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548 Letter to the Editor

Table 1 Summary of results (with 95% condence intervals) of ACE-R and MMSE assessments (n = 243) at optimal accuracy cutoffs

Cutoff ACE-R 73/100 MMSE 24/30

Test accuracy: 0.89 (0.850.93) 0.82 (0.770.87)


Sensitivity: 0.87 (0.800.94) 0.70 (0.600.80)
Specificity: 0.91 (0.860.95) 0.89 (0.840.94)
Youden index (Y): 0.78 0.69
Positive predictive value: 0.83 (0.750.91) 0.77 (0.670.86)
Negative predictive value: 0.93 (0.890.97) 0.85 (0.790.90)
Predictive summary index: 0.76 0.62
Diagnostic odds ratio: 63.7 (39.1103.9) 18.4 (11.629.0)
Area under ROC curve: 0.94 (0.910.97) 0.91 (0.880.95)
Positive likelihood ratio: 9.21 (5.6515.0) = moderate 6.17 (3.919.73) = moderate
Negative likelihood ratio: 0.14 (0.090.24) = moderate 0.34 (0.210.53) = small
Positive utility index (UI+): 0.72 good 0.54 adequate
Negative utility index (UI ): 0.85 excellent 0.76 good

of details on participant sex and average age and period References


between administration of reference standard and
ACE-R. Predictive values were calculated using the Crawford S, Whitnall L, Robertson J, Evans JJ. 2012. A systematic review of the
accuracy and clinical utility of the Addenbrookes Cognitive Examination and
prevalence rate for dementia observed in the study group the Addenbrookes Cognitive Examination-Revised in the diagnosis of dementia.
and not by making any assumptions about prevalence Int J Geriatr Psychiatry 27: 659669.
Davies RR, Larner AJ. 2012. Addenbrookes Cognitive Examination (ACE) and its
rates. Remaining limitations include the particular Revision (ACE-R). In Cognitive Screening Instruments: A Practical Approach,
casemix of this clinic, which may not be generalizable Larner AJ (ed.). Springer: London; 6177.
Larner AJ. 2007. Addenbrookes Cognitive Examination-Revised (ACE-R) in day-to-day
to other situations. The impact of educational experience, clinical practice. Age Ageing 36: 685686.
a possible moderating factor on ACE-R performance Larner AJ. 2012. Screening utility of the Montreal Cognitive Assessment (MoCA): in
place ofor as well asthe MMSE? Int Psychogeriatr 24: 391396.
(Crawford et al., 2012), was not assessed, nor the impact Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. 2006. The Addenbrookes
of patient age or sex. MCI patients were insufcient Cognitive Examination Revised (ACE-R): a brief cognitive test battery for
dementia screening. Int J Geriatr Psychiatry 21: 10781085.
(<20) to report separate results.
In summary, ACE-R is useful for cross-sectional
assessment of cognitive disorders, with excellent test
metrics. However, optimal ACE-R use in unselected A. J. LARNER
patient cohorts may require (downward) revision of Cognitive Function Clinic, Walton Centre for Neurology
test cutoffs. and Neurosurgery, Liverpool, UK
E-mail: a.larner@thewaltoncentre.nhs.uk

Conict of interest Published online in Wiley Online Library


(wileyonlinelibrary.com)
Potential conicts do not exist. DOI: 10.1002/gps.3884

Dead under the bed: a case of Diogenes syndrome?

Dear Editor, An 89-year-old man had been living alone in the


same apartment from the late 1930s. He was described
It was interesting to read Freds story and how this case as a solitary, discreet and wary man. One day, worried
was considered to be the rst true case of Diogenes because nobody had seen him for days, the doorman
syndrome (Jolley and Read, 2009). We would like to tried to get in touch with him. After a few unsuccessful
share a case that we have recently encountered. attempts, the police were called and entered the mans

