Mohammed T. Abou-Saleh

14 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYIn this context, there seemed to be little sense in doing much forthe old. The elderly were discouraged from care in the statepsychiatric hospitals, because they were thought, by virtue of theirage, to be untreatable. If there were low probability that insanitycould be cured even if detected early and treated aggressively, theelderly should not be allowed to take up valuable space that couldbe used to treat the curable. Therefore, custodial care for theelderly insane was the best that could be provided by families,almshouses, or prisons 8,9 .The elderly, nevertheless, represented a significant proportionof the institutionalized population. A comprehensive survey ofinsanity among the general population of Massachusetts conductedin 1854, for instance, revealed that insane people inasylums aged 60 and above made up 9.8% of the inmates. Nearlyone out of every five insane persons in Massachusetts was over 60years old. Despite such data, Rosenkrantz and Vinovskis 10maintain that the pervasiveness of insanity among the elderlywas not recognized by nineteenth century physicians; the elderlyinsane remained the least likely age group to be institutionalized.A lack of systematic record-keeping concerning mental healthadmissions of the aged prior to 1900 makes it hazardous togeneralize about trends. Even so, based on nineteenth centurydata from Massachusetts, the following propositions seemwarranted. On the one hand, admission rates fluctuated fromone decade to the next, which suggests that those who raninstitutions had considerable power to determine who could enter.On the other hand, men outnumbered women in asylums,probably because families found older women more deserving ofsupport and less disruptive or threatening in behavior. Alcoholabuse, it is worth noting, was more likely to be cited as a diagnosisof insanity for males 8 .Because of the prevailing nihilism, the dependent elderly weregenerally sent to local almshouses rather than mental institutionsprior to 1890 11 . Superintendents may have discouraged theadmission of elderly patients, considering them a threat to thetherapeutic mission of the hospital. However, records showed thatpatients over 70 were not troublesome and were kindly tolerated.They did receive less specific medical therapy than youngerinmates. Curiously, given the rampant nihilism, what care theyreceived apparently proved efficacious: more than half of those ininstitutions in their seventh decade were discharged due torecovery or improvement. The rest, however, usually stayeduntil death.Because a significant proportion of mental patients aged inplace, it is not surprising that the percentage of the elderly ininstitutions was greater than that in the general population. In1880, there were 140 public and private mental hospitals caringfor nearly 41 000 patients; 9300 were kept in almshouses; the restwere cared for in their own homes. The Census of 1880 showed91 997 insane persons out of a total American population of50 000 000; 52% were female, 71% native born, and 93% white.Responsibility for the aged insane was usually divided betweenlocal almshouses and mental hospitals. Between 1880 and 1890,insane persons constituted nearly a quarter of the total almshousepopulation. Between 1851 and 1890 nearly 10% of California’sinstitutionalized insane were 60 years or older; in Arizona in 1900the figure was only 1.71%; and in Massachusetts in the 1880s itwas 12.1%. Most of the aged insane were said to be suffering fromsome form of senility.The increasing use of the term ‘‘senility’’ to characterizeimpairments in mental health in later years signals the emergenceof new scientific views of senescence. William James in Principlesof Psychology 12 and George Beard in American Nervousness 13contended that the majority of the elderly invariably experienced adecline in mental faculties and a decreased ability to learn newmaterials and/or to adapt to changing circumstance. CharlesBrown-Se´quard hypothesized that the decline resulted from‘‘diminishing action of the spermatic glands’’. W. A. N. Dorland 14believed that people’s ‘‘creativity’’ declined after age 60.Metchnikoff’s attribution of old age to a chronic disease processis indicative of the pessimistic thought regarding the well-being ofthe elderly in general 15 . In view of such thought, it is notsurprising that the elderly mentally ill were regarded as quitehopeless and undeserving of efforts at rehabilitation. Indeed, therewas so little interest in this population that ‘‘geriatrics’’ did notbecome a medical specialty until the twentieth century under theinfluence of Dr I. L. Nascher 16 .As basic processes of aging became a focus of scientific inquiryfor a growing number of researchers, others tried to understandthe etiology of more late-life disorders. Alois Alzheimer established(in a 1907 report) a histologic picture of the disease thatwould later bear his name. But there was not much interest in oldage-associated dementia until increases in adult life expectancystarted to change the demographic make-up of industrialsocieties 17 .REFERENCES1. Hurd H, ed. The Institutional Care of the Insane in the United Statesand Canada, Vol. 1. Baltimore, MD: Johns Hopkins Press, 1916, 81.2. Deutsch A. The Mentally Ill in America. New York: ColumbiaUniversity Press, 1949, 66.3. Rush B. Medical Inquiries and Other Observations on Diseases of theMind. New York, 1812. Hafner Reprints, 1962.4. Menninger K. The Vital Balance. New York: Viking, 1963, 402.5. Brody JB. The Journal of Nervous and Mental Disease, the first 100years. J Nerv Ment Dis 1974; 159: 1–11.6. Olverholser W. Founding of the Association. In Hall JK, Zilbourg B,Bunker HA, eds. One Hundred Years of American Psychiatry. NewYork: Columbia University Press, 1944.7. Grob C. The State and the Mentally Ill. Chapel Hill, NC: TheUniversity of North Carolina Press, 1966.8. Achenbaum WA. Old Age in the New Land. Baltimore, MD: JohnsHopkins University Press, 1978.9. Haber C. Beyond Sixty-Five. New York: Cambridge University Press,1983, 89.10. Rosenkrantz B, Vinovskis MA. Invisible lunatics. In Spicker S, VanTassel D, Woldwald K, eds. Aging and the Elderly. AtlanticHighlands: Humanities Press, 1978, 96–123.11. Grob G. Inner World of American Psychiatry. New Brunswick, NJ:Rutgers University Press, 1985.12. James W. Principles of Psychology (2 vols). New York: Henry Holt,1885.13. Beard GM. American Nervousness. New York: GP Putnam, 1881.14. Dorland WAN. Age of Mental Virility. New York: Century Co.,1908.15. Metchnikoff E. Prolongation of Life. New York: GP Putnam, 1908.16. Nascher IL. Geriatrics. Philadelphia, PA: P. Blakiston, 1914.17. Iqbal K, Wisniewski HM, Winblad B (eds). Alzheimer’s Disease andRelated Disorders. New York: Alan R. Liss, 1989, 1–2.