually being brought forward. All in all, the clinical differ- ences between Alzheimer’s disease and Pick’s disease seem slight and variable [261]. Even using the pneumoencephalograph, Sjoegren et al. [2336] often found a definite differentin- tion to be impossible [also see 691, 1014, 694, 1026], and finally, significant and constant differences can only be obtained histologically [also see 1807, 1044, 2068, 1029, 826, 1233, 692, 2003, 2218]. Also in relation to etiology and pathogenesis of the presenile dementias, many questions still remain open. However, the fact that heredity plays a certain part in every case is scarcely arguable today. In the case of Alzheimer’s disease, where Sjoegren et al. [2336] believe a multifactorial heritability to be probable, a great deal of information has been reported concerning the forms which occur repeatedly in families [see 813, 488, 140, 2642, 2729, 1497]; and for Pick’s disease, the authors named above suggest a dominant mode of inheritance, which is, however, subject to the influence of modify- ing genes [also see 1290, 220]. The latter is today considered primarily as an autonomous hereditary and degenerative systemic disease, which can be clearly differen- tiated from senile dementia [see 1627, 1255, 692, 261]. Substantially less clear, however, is the nosological position of Alzheimer’s disease 23 [see, for example, 2382, 2334]. On one hand, the observation of early forms even in twenty and thirty-year olds [336]—although it is de- bated [see 849]—which were also reported for Pick’s disease [1588, 1655], sometimes make the characterization of Alzheimer’s disease as a presenile dementia and even its entire connec- tion with the aging process seem questionable. On the other hand, however, interesting recent reports of Ajuriaguerra and his colleagues [for example 40, 42, 41, 38, 2085, 561; also see page 83], show that many later forms of senile dementia cannot be clearly differentiated clin- ically or histologically from Alzheimer’s disease. Arab [138] found Alzheimer’s disease to be even more frequent in old age than in the presenile period and presented the idea that the two affections do not belong to the same noso- logical unit, but that probably all senile dementias became “Alzheimerized” after a cer- tain time, if only the patients live long enough. Obviously without knowing of this report, Albert [47] likewise reported cases of this type and in publications which appeared re- cently [49, 50] arrived at basically the same conclusion [also see 1826, 87, 1807, 1163, 2700, 1223, 2448]. In addition to age and heredity, in the patho- genesis of the presenile dementias according to the multifactorial manner of thinking, the role of additional factors such as the premorbid personality [1505], and somatic or psychic traumas—whose influence, however, was con- sidered by Delay and Brion [692], among others, to be slight and uncertain—is increas- ingly discussed [see 797, 1255, 195, 261]. In addition, in recent years greater attention has been paid to the rare additional presenile dementias such as Jacob-Kreutzfeldt’s disease and Kraepelin’s disease. According to Bernard et al. [261] this has the dual purpose of ex- plaining their anatomical and clinical specific- ity and their relationship to the two other important presenile dementias [see 816, 39, 1743, 347, 1255, 1656, 1228, 877, 26, 1812]. We will now proceed to discuss senile and arteriosclerotic dementia, which frequently overlap each other in their symptomatology and whose general problems are therefore often dis- cussed together in the literature [for example 243, 2144, 1495, 848, 948, 1448]. The differential diagnosis between these two affections is often difficult in individual cases. Among the general features, Hoff [1172] enumerates the influence of hereditary factors, the possibility for release ''24 of endogenous reaction types, the greater fre- quency of delirious states of confusion in cases of basal localization, the influence of the pre- morbid personality, the biography, the actual environmental situation, and peculiar organic or psychic ancillary factors. Rothschild [2157], on the other hand, named the principal differ- ence between this disease and senile dementia as the much more noticeable beginning of ar- teriosclerosis with headaches and _ confusion, greater variability of memory disturbances, affective explosions, possibly apoplectiform and epileptiform phenomena, and heart and kidney disturbances falso see 1652]. Among the more recent publications which are particularly concerned with senile dementia [for example 867, 1188, 1133, 1030, 1977, 178, 245, 246, 1403], we must especially mention an extremely meticulous and copious study of Larsson, Sjoegren, and Jacobson [1490], in which a multitude of clinical, sociological and genealogical data were assembled and analyzed from 377 patients. From the many individual results, we would like to mention only that the risk of morbidity, which amounts to 9.12 per- cent at 65 years and 3.8 percent at 85 years, interestingly enough is not significantly affected by social factors such as martial status or the loss of close relatives, and that also the im- portance of hereditary factors can be demon- strated and a mode of inheritance which is in principle dominant can be concluded; and fi- nally, that the absence of Alzheimer’s disease in families with senile dementia seems to exlude the possibility of a multifactorial heredity with a number of common genes for the two affec tions. Additional reports concerning senile dementia were devoted to the study of psychological and phenomenological [1890, 2660, 2661, 1891, 1892, 104, 843, 1081, 343], biographical [20]. social [825] and familial factors [859, 1960}. Another direction of research, which pri- marily proceeds from comparative clinical anatomy, is intensively concerned with decompo- sition processes in the sensorimotor and vegeta- tive regions. Ajuriaguerra and his colleagues [40, 42, 41, 38, 2085, 561; also see Pilleri 1981, 1982, 1983] discovered many informative re- lationships to phylogenesis and ontogenesis in the fact that the younger regions of the brain break down earlier, while older structures are simultaneously disinhibited. These studies, which were already mentioned earlier [see page 82] concerned, in addition to presenile GERONTO-PSYCHIATRIC LITERATURE dementia, primarily those late forms of senile dementia which could not be distinguished from the appearance of Alzheimer’s disease and therefore were designated by Ajuriaguerra et al., as “Alzheimerized” or by Albert [47] as “Alzheimer syndromes.” Recent studies concerning presbyophrenia as a special form of senile dementia are rare. A confirmation of the findings of Bostroem [355], according to whom this disease picture is closely related to a