Minding the mind in older gamblers: gambling in older adults might signal cognitive declines.

Denny Crane is the fictional lawyer on the television series Boston Legal who fears the creeping onset of "mad cow," his euphemism for Alzheimer's disease. While this television character's portrayal of significant memory loss is intentionally humorous, changes in memory can be subtle and unforgiving for a growing number of older adults who ultimately are diagnosed as having a dementia and a co-occurring gambling problem.

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Dementia is the clinical syndrome characterized by a loss of cognitive and emotional abilities that interferes with an individual's daily functioning. Alzheimer's disease, which accounts for about 70% of cases of dementia, is characterized by progressive decline over the course of 8 to 12 years. With more than 50 illnesses able to cause dementia, about 1% of the U.S. population has dementia by age 60, and that percentage reaches 30 to 50% by age 85. (1)

Frontotemporal dementia is a type of dementia affecting the part of the brain that regulates comportment, insight, and reasoning. Individuals who develop FTD might not exhibit true memory loss (as is typical in Alzheimer's disease), but instead exhibit changes in personality and judgment--particularly social judgment. For example, a usually quiet individual might become more outgoing, boisterous, and disinhibited, lacking flexibility in thinking and being unable to inhibit inappropriate actions. As a result, individuals with FTD might be at risk for putting themselves in jeopardy or being victimized, because they cannot recognize their limitations or use appropriate judgment. They also might engage in impulsive behaviors that initially present as addictive behaviors (i.e., problem gambling, excessive spending on sweepstakes, responding to telemarketing offers) but could actually be the result of an undiagnosed FTD.

Prevalence of problems

While most older adults in the United States are considered "recreational" gamblers (not meeting DSM-IV diagnostic criteria for pathological gambling), there is a growing public health concern for those older adults who exhibit problem or pathological gambling behavior (approximately 5% of the older adults in the general adult population). Because older adults are one of the fastest-growing segments of the population with generally large amounts of disposable time and income, the increased availability and acceptability of gambling has prompted significant public health concerns for gambling problems in older adults. Problem and pathological gambling in older adults often remains hidden (2) and can be devastating (3) to older adults' physical, psychological, emotional, financial, and legal health. (4)

This enhanced concern is occurring at a time when older adults' lifetime gambling rates have increased substantially, from 35% in 1975 to 80% in 1998. Past-year gambling rates increased from 23% to 50% during the same period. (5) One recent study identified gambling activities as older adults' single biggest social activity. (2) Another study suggested that slot machine games, which are often the most popular form of gambling among older gamblers, may be more addictive than other types of gambling. (6) Older adults can face greater problems related to excessive gambling because of their limited ability to replace savings or to recover from losses incurred by excessive gambling, sweepstakes, or telemarketing fraud.

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Older adults in the early stages of dementia have been described among those who engage in excessive lottery and sweepstakes participation. (7) Several state attorneys general have brought lawsuits on behalf of sweepstakes victims, many of whom are older adults. (8) Fraudulent telemarketers alone are estimated by the AARP to realize more than $40 billion each year, most of which is lost by older adults.

Recent studies of the prefrontal region of the brain, including the ventromedial sector that supports reasoning and decision making, have found that this area undergoes disproportionate aging in some older adults, resulting in a premature decline in advantageous decision making. In a test of younger (26 to 55) and older (56 to 85) adults on a gambling task, a subset of the older group showed impaired decision making in spite of otherwise intact cognitive functioning. When members of this older group were presented with a deck of cards that yielded a large immediate reward, they were unable to delay gratification from the reward even if that reward cost a large loss in the future. Their tendency was to return quickly to the decks of cards that yielded high immediate reward. This study finding has raised the possibility that disproportionate aging of the ventromedial prefrontal cortex in these individuals might help to explain why many older individuals are susceptible to fraudulent advertising. (9)

Evaluation tools

While those who regularly evaluate and treat problem gamblers have long been aware of the South Oaks Gambling Screen (10) or the simple Lie-Bet two-question diagnostic screen for pathological gambling (11) tendencies ("Have you ever felt the need to bet more and more money?" and "Have you ever had to lie to people important to you about how much you gambled?"), they could be largely unaware of the importance of also evaluating the cognition of an older adult exhibiting problem gambling behaviors.

