Many of the psychometric instruments employed in dementia research are adapted versions of tests developed in countries different from those in which they are applied. The validity of these instruments has been established in their countries of origin; however, there is little information available regarding their validity when transferred to other cultures. The SKT, a short cognitive performance test for the assessment of memory and attention deficits developed and validated in Germany, was administered in research centers in Chile, Greece, Russia, and England. SKT raw scores were factor analyzed with regard to a prespecified target structure, i.e., the factor solution found for a large German reference sample. The cross-cultural stability of the test was assessed using a statistical method that combined the perfect congruent weights approach and the bootstrapping technique. This procedure allowed for testing the similarity between factorial solutions obtained for the different centers. Results clearly indicate the factorial stability of the SKT in the countries participating in the study.

Today the IPA/Bayer award is bestowed for the fifth time. On behalf of Bayer, I would like to thank the participants, who by their sheer number and level of scientific quality have made this contest a real success. Bayer also thanks IPA and particularly Fern Finkel for providing the corporate and organizational framework for the award. In times of tighter budgets, this very much encourages Bayer to continue its commitment to sponsor the award. Let me reflect briefly about the rationale for this commitment.

Despite their limitations, mental status tests and self/proxy reports of instrumental activities of daily living (IADL) are often used to predict functional competence. In contrast, the Assessment of Motor and Process Skills (AMPS) is a direct observational assessment of IADL competence. Sixty-four community-dwelling elderly (20 Alzheimer's disease [AD] patients and 44 nondemented) were assessed with the AMPS, the Mini-Mental State Examination (MMSE), and the Older Americans Resources and Services (OARS)-IADL. Performance on all three assessments was significantly lower for the AD sample. The MMSE did not correlate significantly with the AMPS motor ability measures but it correlated modestly with the AMPS process ability measures. The OARS-IADL correlated significantly with the AMPS motor ability measure for the nondemented sample alone. Although mental status and self/proxy assessments provide some insight into individuals' IADL competence, direct observation of IADL task performance provides additional information regarding the subtle process and motor skills changes that occur in progressive dementing conditions.

Vascular dementia (VaD) is the second most common cause of dementia. In addition, cerebrovascular diseases (CVD) coexist with other causes of dementia. Cognitive impairment related to CVD may be preventable and these patients could benefit from therapy, which emphasizes the importance of early detection and accurate diagnosis of VaD. The conventional concept of VaD is that of multi-infarct dementia (MID). However, VaD is not only MID; it relates to different vascular mechanisms and different changes in the brain, and has different clinical manifestations with different causes. Critical conceptual questions include the cognitive syndrome and the vascular causes. It is unclear whether the conventional concept of dementia is appropriate or should be substituted with a milder and broader definition, such as vascular cognitive impairment. Furthermore, there is confusion about the causes, especially the role of lesion characteristics and the noninfarct factors. The current diagnostic criteria for VaD are based on the infarct concept. The NINDS-AIREN criteria include dementia, CVD, and a relationship between these two disorders. The criteria define the CVD and the relationship between dementia and CVD, and list supporting clinical features for the diagnosis of VaD, as well as features that make the diagnosis uncertain. The interrater reliability of these criteria is moderate to substantial (κ .46 to .72). The expected antemortem accuracy using these criteria approaches 90%. The challenge is to correctly diagnose combined cases with both vascular and Alzheimer-type pathology. Main tools in the diagnosis include a detailed medical history, neurological examination, clinical or neuropsychological mental status examination, and basic laboratory examinations. Brain imaging should always be performed, preferably using magnetic resonance imaging. The diagnosis, especially in early cases, is usually made by a neurologist. The challenge for the primary care physician is to identify the early cases needing further examinations and organizing treatment and follow-up after diagnosis.

Noisemaking is one of the most disturbing behavior disorders associated with dementia. Standard management practices, including pharmacological interventions, are not very successful in treating the behavior. Very little research has been carried out to evaluate innovative treatments or to determine the etiology of noisemaking. In this article, we report on a series of 12 case studies in which we tested the efficacy of some psychosocial interventions in reducing the frequency of noisemaking in long-term-care residents with severe dementia. Interventions were contingent reinforcement of quiet behavior and environmental stimulation tailored to individual preferences. Of the 12 patients recruited into the study, 2 died during the course of observations, 3 were not observed to be as noisy as reported by staff, and 3 showed a clear reduction in noise during the intervention period. Four patients did not show any overall reduction in noisemaking during psychosocial interventions. Future research could differentiate between types of interventions in successful cases and attempt to control further for the consistent application of interventions by long-term-care staff.