syntonic-sthenic premorbid personality structure, is universally lacking [2180]. Bessiere [275], who studied the entire question of presbyophrenia in detail in 1948, decided on an “organo-dynamic” explanation for this special syndrome, which he did not consider as constituting a disease. Hughes [1202] discussed, without presenting new re- sults, the symptomatology and a few histological findings on the basis of three cases. Delay and Brion [692] were not able to find any definite anatomical-clinical correlations on the basis of 9 cases, but did present the opinion of particular damage in the area of the hip- pocampal-mamillary-cingulate system. The problem areas of vascular and arterio- sclerotic disturbances were presented in detail by Eros [811], Fattovich [824], Kehrer [1345], Borel et al. [343], Marks [1664], and others [see 940, 67, 623, 602, 612, 182, 1648, 6, 1761, 1997, 24, 2101, 265]. H. E. Kehrer’s book [1345] summarizing the issue demonstrates how many additional aspects touch upon the problem. However, the detailed interplay of the numer- ous factors involved has been poorly explained up the present. Thus, for example, Vallet et al. [2521] were not able to determine any uni- form correlations between psychopathological, medical, biochemical and anatomical findings in the case of 225 presenile men with probable cerebral-arteriosclerotic damage. Psychic dis- turbances which were present cannot be ascribed to a simultaneously existing arteriosclerosis without further thought, as Butler [482] demonstrated in a comparative study of patients without arteriosclerosis, who exhibited quite similar psychopathological symptoms. According to a report of Borel et al. [342], social situa- tion, previous diseases and probably intoxica- tions (alcohol) played no role. The factors which were found to be important in a causal or a precipitating sense were affective traumas, heredity, and hypertension. The relationships between blood pressure and arteriosclerosis formed the substance of a ''IN THE POSTWAR PERIOD number of special studies [1440, 185, 2572, 1950, 1043, 1146, 166, 1883, 1364], whose con- clusions vary widely. According to Rothschild [2157], for example, arterial hypertension is only a little more frequent in cases of cerebral arteriosclerosis than in senile dementia and therefore cannot serve to differentiate the two affections. Additional reports concerning arteriosclerosis deal with the clinical manifestations [2736, 67, 1779, 866, 10, 1693, 2531, 612, 1645], the un- favorable influence of an unstable premorbid personality [2158; also see 167], the disintegra- tion of the personality structure [1751], psy- chosomatic aspects [651], epidemiological questions [2198, 1459], and psychological in- vestigations [1154, 1182, 1618, 1086]. Delay et al. [696], using suitable tests, found a latent aphasia much more frequently in cases of cere- bral sclerosis than in cases of senile dementia. This fact was able to be included in the dif- ferential diagnosis [also see 370]. We will also describe a series of additional organic brain disturbances in brief at this point, which to a certain extent belong more to the area of neurology and thus are but little men- tioned in the psychiatric literature. Concerning progressive paralysis, for exam- ple, a few statistical reports are primarily available, which are concerned among other things with the general abbreviation of life expectancy in syphilitics [2124, 2515, 2507, 1879, 790, 116], with a relative decrease in the mortality from paralysis as a result of modern treatment methods [1636] and with the fre- quency of these illnesses in the average popula- tion. Denker and Nielsen [613], for example, using teleological methods, found a frequency for these illnesses among the 65- and 75-year-old inhabitants of Bornholm of 1.7 to 1.9 percent [also see 1640]. The eventual fate of 299 paralytics treated with malaria between 1925 and 1936 was studied by Taddei and Cossio [2431], while Dattner et al. [655] in their running study on 69 patients primarily pursued the connections between treatment and CSF findings [also see 1429, 1157, 34, 224]. A number of reports concerning Parkinson’s disease were predominantly dedicated to psycho- logical, psycho-social or therapeutic questions, with the exception of the reports of Doshay [758, 756, 757], but seldom to specific problems of old age [see 601, 2257, 1814, 728, 129, 545, 2102, 910, 1161, 730, 1162, 1102, 1967]. 25 The relationships between brain trauma and elevated age were analyzed by K. Walter [2577] on the basis of 586 cases of concussion in patients over fifty. With increasing age, he observed a prolongation of clouded conscious- ness with simultaneous abbreviations of coma duration and a general leveling off of the entire symptomatology [also see 1958, 4, 2162]. Por- tius [2007] discussed the possibility that brain injury at elevated ages could lead to premature phenomena of aging. On the question of brain tumor, Walter- Buel [2580] described a clear increase in organic breakdown manifestations in cases of neoplasms in old age after studying the material of 600 cases. This agrees with the conception of Bleuler, according to which the aged brain, in contrast to the younger one, is supposed to react to a cerebral process primarily with dementia symptoms [also see 1207]. The diagnostics of brain tumors in old age were discussed by Laux among others [1498; also 1597, 11, 416, 4, 779, 765, 1463, 2482, 2275]. In addition, it is well known that brain tumors are one of the possible causes for epilepsy in old age, which has obviously been treated in the past almost exclusively from the viewpoint of so-called late epilepsy, which only appears after the change of life [see, for ex- ample, 1732, 256, 2647, 2199, 2529, 1442, 1, 1837, 2258, 2232, 2482, 1463]. The etiology, manifes- tation form and course were primarily studied. According to a summarizing report by Richard- son [2086], grand mal dominates the symptoma- tology; the frequency of attack decreases with increasing age; and etiologically, processes which require space, degenerative-atrophic and most of all vascular-cerebral processes play a prin- cipal role. Vascular changes in the area of Ammon’s formation are also supposed to have a great significance [1836, 1837]. Among the psychopathological symptoms, according to Niedermeyer [1836] the overall slowing down was the most frequent [also see 5]. In a recently published catamnestic report on 80 patients with attacks which appeared for the first time after the fiftieth year of life, Woodcock and Cosgrowe [2701], found the causes to be brain tumors in 36 percent, atherosclerosis in 26 per- cent, miscellaneous etiologies in 13 percent and no recognizable cause in 26 percent. In contrast, very little is known concerning the relationship between