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

It was interesting to read Freds story and how this case
was considered to be the rst true case of Diogenes
syndrome (Jolley and Read, 2009). We would like to
share a case that we have recently encountered.
same apartment from the late 1930s. He was described
as a solitary, discreet and wary man. One day, worried
because nobody had seen him for days, the doorman
tried to get in touch with him. After a few unsuccessful
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
apartment. Inside, there were hundreds of carefully
cataloged newspaper cuttings connected to his job
as a private investigator. His slippers and trousers
were on the bedroom oor, the bed was unmade and
a corner of the duvet was folded back over the
mattress. The man was found lying supine on the
oor under the bed in a pool of blood. His head
touched the wall; the limbs were extended. Around
his head, there was a dried pool of blood, and the
wall was stained with splashes of dried blood that
had come out from his mouth. The abdomen was
bare and presented the typical putrefactive green
color. The prosecutor ordered a forensic autopsy to
rule out foul play; the cause of death was gastric
hemorrhage.
The Diogenes syndrome is characterized by symp-
toms that include severe self-neglect, senile break-
down, poor personal hygiene, domestic squalor,
social withdrawal/isolation, syllogomania and refusal
of help (Clark et al., 1975). The Diogenes syndrome
gets its name from Diogenes of Sinope, a Greek
philosopher who lived in the 4th century BC and was
one of the founders of cynic philosophy. He lived in a
tub (pB), defying laws, conventions and public
opinion and practiced a life of ascetic self-sufciency
(autrkeia). The appropriateness of the syndrome
name has been questioned (Cooney and Hamid,
1995). In fact, it seems that this behavior is more
connected to the rejection of the world rather than
to the achievement of ascetic self-sufciency. More-
over, Diogenes spoke to his community instead of
withdrawing from it. These considerations appear
to be on the basis of Jolley and Reads Letter to
the Editor (Jolley and Read, 2009). Unfortunately,
we do not have any clinical information or neuro-
psychological evaluation of the case, apart from a
certicate in which the mans personal doctor states
that her patient should not be exposed to stressors.
It is well known that the Diogenes syndrome may
represent the response to biopsychosocial stressors
associated with aging in persons with predisposing
personality traits.
Secondary Diogenes syndrome may be due to dis-
orders such as major depressive disorder with psy-
chotic features, according to DSM-IV. This disorder
is a severe subtype of major depressive disorder, and
the psychotic symptoms are delusions and/or halluci-
nations that are frequently consistent with depressive
themes of guilt and worthlessness (Johnson et al.,
Copyright # 2013 John Wiley & Sons, Ltd.
549
1991). In extreme cases, the person may be unable to
perform minimal self-care or to maintain minimal
personal hygiene. Major depressive disorder with psy-
chotic features is closely correlated to social isolation,
especially among geriatric patients. In this regard, an
ethological perspective may be proposed. It is instinc-
tive for most animals to hide and seek solitude when
they are very sick, injured or dying. There are two
main reasons for this. First of all, animals need to stay
in a place that would be safe from predator attacks
where they can hide and recover. The second major
reason is to protect the other members of the herd,
family or whatever group they belong to. Animals have
an instinctive urge to isolate themselves when sick or
hurt, and by doing so, they protect the other members
of their group. This behavior can be seen often in ani-
mals such as cattle and elks, and recently, it has also
been noticed among some insect species (Heinze and
Walter, 2010).
In our case, may the decision to die alone under the
bed be regarded as a form of extreme isolation or as a
nal demonstration of self-sufciency? In other words,
can we consider this case as an example of Diogenes
syndrome stricto sensu? Or it is just the expression of
major depressive disorder with psychotic features?
Conict of interest
None declared.
References
Clark AN, Mankikar GD, Gray I. 1975. Diogenes syndrome. A clinical study of gross
neglect in old age. Lancet 1: 366368.
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.
Johnson J, Horwath E, Weissman MM. 1991. The validity of major depression with
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.
Curr Biol 20(3): 24952.
FABIO DE-GIORGIO1, VINCENZO M. GRASSI1,
ELEONORA CHILLEMI2 AND GIOVANNI MARTINOTTI2
1
Institute of Legal Medicine, Catholic University, Medical
School, Rome, Italy
2
Department of Neuroscience and Imaging, University G.
DAnnunzio, Chieti, Italy
Published online in Wiley Online Library
(wileyonlinelibrary.com)
DOI: 10.1002/gps.3883
Int J Geriatr Psychiatry 2013; 28: 547549.