As part of a multicenter project to study noncognitive behavioral disturbances in dementia, the authors developed a comprehensive caregiver-rated questionnaire for these behaviors. The authors determined the reliability of caregiver ratings and compared caregiver ratings with clinician ratings using standard instruments. Caregivers showed good test/retest reliability for ratings of all types of patient behavioral disturbance. Caregiver interrater reliability was highest for depression and lowest for psychosis. The correlation between caregiver reports and professional assessments was highest for agitation, intermediate for psychosis, and lowest for depression. The match between caregiver and clinician assessments of patient behaviors appears to vary significantly by the type of behavior assessed.

The effects of a daily program of various activities on disturbed behavior were studied prospectively in three patients with severe dementia. Prior to the study, patients had not responded to treatment with benzodiazepines and/or neuroleptics. The study consisted of three periods, each lasting for 4 weeks: i.e., baseline, intervention, and follow-up. During each period, behavior was assessed by means of observation scales: GIP, SDAS, and CGI. Psychotropic medication was held as constant as possible. During intervention, the patients took part in a program of activities, including group, musical, physical, and social activities. During baseline and follow-up, patients followed the regular ward activities. The patients showed different responses, probably related to personal interests. Possible implications for the treatment of patients with dementia, complicated by disturbed behavior, and suggestions for future research are discussed. The enthusiasm of the nursing staff dealing with these patients was a promising result.

Blessed-Roth Dementia Scale has been one of the most widely used rating scales in dementia. Previous studies indicated that this behavioral assessment scale is a useful tool for differentiating elderly subjects with no or minimal intellectual decline from those with cognitive deterioration. In the present study, the authors examined the validity of the Chinese version of the Blessed-Roth Dementia Scale (CDS) in Hong Kong. A total of 106 Chinese subjects were recruited from a social center, an old-age home,and psychogeriatric outpatient clinics. At a cutoff score of 3 of 4, the CDS achieved a sensitivity of 90.5% and specificity of 98.1% in differentiating demented from healthy control subjects. In the Chinese population studied, the scale was readily acceptable and considered to be an useful adjunct in screening of dementia.

Subcortical hyperintensities are easily visualized areas of signal abnormality that are seen on T2-weighted magnetic resonance imaging (MRI). Characteristically they occur in the white matter of the brain and are more common in elderly people. In depression, little is known of the clinical significance of subcortical hyperintensities or their contribution to the prognosis. Fifty-eight consecutive patients with DSM-III-R depression and an age range of 65 to 85 years were prospectively collected from an old-age psychiatry service. Response to treatment was assessed with a clinical global outcome measure. A neuropsychology battery was completed on all patients after treatment. Forty-four patients completed MRI scanning. The scans were scored using a regional rating system for hyperintensities. Forty-eight percent of patients had a favorable response to treatment on the clinical global outcome scale. Poor outcome was associated with female sex (p = .07), poor physical health (p = .040), diabetes (p = .018), psychosis (p = .026), and an early age at onset of first episode of depression (p = .036). Even after adjustment for confounding effects, there were significant neuropsychological associations with the regional hyperintensities. Distribution in the periventricular area correlated with delayed recall after distraction (p = .025), and punctate lesions in the basal ganglia correlated with impaired category production (p = .020). Pontine reticular formation hyperintensities were related to impaired psychomotor speed (p = 0.04). Location in the frontal deep-white matter (p = .024), basal ganglia (p = .03), and pontine reticular formation (p = .02) was associated with a poor acute response to treatment. However, the response to treatment was not related to total cerebral white-matter hyperintensity load. A logistic regression equation included all the significant prognostic features and found four independent predictors of poor outcome: More than five punctate lesions of the basal ganglia, diabetes, lower mean arterial pressure, and hyperintensity of the pontine reticular formation significantly predicted outcome. These four factors correctly predicted 95.6% of patients with a poor outcome and 85.7% with a favorable outcome. In late-life depression, subcortical hyperintensities are common. Lesions in the cerebral white matter are predominantly associated with memory disturbance, and those in deeper infratentorial areas, with psychomotor slowing and executive deficits. Total white-matter load has no prognostic value, and although some subcortical regions are associated with poor response, individually they have little specificity. However, a combination of involvement in three areas (basal ganglia, pons, and frontal lobe) is clinically relevant and predicts outcome with great accuracy (91%). Patients with lesions in the basal ganglia and deep white matter had an especially poor response to pharmacotherapy.