age and the majority of preexisting epilepsies. Merlis et al. [1729] determined, on the basis of 250 patients, that ''26 an improvement in the general condition and abatement of attacks was customary in old age. A shortening of the life expectancy—American insurance companies, for example, count on a life expectancy reduced by twenty years on the average [1261]—is cast into doubt by these authors. Bostroem [356] only mentioned that the psychic process of aging is almost completely masked by the manifestations of the epileptic changes in nature, whereas Gruhle [1055] in- dicated a certain tendency toward placation and resocialization of severe epileptics in old age. V. Predominantly Congenital and Constitutional Psychic Disturbances It seems that amazingly little is known con- cerning the changes with aging in the last two groups of psychic affections, the psychopathies and oligophrenias, which we will now discuss. In the case of psychopathies [in the sense ot inborn absence of character (according to K. Schneider)] the rareness of geronto-psychiatric studies is probably related to a certain extent with the delineation of this disease concept, which differs from country to country and is often unclear. In the Anglo-Saxon literature, for example, it is mostly included among the neuroses. However, in the German literature also, it seems that aside from a few observations scattered throughout the literature [for exam- ple in 356, 1055, 2714, 978], there are very few systematic investigations concerning the old- age psychopaths. But there is the very instruc- tive report of Burger-Prinz [439] concerning the terminal state of 54 hyperthymic personalities, whose pathological features seem to have led after the fourth or fifth decade of life to rigidity, leveling and slackening off into vacuous mannerisms, a constancy of habits, to increasing egocentricity, “conflict accumulation” with the environment, isolation and social losses. In addition, if we go back to a report by Kahn [1280] from 1928, then we encounter the statement that many psychopaths gain a greater equilibrium and tranquility in old age, but that others become less adjusted and more troublesome as they see that their hopes for life have been completely dashed and that death is approaching. Kahn also described typical fates and outcomes of psychopaths, for example, saturation, false victories, resignation, or suicide, which as a whole are reminiscent of the residual states of neurotics as described by GERONTO-PSYCHIATRIC LITERATURE Ernst [810; see page 14]. At this point we must also mention the report of Scheid [2217] from the year 1933 concerning senile character devel- opment (exaggerations or leveling off of certain character features), although Scheid’s cases were not exclusively diagnosed as psychopathic. Ruffin [2172], on the other hand, thought more of a “resocialization through loss of vitality” than of the increase in intelligence and cleverness of explosive, fanatic or queru- lous psychopaths in old age. Instead of a certain social accommodation, the decrease in vitality brought about by age can also lead to chronic blunting of the intellect, simple-mindedness and idiocy without dementia manifestations. A certain tranquilization of psychopathic disturbances in advanced age is also supported by the decreased frequency of psychiatric hospitalization with increasing age, as reported by Ullman [2498], Helmlich [1142] and Reisinger [2067]. However, a recently published catamnestic report from our clinic by Menotti [1732]—a study which was concerned with the relationships between psychopathy and old age, taking into consideration a multitude of biographical, social, and somatic factors—states that the age of first hospitalization is generally surprisingly high (usually fourth to fifth dec- ade). In addition, this author found a decrease of the psychopathic symptomatology in 21 of 35 cases at advanced ages, whereas in 13 cases they persisted with only slight changes and were only clearly worsened in one case. The second predominantly congenital psychic affection is made up of the oligophrenias, the relationship of which to old age was handled in a summarizing report by Kaplan [1311]. While citing a few pertinent reports [including 1306, 1307, 2709, 2445, 1804, 2457], he discussed the decreased mean length of life for oligophrenics and mentioned the very probable, but difficult to prove, premature conclusion of intellectual development and untimely onset of organic breakdown. These patients also are not immune to the usual psychoses of old age, which can naturally lead to difficulties in the diagnostic differentiation with respect to psychotic states in breakdown victims with originally normal intelligence [also see 2327, 1975, 917, 656, 916). According to a study by Sabagh [2179], the hospital mortality of oligophrenics is extraor- dinarily high, particularly at the beginning of hospitalization; and in a manner similar to ''IN THE POSTWAR PERIOD general mortality, the resistance seems to be less, the lower the level of intelligence. Finally, the premature appearance of senile dementia in mongoloids has received a certain 27 amount of attention: according to Jelgersma [1252], out of 16 cases, 6 developed typical dementia symptoms between 36 and 53 years of age [also see 1256, 2534, 606, 607]. E. Therapy and Prophylaxis In the area of therapy, it has been generally determined that in contrast to the earlier resig- nation to psychic disturbances of old age, which was probably caused by the lopsided fixation on irreversible psycho-organic decomposition phe- nomena, the present idea is to make room for a much more active and optimistic attitude. Progress has been achieved particularly in the improved recognition and therapeutic utiliza- tion of the relationship between the general state of body and mind in old age, in psycho- pharmacology, in psycho- and socio-therapy, in psychohygiene and in the reorganization of the institutional foundations of psychiatric treat- ment for the elderly. I. Somatic Therapy Here, we would like to deal with questions of somatotherapy in old age only insofar as they have a direct relation to special psychiatric problems. We should first mention the re- peatedly emphasized importance of a good gen- eral medical treatment [see, for example, 698, 1831, 2472, 217, 1954, 737, 819, 1451, 2538, 2419, 186, 1818, 216, 1659, 1548, 1078, 2410, 236, 2187, 891, 1616, 2368, 2100]. Within this framework also belong the so-called “rejuvenation cures” [see 2254, 366, 319, 373, 1604, 2208], which aim at extensive improvement of the general bodily and psychic conditions. The most famous of these cures a few years ago, in addition to the Bogomolet’s serum and the fresh-cell therapy of Filatov, was the so-called “Romanian cure” using procaine or novocaine