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2013; 28: 547549.
Letter to the Editor 549

apartment. Inside, there were hundreds of carefully 1991). In extreme cases, the person may be unable to
cataloged newspaper cuttings connected to his job perform minimal self-care or to maintain minimal
as a private investigator. His slippers and trousers personal hygiene. Major depressive disorder with psy-
were on the bedroom oor, the bed was unmade and chotic features is closely correlated to social isolation,
a corner of the duvet was folded back over the especially among geriatric patients. In this regard, an
mattress. The man was found lying supine on the ethological perspective may be proposed. It is instinc-
oor under the bed in a pool of blood. His head tive for most animals to hide and seek solitude when
touched the wall; the limbs were extended. Around they are very sick, injured or dying. There are two
his head, there was a dried pool of blood, and the main reasons for this. First of all, animals need to stay
wall was stained with splashes of dried blood that in a place that would be safe from predator attacks
had come out from his mouth. The abdomen was where they can hide and recover. The second major
bare and presented the typical putrefactive green reason is to protect the other members of the herd,
color. The prosecutor ordered a forensic autopsy to family or whatever group they belong to. Animals have
rule out foul play; the cause of death was gastric an instinctive urge to isolate themselves when sick or
hemorrhage. hurt, and by doing so, they protect the other members
The Diogenes syndrome is characterized by symp- of their group. This behavior can be seen often in ani-
toms that include severe self-neglect, senile break- mals such as cattle and elks, and recently, it has also
down, poor personal hygiene, domestic squalor, been noticed among some insect species (Heinze and
social withdrawal/isolation, syllogomania and refusal Walter, 2010).
of help (Clark et al., 1975). The Diogenes syndrome In our case, may the decision to die alone under the
gets its name from Diogenes of Sinope, a Greek bed be regarded as a form of extreme isolation or as a
philosopher who lived in the 4th century BC and was nal demonstration of self-sufciency? In other words,
one of the founders of cynic philosophy. He lived in a can we consider this case as an example of Diogenes
tub (pB), defying laws, conventions and public syndrome stricto sensu? Or it is just the expression of
opinion and practiced a life of ascetic self-sufciency major depressive disorder with psychotic features?
(autrkeia). The appropriateness of the syndrome
name has been questioned (Cooney and Hamid,
Conict of interest
1995). In fact, it seems that this behavior is more
connected to the rejection of the world rather than
None declared.
to the achievement of ascetic self-sufciency. More-
over, Diogenes spoke to his community instead of
References
withdrawing from it. These considerations appear
to be on the basis of Jolley and Reads Letter to
Clark AN, Mankikar GD, Gray I. 1975. Diogenes syndrome. A clinical study of gross
the Editor (Jolley and Read, 2009). Unfortunately, neglect in old age. Lancet 1: 366368.
we do not have any clinical information or neuro- Cooney C, Hamid W. 1995. Review: Diogenes syndrome. Age Ageing 24: 451453.
Jolley D, Read K. 2009. Diogenes syndrome. Int J Geriatr Psychiatry 24: 778779.
psychological evaluation of the case, apart from a Johnson J, Horwath E, Weissman MM. 1991. The validity of major depression with
certicate in which the mans personal doctor states psychotic features based on a community study. Arch Gen Psychiatry 48: 1075.
Heinze J, Walter B. 2010. Moribund ants leave their nests to die in social isolation.
that her patient should not be exposed to stressors. Curr Biol 20(3): 24952.
It is well known that the Diogenes syndrome may
represent the response to biopsychosocial stressors FABIO DE-GIORGIO1, VINCENZO M. GRASSI1,
associated with aging in persons with predisposing ELEONORA CHILLEMI2 AND GIOVANNI MARTINOTTI2
1
personality traits. Institute of Legal Medicine, Catholic University, Medical
Secondary Diogenes syndrome may be due to dis- School, Rome, Italy
orders such as major depressive disorder with psy- 2
Department of Neuroscience and Imaging, University G.
chotic features, according to DSM-IV. This disorder DAnnunzio, Chieti, Italy
is a severe subtype of major depressive disorder, and
the psychotic symptoms are delusions and/or halluci- Published online in Wiley Online Library
nations that are frequently consistent with depressive (wileyonlinelibrary.com)
themes of guilt and worthlessness (Johnson et al., DOI: 10.1002/gps.3883

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2013; 28: 547549.