Whether an older problem gambler has an undiagnosed dementia largely depends on the severity of functional decline, which is best indicated by the individual's history and the specific cognitive and behavioral changes seen in the individual (i.e., any symptoms suggesting existing medical, neurologic, or psychiatric illnesses). Because individuals with dementia are often unaware of their problems, it is best to obtain their history from informants (spouse, adult children, caregivers). Important questions to ask an informant include: any perceived changes in the older individual's functioning; potential risks to safety; and any family history of dementia, depression, or stroke.

An older adult's cognition is assessed through a mental status screening, which is most easily done through standardized instruments such as the Mini-Mental State Examination. (12) The MMSE (www.minimental.com) assesses orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal and written commands. It also provides a total score that places the individual on a scale of cognitive functioning. A score of less than 24 out of a possible 30 points on the MMSE generally indicates dementia in patients who are well-educated and not also acutely confused, severely depressed, or psychotic. Given serially, this measure is used as a guideline and not as a diagnostic test. Crum et al describe the normative data for the MMSE, adjusted for age and education. (13)

Additional screening measures also may be used to help identify the extent and pattern of impairment in an older adult problem gambler (for a list, see an article by Geldmacher and Whitehouse (14)). Many measures are easy to use and help to further assess deficits in specific functional domains (memory, language, praxis, visuospatial, judgment and reasoning, and attention and concentration). If an older problem gambler is suspected to have an undiagnosed frontal lobe dementia, that individual likely would not perform well on questions of judgment and reasoning. That individual also might demonstrate inflexibility in thinking, as exhibited in poor performance on attention and concentration or visuospatial assessments. The individual also might exhibit a loss in personal and social awareness, and the person's informant might report personality changes, impulsivity, and increased disinhibition, particularly in social situations.

If an older adult problem gambler exhibits cognitive deficits, particularly if those deficits occur on a repeated evaluation, the individual ought to be referred to his/her primary care physician for a more comprehensive dementia evaluation. In this case, the older adult's presenting problems with excessive gambling could more likely be related to changes in cognition than in the development of behaviors diagnosable as pathological gambling.

Conclusion

As older adults have increasing access to more locally available gambling venues throughout the country, they have discovered gambling (particularly slot machine gambling) as a recreational pastime. However, for those older individuals who also develop problematic gambling behaviors, it is important for the assessing clinician to be aware of how cognitive changes might be a contributing factor to the problem.

It is incumbent upon those involved in the treatment of problem gamblers and other addictions to be aware of screening assessment measures commonly used to measure changes in an older individual's cognitive status.

Dennis P. McNeilly, PsyD, is an Associate Professor at the University of Nebraska Department of Psychiatry and President of the National Council on Problem Gambling. He is a member of the Addiction Professional Editorial Advisory Board. His e-mail address is [e-mail].

References

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4. McNeilly DP, Burke WJ. Late life gambling: the attitudes and behaviors of older adults. J Gambl Stud 2000;16:393-415.

5. Gerstein D, Hoffmann J, Larison C, et al. National Opinion Research Council: Gambling Impact and Behavior Study. Chicago: University of Chicago Press; 1999.

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7. Mendez MF, Bronstein YL, Christine DL. Excessive sweepstakes participation by persons with dementia. J Am Geriatr Soc 2000;48:855-6.

8. Gosker E. The marketing of gambling to the elderly. Elder Law J 1999;7:185-216.

9. Denburg NL, Tranel D, Bechara A. The ability to decide advantageously declines prematurely in some normal older persons. Neuropsychologia 2005;43:1099-1106.

10. Lesieur HR, Blume SB. The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers. Am J Psychiatry 1987;144:1184-8.

11. Johnson EE, Hamer R. The Lie/Bet Questionnaire for screening pathological gamblers. Psychol Rep 1997;80:83-8.

12. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method of grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.

13. Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:2386-91.

14. Geldmacher DS, Whitehouse PJ. Evaluation of dementia. New Engl J Med 1996;335:330-6.

BY DENNIS P. MCNEILLY, PSYD