according to Aslan [151, 152, 158, 153, 154, 155, 156, 157, 159]. At first, many authors reported good and even spectacular successes [for example 317, 767, 1900, 1444]. According to Luth [1602], how- ever, the effect is generally limited to a certain regeneration of the skin and a general “euphori- zation.” Other authors later expressed negative opinions [for example 1489, 1987, 944, 736, 2691, 1756]. May et al. [1679] carried out a careful double-blind experiment on 107 patients and determined that procaine had _ practically no specific action in contrast to sodium chloride injections [also see 1299]. Long et al. [1581], following critical evaluation of the literature and their own double-blind studies on 72 pa- tients, in 1964 reached the viewpoint that after one year of treatment, a favorable effect on orientation, awareness, intellect, and body weight must be recognized [also see 1164, 1460, 268, 832, 1951, 1842, 2471, 2312, 2226, 1257, 1427, 1433, 1778, 632, 339, 430, 1785, 2350, 1208, 973, 1540, 2209, 1943, 2339, 2716]. In addition, positive general psycho-physical effects of various other substances such as vasodilators [1925], analeptics [532], anabolic hormones, and vitamins [235, 1839, 187, 977, 272, 1273, 1936] were reported [also see 372, 2360, 906, 504, 512, 951, 650, 1757, 505, 2108, 2738, 262, 452, 503, 1098]. Kleinsorge and Bauer [1387, 211] introduced various psychological test methods in order to demonstrate the difficulty of accurately eval- uating the effects of medicinal preparations on the psyche of old age. In the foreground of somatic therapy, we see the treatment of acute states of confusion, which are often based on silent cardiac, renal, or toxic infectious maladies [see 2166, 1017, 202, 47, 1576, 2691, 2673, 980]. A typical border area between somatic and psychiatric therapy is represented by the prob- lem of rehabilitation, or the reintroduction of physically or psychically feeble elderly patients into their family and society, which is more and more becoming the principal recommen- dation of geriatrics and geronto-psychiatric treatment, instead of merely calling these indi- viduals “nursing cases.” The best possible cure for bodily pains is the most pressing problem, but a similarly great role is also played by the combating of many feelings of guilt and in- sufficiency. In addition, particularly in old age, the acute problem of death which underlies all chronic diseases must be considered [see 2294, 2705, 2249]. The decisive factor in the success or failure of rehabilitation is often, as a comparative study of Tarpy et al. [2436] using intensive casework has shown, a precise ''28 knowledge of an attention to the entire social situation to which the returning patient will come back. Thus, the modern multifactorial theoretical viewpoints have never found a more practical applicability and usefuln ss than hure [see, for example, 627, 1622, 70, 1024, 2343, 750, 840, 2178, 1047, 838, 323, 2097, 1699, 1107, 1301, 657, 1518, 671, 868, 1819, 989, 1096, 1789, 889, 747, 1013, 1022, 703, 2337, 2510, 1269, 548, 2305, 402, 814, 2649, 2593, 2367, 1012, 1099, 566, 2052, 2269, 1539, 2545, 684, 1096, 975, 2040, 405, 2058]. However, we probably do not even need to mention here that the sharp dichotomy be- tween somatic and psychiatric therapy is even less possible in old age than in other periods. Il. Psychiatric Therapy Summarizing presentations on this theme were published in recent years by, among others, Bronisch [418], Goldfarb [990, 997, 999, 1000], Busse [459, 464], Ross [2140], Pichot et al. [1976], Cazzullo et al. [535; also see 2459, 2450, 1731, 1705, 1550, 1672, 121, 591, 1718, 2444, 784, 675, 1286, 560, 133, 60, 48]. With respect to the special area of psychiatric pharmacotherapy, which has undergone a powerful expansion through the introduction of many new psychotropic drugs, the present possibilities were described in summaries and the like by Linke [1567], Schmied [2227, 2228], Chatagnon et al. [554], Lifshitz et al. [1552], Barucci et al. [201; also see 2190, 882, 1224, 844, 1450, 1276, 36, 1319], whereas Cerletti [538] gave a bird’seye view concerning the phar- macodynamic foundations of this treatment [also see 231]. In the case of depressive conditions of anxiety and despondency [see 597, 2579, 2321, 1369, 997, 882, 786, 59, 2542, 2082], many re- ports are available concerning the helpful action of thymoleptics and particularly imipra- mine [for example 506, 571, 1868, 1232, 1520, 802, 652, 2434, 718, 2193, 1113, 909, 333, 1101, 1439]. However, motor excitability and per- plexity are not infrequently observed as side effects [2229, 2434, 1439]. Sometimes neurolep- tics are also used, alone or in combination with imipramine [1567]. According to Schmied et al. [2229] imipramine has also proved to be of value in certain somatic maladies such as, for example, severe states of grief, which react on the psyche by way of the hormonal system. Good results were also obtained many times in cases of old-age depression with monoamine GERONTO-PSYCHIATRIC LITERATURE oxidase inhibitors [see 882, 1106, 170, 2563, 2401, 2563; also see 2696, 533]. Occasionally, resulting from the viewpoint that depressive symptoms in the second half of life are primarily caused by disturbances to the cerebral blood perfusion, application of vasodilators is defended [786]. Along with medicines such as Ritalin and amphetamine [1231, 1449, 1276; also see 2260], they were also used against the very frequent general apathy and stodginess [1567; also see 1686, 564, 2310, 1356]. In the case of psychomotor confusion and exaltation, Linke [1567] recommended the combination of barbiturates with neuroleptics as the best method. Wolff [2691] was able to confirm a favorable effect of Metrazol (car- diazol) [also see 1313, 1131]. Recently, Luncidril has also been successfully applied [1276, 2518; also see 2340, 2280, 2238, 1071, 2078, 2239, 820]. In order to treat disturbances of sleep (com- pare 2045, 1736, 1700), combinations of bar- biturates with neuroleptics (according to Linke [1567] particularly with chlorpromazine, pro- methazine or promazine) have likewise proven to be of value, in addition to the use of valer- iana, bromide preparations, and hexabarbital. Junod [1276] reported particularly favorable results, in addition to those with chloral hy- drate, with a combination of Valium and Nito- man. The application of neuroleptics in old age was reported very shortly after their introduc- tion into general psychiatry [for example, 1105, 1195]; additional publications followed along with the discovery of new effective sub- stances [for example, 169, 1355, 1423, 644, 1225, 1097, 1275, 2682, 334, 563, 1752, 1566, 2421, 759, 1663]. The same was true for tranquilizers [see, for example, 1591, 2616, 818, 1260, 562, 2378]. In the