Dementia and depression are the two most common mental illnesses in late life, and it is probable that they will coexist in many patients. This coexistence is complicated by the fact that both illnesses can be mistaken for each other, so that many patients with Alzheimer's disease (AD) may initially be diagnosed as depressed, whereas depression is a recognized cause of cognitive impairment. It is important to correctly differentiate between these two diagnoses; if depression is the cause of the cognitive impairment, full recovery is possible. It is also important to recognize depression in patients with AD, because depression represents a treatable source of additional disability. For patients with AD living in the community, functional limitation can determine whether the patient remains at home or is institutionalized, so treatment that can improve functional ability should be strongly considered. The newer antidepressants are better tolerated without increase in cost, so these drugs may provide a therapeutic advantage over the older tricyclic drugs. This article focuses primarily on techniques for establishing a differential diagnosis, with particular emphasis on patients in the primary care setting, and briefly considers the value and impact of treatment.

In order to determine the factors associated with good and poor 1-year prognosis of demented patients, the caretakers of 100 home-based patients attending a specialist memory clinic were inteviewed. After the follow-up, 71% continued to live at home. Mild dementia, independence in activities of daily living, fair independence in functions of instumental activities of daily living, and lack of depression were clear signs for a good prognosis. Some patients with severe dementia and poor functional capacity continued to live at home. Continuing home care was also more likely if memory impairment, as opposed to functional problems, was expressed as the main concern. The proportion of caretakers mentioning memory decline as the main problem decreased during 1 year from 38% to 9% and the proportion mentioning functional problems increased from 48% to 64% among those continuing in home care. Memory disturbances are the first to appear and cause problems, but only functional decline threatens living at home.

To determine predictors of cognitive deterioration, the authors performed baseline and 1- to 5-year follow-up (mean ± SD = 2.5 ± 1.2 years) neuropsychological assessments on 36 persons (mean age ± SD = 62.1 ± 8.0; range = 50 to 81 years) with age-associated memory impairment. Subjects were recruited from a larger group of volunteers, had minimal medical comorbidity, and 25 of them had a family history of Alzheimer's disease. Baseline age and a subjective memory measure indicating reported frequency of mnemonics usage were significant decline predictors. Subjects reporting more frequent mnemonics use at baseline were more likely to show objective cognitive decline at follow-up. Baseline full-scale IQ, educational level, and family history of Alzheimer's disease failed to predict decline. These findings suggest that although age is the strongest decline predictor in some people with age-associated memory impairment, self-perception of memory function may also predict subsequent cognitive loss.

In recent years, patients who are at high risk for developing Alzheimer's disease (AD) have become a focus of study. Several research groups have identified these patients, developed diagnostic criteria, and followed the patients longitudinally. These patients therefore constitute a clinical entity that is suitable for therapeutic interventions. In this article, we report our 5-year experience at the Mayo Clinic in characterizing a group of patients with mild cognitive impairment. These subjects were recruited from community-dwelling individuals who were receiving general medical care in the Department of Internal Medicine. They received the diagnosis of mild cognitive impairment if they met the following criteria: (a) complaint of defective memory, (b) normal activities of daily living, (c) normal general cognitive function, (d) abnormal memory function for age, and (e) absence of dementia. In following more than 75 of these patients, some of whom have been studied for as long as 5 years, it appears that approximately 10% to 15% of the subjects evolve to AD each year. We therefore evaluated the cognitive profiles of these patients at the time of their initial diagnosis in an attempt to predict who would remain stable and who would evolve to AD. Certain features of learning and memory performance indicated patients who were more likely to progress, but the strongest predictor was their apolipoprotein E status. The patients who possessed an ε4 allele were more likely to convert to AD at a more rapid rate then those who were not carriers. Our results and similar data from other study groups indicate that diagnostic criteria can be defined for patients who are likely to convert to AD; the natural history of these patients is becoming apparent, and variables that predict ultimate conversion can be defined. Consequently, patients with mild cognitive impairment constitute an important group for study, particularly from the aspect of therapeutic interventions.

