The rapid development of neuroanatomical and neurophysiological studies has increased our understanding of the role of particular elements of the limbic system for the central nervous system functioning, including emotions. It is the more important that growing everyday life pressures lead more and more of ten to dysfunctions of the c.n.s., manifesting themselves in various emotional disorders. The paper presents an overview of current concepts on the structure and junction of the two main constituents of the limbic system: the hippocampus and the amygdaloid body.
In the terminal stage of Alzheimer's disease the average volume of the amygdaloid body is by about 56% smaller than that in control cases. The total number of neurons in the amygdaloid body amounts to about 4 million, while in patients with Alzheimer's disease it is decreased to about 1.2 million (by 70%). Even in the terminal stage of the disease degenerating processes in nerve cells are continuing – on the average 65% of neurons indicate neurofibrillary pathology, while in the control group only in about 2% of neurons neurofibrillary tangles are found. Due to both neuronal loss and marked neurofibrillary pathology in the terminal stage of the disease the total number of neurons showing no pathological alterations decreases to about 460 thousand. Such neurons are relatively the least numerous in the following structures: the cortical nucleus, the additional basal nucleus, and the transitory cortical-amygdaloid field.
Density and distribution of senile plaques, neurofibrillary tangles and neuronal loss in various sites within the hippocampal system were examined at autopsy in the brains of 10 patients with Alzheimer's disease and in 5 control brains. The presence of neurofibrillary changes was found mostly in layer II of mid-olfactory cortex and in CAI sector of the hippocampus, while the largest number of senile plaques was noted in deep layers of the mid-olfactory cortex and in the molecular layer of the dentate gyrus. Morphometric examination indicated the presence of pathological changes both in the structures of origin of the main hippocampal tracts as well as in those of their termination. However, neurofibrillary pathology turned out to predominate in sites of penetrating tracts departure, while in areas in which they terminate senile plaques prevailed. Observed pathological changes lead to a dramatic loss of nerve cells, most marked in the mid-olfactory cortex (56%) and in CAI sector (46%). Neuronal loss results in damage of main afferent tracts conveying information to the hippocampus from various parts of the central nervous system.
Due to heterogeneity of dementia, a condition affecting a significant portion of the elderly population, a multi-specialist diagnostic approach is often required. Elements of the diagnostic procedure most frequently employed by the neurologist are outlined by the author, who refers also to standards developed in this respect in other countries.
The paper presents results of neuropathological examination as well as clinical and neuropsychological features typical of dementia of the frontal type (DFT). It is emphasized that DFT is a separate form of the primary degenerative dementing disorder, and that it should be differentiated from the dementing process in Alzheimer's disease.
Both in Alzheimer's disease and in schizophrenia structural and functional changes in the frontal lobes are noted. They are manifested by an impairment of cognitive junctions associated with this cerebral region. The paper presents results of neuropsychological testing sensitive to the frontal lobe functioning in 30 patients with Alzheimer's disease and in 33 schizophrenics. The frontal lobe dysfunction was found to be more marked in patients with Alzheimer's disease than in those with schizophrenia. The intergroup differences were most pronounced in the Trail Making Test (Part B). Obtained neuropsychological data suggest also differentiation of the frontal lobe dysfunction in the two conditions.
The concept of pseudodementia remains ambiguous up to this day. Since 1952, when this term was introduced in British and American psychiatry, its meaning has broadened considerably. Initially the category included hysterical symptoms with complaints concerning cognitive disorders, and the Genser syndrome, while in later year's pseudodementia was defined as a concurrence depression and dementia. The clinical concept of depressive dementia has been recently more and more often used to denote the presence of concurrent symptoms of both these syndromes indicated by objective neuropsychological tests and psychopathological scales. Neuroimaging techniques have greatly contributed to the development of a more precise definition of this condition. Findings obtained by these methods suggest that anatomical changes may have a common localization in depression and dementia. Unfortunately, the two conditions still are often clinically undistinguishable. In view of a high prevalence of such syndromes it is recommended to use in antidepressive treatment medications that do not affect cognitive functions. Antidepressive treatment may help in about 20% of cases diagnosed as dementing disorder, and alleviate the caregivers' sense of hopelessness.
Autor dokonuje przeglądu wybranych zagadnień aktualnego stanu wiedzy na temat wzajemnych związków zespołów depresyjnych i choroby Alzheimera, z uwzględnieniem możliwych uwarunkowań etiopatogenetycznych.
Subjects in the study were 42 patients with depressive disorder without dementia and 32 patients with Alzheimer's disease and depression, alt aged over 59. The clinical pattern of depressive disorder was analyzed using the DSM-IV diagnostic criteria. Major depression symptoms were found in 71.4% of the patients without dementia and in 27.3% of those with Alzheimer's disease. The criteria for minor depressive disorder were met by 14.3% of patents without dementia, while dysthymic disorder was recognized in 9.5% of this subsample. In the group of Alzheimer patients with depression not meeting the criteria for a major depressive episode, the most frequent symptoms were: tearfulness (75%), helplessness (62.5%), and depressed mood (50%).
A case of cognitive disorders in the course of depressive syndrome in an elderly patient is presented ill the paper.
On the grounds of the literature and the author's own studies the problem of diagnosis and treatment of depression and affective (dysthymic) attacks in patients with epilepsy is discussed.
An overview is presented of major methods used in combined treatment of depressive states in the course of affective disorders and schizophrenia: namely, I and II generation antidepressants may be combined with neuroleptics, anxiolytics, lithium carbonate, and anticonvulsant drugs. The most important indications to the combined treatment as well as its limitations are discussed. Main interactions between the above mentioned groups of drugs are outlined, with the emphasis on the risk of dangerous sequelae of come combinations of psychotropic drugs.
Indications and counterindications to the ECT treatment in the elderly, as well as the principles of this method administration are discussed.
Due to the specificity of methods applied by the geriatrist, an early diagnosis of dementing disorders is possible. In collaboration with other specialists he may alleviate the patients' and their caregivers' suffering.
The authors stipulate that more attention should be devoted to the issues of psychogeriatry both in the curriculum of undergraduate medical studies and in the postgraduate training of family doctors. They argue that such changes are needed in view of the ageing of the population in Poland and the modification of the health care model in our country.