case of elderly chronic schizophrenics, according to a report from Post [2020], month- long treatments with high doses of pheno- thiazine led to a clear decrease or even to a complete disappearance of inveterate delusions of persecutions. The existence of an additional depressive component proved to be prog- nostically favorable [also see 2696]. The treatment of arteriosclerotic disturbances of old age was particularly penetratingly dis- cussed in the book of Kehrer [1345] and re- cently that of Vallet [2518; also see 1984, 764, 1155, 1087, 2543, 524, 785, 1916, 525, 1805, 493]. Corresponding to the complexity of the pathogenesis, Kehrer in 1959 demanded an ''IN THE POSTWAR PERIOD exquisite multidimensional therapy which in- cluded prophylactic, dietetic, somatic, socio- therapeutic, and psychotherapeutic measures. He recommended medicinal treatment to regu- late sleep, combat hypertension or possible hypo- tension, improve the cerebral circulation; he also recommended sedation and the treatment of depressive syndromes [also see 2443, 1736, 21, 1925, 1060, 2176]. In the report from Vallet [2518] in 1964, the broad symtomatic applications of new psychological drugs such as the MAO inhibitors, thymoleptics and neuro- leptics, tranquilizers, and Luncidril are primar- ily described. In addition to vasodilation, dietetic, and roborant measures, a careful ob- servation and correction of metabolic disturb- ances and in cases of hemorrhage possibly a careful anticoagulant therapy are required [also see 2520]. Robinson, who also treated gen- eral methodological questions of experimental treatment with medicine in old age [2115], nevertheless saw that in comparison with a control group treated with placebos, no favor- able effects were observed from chlorpromazine, reserpine, or pentylenetetrazol on arterioscle- rotics [2113]. Delachaux and Schwed [687] were able to demonstrate a definite effect of imipramine in comparison to the placebo in depressive arteriosclerotics [also see 1138, 523, 1920, 1877, 2713]. The treatment of additional vascular dis- turbances, particularly apoplexy, which was treated in detail by Fazio et al. [829] or once more Kehrer [1345] belongs more to general geriatrics than specially to geronto-psychiatry and will therefore be mentioned only in passing here [see 1784, 872, 2134, 605, 1405, 1758, 1205, 2058]. Electroshock treatments have generally re- ceded into the background with the introduc- tion of psychoactive drugs. However, since Hoffet [1178, see also 1531] prefers them over medicinal therapy in cases of severe depression, the question of their possible applications in old age is still interesting to a certain extent. Most reports concerned with this method were written before the introduction of the thymo- leptics. Thus Prout et al. [2042] reported fol- lowing a detailed study of the literature con- cerning the electroshock treatment of 104 patients from 60 to 82 years of age that only four cases resulted in slight cardiovascular injuries and only one resulted in collapse. The possible dangers of this form of therapy in old age are highly exaggerated. Neither a hyper- 29 tension, an abnormal EKG, an angina pectoris, or a coronary thrombosis in the prehistory rep- resent contraindications for electroshock treat- ments carried out in the proper manner with muscle relaxants and short-term narcosis. Lassen- ius et al. [1494] also came to the viewpoint that there are almost no somatic contraindications for electroshock treatments in old age. K. Freud et al. [894] found no increase in the transitory psycho-organic breakdown phenomena following electroshock in older patients in contrast to younger ones. Also, Kehrer [1345], Eckmann [786] and Bronisch [418] still recommended elec- trotherapy in old age, even after introduction of the thymoleptics [also see 168, 839, 919, 2654, 1586, 864, 305, 920, 2432, 788, 1852]. However, it is remarkable that more recent summarizing re- ports concerning this therapy of psychic dis- turbances of old age, such as those of Linke [1567] or Junod [1276], do not mention electroshock treatments at all any more. In addition, psychotherapy has achieved in- creasing importance in old age. Its various methods were subdivided by Busse [466] into supportive, directive and introspective pro- cedures. They comprehend the entire spectrum from “counseling” [1353, 2051] and “com- municative psychotherapy” [Schulte 2248] through group psychotherapy with various orientations [such as 179, 1417, 509, 2192, 2690, 1203, 903, 1084] all the way to psychoanalysis [also see 587, 22, 2118, 32, 2131, 1166, 1711, 487, 2693, 2692]. Not only reactive [see 321, 2477] or neurotic [such as 1862, 507, 673, 467, 1204] disturbances of old age are treated, but also to an increasing extent predominantly organically caused syn- dromes, perplexed states, etc. [see 1701, 2641, 2691, 1083]. One of the principal representatives of the analytically oriented systematic psychotherapy in old age is Goldfarb, and in his reports [including 1008, 1007, 984, 985, 987, 988, 1002, 1003, 1006; also see 1050, 1051, 2693] he thought through the basic theorems of psychoanalysis from the viewpoint of the problems of old age. He emphasized, first, the dependent relation- ships of elderly patients, performed by the early parent-child relationships, and the fre- quently entreating character of their symptoms. The physician must intentionally assume the role of a parent figure which the patient presses on him, and which can sometimes change into the role of a scapegoat and sometimes to that of an all-powerful helper [995; also see ''30 468]. The goal of the treatment, which does not differ basically either in technique nor in psychodynamics from that administered in younger years, is a strengthening of self- reliance and self-respect, a diminution of internal stresses and anxiety, and thus a better overall adaptation. In the case of 100 patients, some of whom had suffered considerable organic damage, the results (consisting of one-third remission, one-third stabilization and one-third unsuccessful) corresponded completely with those for younger patients [986, also see 2693]. A study of Kahn et al. [1285], is interesting: he showed that even in old age intensive psy- chotherapy is predominantly used for patients from the higher social strata, thus constituting an injustice and a disadvantage to patients particularly in need of therapy. This circum- stance is usually explained by the tendency of the physician to provide psychotherapeutic treatment primarily to those patients who are as similar as possible to himself. Linden [1556, 1558] recommended as the principal psychotherapeutic measure the crea- tion of a suitable environment, for example in special hospital sections, in which the elderly patient can really feel that he is accepted. But- ler reported on the first encouraging results of this type from Chestnut Lodge, where a small division for the intensive, analytically oriented psychotherapy of elderly patients was created [480; for additional material concerning psy- choanalysis in old age, see pp. 17 ff.]. Many authors, such as Bitter [316] or Vetter [2539] consider the Jungian directions of psy- choanalysis or existential analysis to be more suitable than Freudian psychoanalysis, in order to apprehend correctly the psychic situation of aging and of being old. An example of Jungian analysis at an advanced age was published by Cutner [674]. Petrilowitsch [1966], in his monograph concerning psychotherapy in old age which appeared in 1964, turned away from the Freudian or Adlerian type of psychoanalysis, which is better suited to the impulsive or authority problems of youth, in favor of an existential logotherapeutic method according to Frankl and Buber, which is primarily concerned with the ethical questions of meaning and value which are so prominent in old age. Wendt [2632] described the special prob- lematics of the old-age situation and the psy- chotherapeutic statements which result from it as the turning point of a personality develop- ment which progresses by stages until old age is GERONTO-PSYCHIATRIC LITERATURE reached. Opitz [1887] indicated a series of neurotic misconceptions, which had their origin not in childhood disturbances, but in the situa- tion of the approaching’ end. Here it is appro- priate for psychotherapy to point out an “inner path,” but the choice of this path is finally left to the patient himself. In addition, environmental, occupational, and athletic therapy [see, among others, 965, 1556, 2686, 2740, 1181, 1147, 2185, 1144, 557, 2109, 1593, 2694, 2650, 1528, 2436, 1137, 2084] also belong in the framework of modern thera- peutic endeavors. The manner in which ergo- therapeutic, ludotherapeutic, and group thera- peutic procedures can be integrated into the total treatment of geronto-psychiatric patients was briefly reported from our clinic by Villa [2546, 2545]. Cosin et al. [631] were able to determine, even in senile patients whose minds were heavily destroyed, an effect of even the simplest occupational therapy activities, al- though this rarely lasted very long [also see Post, 2019]. Il. Hospital Organization and General Old-Age Nursing General considerations. As was already pre- sented in the section concerning general psychopathology, the fraction of elderly patients out of the total number hospitalized for psychiatric and general illnesses has con- stantly increased in the last decade. The mul- titude of nursing and organizational problems on the one hand, which this overload with elderly patients has presented in clinics which were not specially set up for them [see 2112, 1052, 2475, 1538, 1813, 621, 1485, 878, 808, 1400, 2352, 1183, 1486, 2610, 2353, 1058, 2688, 2586, 2583, 1199, 1696, 1488, 1845, 719, 2066, 1200, 2268, 861, 686, 1616, 577], and on the other hand the will and the possibility for intensive therapeutic activity, has led in the past ten to fifteen years to the general recognition that the entire organizational structure of psychiatric nursing of the elderly deserves basic reform. First of all, the outfitting of special divisions for diseases of the elderly in general and in psychiatric clinics has been raised from all sides, and also partly realized [see, for example, 2716, 2557, 654, 1077, 2737, 1384, 2116, 1492, 419, 2066, 1676, 1633, 690, 107, 145, 975, 1947]. A certain organizational assimilation of psy- chiatric treatments for the elderly into those for ''IN THE POSTWAR PERIOD physical diseases would also help to combat bias against psychiatric clinics [1972]. As Bernard et al. [259, 260] as well as Villa [2544] and others have made quite clear, clinical treatment centers of this type for the psychiatric care of the elderly should only be the last link in an entire chain of institutions, which would be completed by outpatient centers, day-care hospitals, homes and nursing help in the family [also see 2584, 1668, 932, 2676, 992, 1046, 735, 2737, 689, 122, 1995, 94, 1832, 1707, 1846, 438, 123, 83, 248, 1493, 1726, 667, 2184, 596, 686, 1616, 2400]. Only through a flexible system of this type, which in addition to clinic admission would also offer a sufficient number of other possibilities, could the burden on the hospitals be relieved and the ever more frequent unnecessary hospitalization be reduced to a minimum [676]. Hospitalization or admis- sion into a home represents a severe psychic trauma for the elderly patient and one which often has an undesirable effect; as long as it is possible, therefore, elderly persons should be permitted to remain among their families and their accustomed surroundings [see 1918, 241, 2516, 683, 1979, 1354, 2171]. A new solution in this connection was also suggested by the motto: “meals on wheels,” which would make it possi- ble for elderly patients living alone to remain in their houses if necessary by bringing their meals to their homes [134, 395]. As Codd [595] reported, among 873 patients in an English clinic, for example, who had sought clinical treatment within a period of one year, more favorable possibilities could be found for 28 percent. Half of these were taken care of at home, and it was found that the often unselfish cooperation of the family members could be obtained even today, regardless of certain prej- udices, if corresponding help from outside was offered. Reports of Kidd [1362, 1360, 1363; also see 762, 2237] provide orientation concerning the latest and very important practical problems of triage, which naturally follow from the availability of an entire system of psychiatric nursing possibilities in old age. A detailed view concerning the organization of old-age nursing in various European coun- tries and in the U.S.A. was presented by Kleemeier [1383], as well as Cath [527, 528; also see 1880, 2069, 2742, 1995, 2706, 2525, 108, 1720, 2511, 19]. Panse [1924], in his new book concerning psychiatric hospitals, described very conclusively the basic theorems which are to be 31 observed in the organization of various modern old-age nursing institutions. ine ways aud means by which the individual geriatric and geronto-psychiatric treatment centers can be planned and organized are dis- cussed, for example, by Bainbridge [173], who foresaw a geriatric hospital with 200,000 in- mates [also 481, 957, 2027, 109, 1226, 2545]. The experience up to this time with such in- stitutions, which can be gathered, for example, from the home for the aged at the municipal hospital at Basle, Switzerland [2557, 1274; also 1399], or more recently from the geronto- psychiatric division of the psychiatric clinic at Lausanne [see Villa 2544, 2546], as well as from the English Ministry of Health [see, for ex- ample 2165, 106, 769, 2039, 23; as well as 420, 2645, 1411, 341], were on the whole positive. Many elderly patients who would perhaps at an earlier time have been hospitalized until they died, were rehabilitated and returned to their families. Thus, for example, out of 204 elderly patients of Friedman and Bressler [903] with primarily affective disturbances, 139 were able to leave the hospital; 75 of them needed no further care by a physician. A few of the newly formed geronto- psychiatric divisions specialized primarily in specific areas such as intensive psychotherapy [481] or acutely and chronically confused patients [109, 862]. The formation of an actual “therapeutic society” with sufficient social contacts and close cooperation between physi- cians of various specialties, well instructed nursing personnel [see 677], and auxiliary per- sonnel is repeatedly named as the most im- portant prerequisite for a _ well-functioning geriatric and geronto-psychiatric treatment cen- ter [see, for example, 284, 1432, 2574, 2351, 2169, 1411, 1848, 2100, 903]. The extensive effect of the configuration of the entire hospital milieu and the health state of elderly patients is described, among others, by Panayotopoulos [1919; also see Wretmark 2708]. The obvious advantages of day hospitals, especially for elderly patients, as recently described by Shaw et al. [2285], Fine [856], McComb et al. [1697] were seen in the possi- bility that in this manner elderly patients could be cared for ergo-, physio-, psycho- and pharmacotherapeutically without its being necessary to tear them completely from their accustomed surroundings [also see 628, 2326, 2469, 1476, 2702, 855, 2544, 408]. The percentage of elderly people who live ''32 in homes for the aged is reported from varians countries as between 2 and 6 percent [2290, 1038, 2552, 2154]. Beske [274] counted on the necessity of providing homes and nursing in- stitutions for 5 percent of the population over 65 years of age. Studies concerning the physical and psychic health of inmates from different homes were made by Vettiger et al. [1541] and more recently by Stengel [2373], Goldfarb [996, 998, 1000, 104] and Jensen [1253; also see 970, 1949, 2127, 2582, 1420, 542, 1861, 2349]. The latter were able to show that a high per- centage of the inmates of homes suffered psychic and physical disturbances of various types. For this reason, even today an intensifica- tion of psychiatric care in these homes is neces- sary [1179, 921, 982, 981, 985, 2142, 2735, 1956, 568, 1792, 2323, 2326, 1544, 640, 2344]. To the extent of our knowledge, the most basic recent study which is also provided with a very comprehensive literature survey concern- ing European homes for the elderly is that of Beske [274]. From 575 of 605 inmates from nine homes in Kieler, he was able to obtain a multitude of important information concern- ing the reason for their living in a home and their life in the home. The most important conclusion includes the requirements of build- ing homes for the elderly in the midst of society and not at an inaccessible spot in the country, to provide them primarily with indi- vidual rooms or double rooms for married couples, to permit them to provide their own furniture, to outfit a capable nursing division for persons who become ill, and to keep the inhabitants busy for psychohygienic reasons, but not for utilitarian ones [also see 548, 2541, 17, 2554, 2371, 2603, 120, 1829, 946, 1828, 2573, 2109, 1593, 127, 95, 2064, 2505, 2203, 1853, 1412, 1747, 2121, 2476, 2568, 2299, 1348, 190, 128, 1303, 2126, 2342, 205, 2050, 1924]. As an additional link in the chain, we must mention the construction of special residences for the elderly, but this belongs more in the area of psychic hygiene, and thus is an excep- tion. IV. Psychic Hygiene General considerations. A large number of articles with general content have appeared in the past two decades on the question of psychic hygiene and prophylaxis for the elderly, but we believe that we should be permitted to avoid enumerating them exhaustively here. In GERONTO-PSYCHIATRIC LITERATURE German-language publications, these problems were particularly handled by Stransky [2402, 2403, 2407, 2409], Stoll [2393], Kielholz [1367, 1368], Vischer [2556], Stengel [2372], Panse [1921, 1923], Kehrer [1346; also see 172, 264, 852, 943, 1721, 1924]; in the French literature, by (among others) Répond [2073, 2074, 2075], Maréchal et al. [1654], Postel et al. [2027, 2026], Carmel et al. [519; also see 1858, 2630, 123]; in Italy, Bisio [313]; and in the Anglo American areas, by authors such as Donahue [739], Stieglitz [2390], Lewis (1545), Busse [460], Roth [2147], Tuckman [2487], Klee- meier [1383], Goldfarb [1001; also see 907, 1522, 1730, 1158, 1833, 2411, 2167, 1972, 2273, 2161, 92, 1478]. The requirements of psychohygiene are based on the fundamental affective necessities, the “basic needs” of elderly human beings, as they were formulated in recent years, such as by Newton [1825] in the words “somewhere to live, something to do, someone to care.” Vischer [2560] in the same sense enumerated as decisive factors the need for internal and external security, for love and the warmth of the nest, the feeling of being needed and of being taken seriously. He thus showed that these “basic needs” of the elderly hardly differ at all from those of younger people [also see 1499, 2605, 1121, 626, 1946, 870, 137, 608, 885, 682, 1563]. In this connection, we should also mention the findings of Kielholz [1368] concerning the social circumstances and facts which precipitate depression and must therefore be avoided (com- pare p. 17). Very important for the feeling of security as well as for the maintenance of sufficient social contact is the question of residence which has already been mentioned. Actual communities of the elderly, as they exist for example in the U.S.A. [1773, 2128] were disapproved of by Beske [274] in spite of favorable circumstances encountered in German communities in Switzer- land—due to the danger of one-sided contacts and isolation from society. Panse [1924] re- ported interesting solutions in Copenhagen, where as early as 1919 a “city of the elderly” existed and where recently special residences for the elderly have been constructed where residents can associate with the people from their old neighborhoods [also see 2006, 955, 1298]. An ideal which has been realized only in a rural setting, particularly in Switzerland, is represented by the farm family’s institution of a place for the elderly or “Stocklis,” which ''IN THE POSTWAR PERIOD happily permits the maintenance of close con- tacts with the younger generation and with the accustomed work and environment, as well as permitting the aged person to keep his distance if he wishes [2560]. Today, under urban con- ditions, the most suitable solution is considered to be [see 1545, 2438] for the grandparents not to live under one roof with their children or with other relatives, but to live close by [also see 2053, 714, 598, 1216, 2348, 2527, 1035, 1647, 150, 2120, 2504, 2635, 2667, 1483, 149, 72, 1617, 1468, 2524, 279, 2338, 2464, 2589, 565, 1840, 2135, 2281, 876, 2588, 280, 2523, 2590, 2186, 2704, 111, 2513, 573, 2083]. In addition, as has been mentioned many times earlier, the questions of free time and possible occupation in old age are essential (see also page 3). Ever more frequently, the suggestion is made of a “second career” follow- ing retirement, possibly including the corre- sponding schooling [see 576, 126, 125, 2197, 2235, 131, 1871; also 604, 429]. Stransky [2402] suggested that all the areas of executive creativity be reserved for younger and stronger men, but that the elderly should be permitted to participate in all consultative activities (for example, as adviser, teacher, expert, examiner, juror, supervisor, etc.). One activity which is practically ideal from all aspects, but which is not always possible, is naturally taking care of the grandchildren [1368]. Hobbies and other kinds of avocations are frequently discussed, but as Kielholz [1368], among others, showed, they are only useful if they are suitable for a slow hand and if they are of some use to the outside world. Particularly in the U.S.A., a great deal of attention is devoted to keeping the elderly busy with their own leisure time programs, organizations, clubs, community cen- ters, canteens, etc. [588; also see 1963, 1924, 1528]. Appropriate athletic activity [see, for example, 1406, 1989, 396] is considered to be good prophylaxis for the elderly up to very old age [also see 2035, 282, 1537, 1827, 2730, 1025, 2657, 1834, 633, 1607, 428, 132, 1664, 2046, 33 2722, 351, 1385, 1126, 2449, 2143, 1677, 2648, 1151, 2088, 2694, 720, 555, 1528]. However, not everyone is convinced that the greatest amount of activity possible for as long as possible is invariably beneficial. According to the “disengagement” theory, for example (see page 8), elderly people should be permitted to withdraw gradually from activity and from the external environment in the way which is most comfortable to them. Havighurst [1125], in hope of confirming either the activity or the disengagement theory, attempted to find objec- tive methods of measuring the degree of happi- ness in old age. However, even with different “rating scales” he did not succeed in drawing any definite conclusions. Therefore, he warned against generalization and presented for thought the opinion that activity or passivity in old age has favorable or unfavorable effects according to the individual personality structure and temperament [also see 174, 1820, 1127, 1492, 2148]. An important additional requirement of psychohygiene is the care and maintenance of as many varied and lively interests as possible. Since according to the determinations of psychologists, a higher level of education works against the process of aging, Pacaud [1902], for example, recommended as prophylaxis against old age a deeper and longer formal edu- cation and recommended periodic continuing education courses for manual workers, in order to promote their general education. In the same sense, particularly in the U.S.A., the importance of adult education is mentioned with increasing emphasis. As Donahue [743] showed on the basis of a practical example, such adult educa- tion can serve as an actual psycho-hygienic preparation for old age [also see 2459, 16, 1118, 815, 740, 742, 745, 744, 746, 2094, 353, 478, 1820, 581, 2204, 1316, 928]. Thus it is also evident here that the founda- tion for a happy twilight of life can never be laid early enough and that, as Vischer [2556] says, one is actually preparing his soul for old age during his entire life. F. Concluding Remarks In conclusion, if we attempt to glance over the literature which was referred to in a brief summary, our attention is caught first by gen- eral surprise, mentioned in almost every geronto-psychiatric publication, concerning the constant increase of the elderly population segment, and at the same time by an increasingly clear consciousness of the problematics gen- erated by this phenomenon. In addition to prog- ress in the knowledge concerning old-age psy- chology and a few special areas such as presenile and senile dementia, probably the most impor- ''34 tant result of recent research can be designated as the extensive refinement and differentiation of the diagnostics, the development of multi- dimensional thinking, and in particular the increasingly noteworthy attention paid on one hand to sociological, affective and psychological factors, and on the other hand to somatic factors. With the support of many recently- introduced, effective psychotropic drugs, a multitude of therapeutic possibilities for dis- ease conditions become available, which were previously ascribed to organic decomposition of old age and therefore were amost exclusively observed passively. An increasingly well delin- eated reform of the entire organizational struc- ture of psychiatric nursing for the elderly is the result of this growing therapeutic activity. The immense number of reports published in the postwar period is surprising and impres- sive. However, our overall glimpse also reveals the gaping holes which remain in our knowl- GERONTO-PSYCHIATRIC LITERATURE edge. These lacunae are probably most striking in the case of an entire series of pre-existing psychiatric affections, not specific to old age, such as neuroses and psychopathies, alcoholism, oligophrenia, and epilepsy, as well as various organic and post-traumatic psychic illnesses. Extremely little seems to be known concerning their progress in the second half of life, con- cerning the effect of old age on them and con- cerning their effect on old age. Only long-term longitudinal section studies, which are today recommended on all sides [see, for example, 2356, 115, 1437, 1262, 2646, 1584, 1263, 2626, 2022, 1886; and also concerning methodological questions of old-age research see 1675, 2550, 1407, 1191, 1776, 1117, 1583, 1308, 141, 1748, 409, 777, 1347, 2012, 1964, 400, 1165, 1599, 2212, 1658, 2063, 1775, 2319, 2744, 1985, 142, 2626, 1248, 1913, 1595, 352, 582] will succeed in creating increased clarity. ''-_ n wo > oO x 10 1 References Aaronson, B. S.: Age, intelligence, aphasia and the spiral after-effect in an epileptic population. J. clin. Psychol, 14 (1958), 18—21 Aaronson, B. S.: A dimension of personality change with aging. J. clin, Psychol. 16 (1960), 63—65 Aaronson, B. S.: Aging, personality change and psy- chiatric diagnosis. J. 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