The efficacy and safety of risperidone, haloperidol, and thioridazine for treating dementia-associated behavioral disturbances were evaluated in a retrospective study of 186 patients aged 65 years or older with DSM-III-R or DSM-IV diagnoses of Alzheimer's dementia, senile dementia NOS, or organic brain syndrome. Study patients were selected from the charts of 12,000 residents of 60 long-term-care facilities in New Jersey if they were treated with one of the three agents for behaviours dangerous to themselves or others. The 186 selected patients included 60 treatedwith risperidone (mean, 1 mg/day), 83 with haloperidol (mean, 2 mg/day), and 43 with thioridazine (mean, 33 mg/day). Target behaviors were violence (74 patients), shouting (31), delusions (26), paranoia (19), pacing (3), and mixed behaviors (33). Target behaviors improved in 94% of patients given risperidone, 65% given haloperidol, and 67% given thioridazine (p < .001). Treatment failures (treatment discontinued in patients because of side effects or no improvement) were more frequent in patients started on haloperidol (28) or thioridazine (15) than on risperidone (3). Extrapyramidal symptoms were reported in 7% of patients taking risperidone, 22% taking haloperidol, and 18% taking thioridazine. Safe, effective doses are readily achieved with risperidone but difficult to achieve with haloperidol or thioridazine because their effective doses often cause unacceptable side effects. These data are only suggestive because no guidelines exist for defining or measuring behavioral disturbances or for how they are affected by social, psychological, or environmental factors.

Reductions in healthcare spending and current demographic trends will result in increasing demands to care for aging relatives, especially those with cognitive impairment (e.g., Alzheimer's disease). Taking care of older individuals with cognitive impairment can be very challenging and burdensome. Caregiver burden is associated with negative outcomes such as caregiver depression and increased likelihood of patient institutionalization. One hundred eleven patients and their spousal caregivers were studied using a pre-post design. All subjects received a comprehensive medical intervention that included medical management of patients' problems and education of caregivers. We examined changes in patients' function and caregiver burden. At follow-up, patients' cognition and independence in activities of daily living had continued to deteriorate whereas their mood was improved. Regression analyses showed that changes in caregiver burden were positively associated with changes in the frequency of dysfunctional behaviors but not with changes in cognition. Gender was also related to changes in caregiver burden; male caregivers were more likely than female caregivers to report reductions in burden at follow-up. These data suggest medical interventions may provide some relief to caregivers of cognitively impaired older patients, but more research is required to identify the causal agents of this effect.

In the studies on the effects of temporary institutional respite (TIR) published to date, a slight reduction of subjective burden has been established. The hope that this form of respite care might have a positive effect on the activities of daily living or on the health of the care recipients has not yet been confirmed. A considerable deficit in the methodology applied might be a reason for this. There is no denying the fact that there is a clear need for respite services, particularly because every seventh person providing care for a dementia patient requiring personal care belongs to a high-risk group that is characterized by serious reduction in his or her physical health and psychological well-being. TIR is primarily utilized by adult child caregivers (daughters and daughters-in-law) affected by high subjective burden who are providing care for dementia patients with extensive nursing needs.

The role of the physician is critical in the evaluation of cognitively impaired patients for two reasons: (a) The longitudinal relationship between the patient and physician provides a unique opportunity to observe changes over time, generating confidence that may encourage the patient and family to report any concerns; (b) All research in this field is geared toward the earliest possible intervention, a process made possible by early diagnosis. Preparations for interview and the interview process itself require special knowledge of dementia on the part of the evaluating physician, who must understand the potentials and problems of both the content and the process of taking a history from the demented patient and his/her caregivers.

Eighty-seven out of a clinical cohort of 124 patients with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) dementia were followed up at monthly intervals for 1 year. Psychotic symptoms were assessed using the Burns's Symptom Checklist, and cognitive functioning was evaluated with the CAMCOG. The annual incidence rate of psychotic symptoms was 47%, although many of the incident symptoms lasted less than 3 months. Fifty-three percent of patients with psychosis experienced resolution of their symptoms. Patients either experienced brief or persistent psychotic disorders, with few having an intermediary course. Persistent psychosis was significantly associated with a 3-month duration of symptoms at baseline. Neuroleptics did not significantly influence the course of psychotic symptoms.

Using magnetic resonance imaging-based planimetry, we measured cortical and cerebral (cortical and ventricular) atrophy in 26 patients with Alzheimer's disease (AD) (age, 72.2 ± 7.0) according to NINCDS-ADRDA criteria and 22 control subjects (age, 71.5 ± 5.4). AD patients exhibited greater cerebral atrophy (p < .05) than control subjects. Cerebral atrophy was significantly correlated with age (r = .72, p < .0005) in healthy volunteers but not in AD patients. In AD patients, age of onset was negatively correlated with the estimated rate of disease-attributed cerebral degeneration ([observed atrophy - atrophy in normal aging calculated from the regression equation derived from the control group]/[duration of illness]) (r = −.54, p < .005). Multiple regression with interaction analysis demonstrated that age, age of onset, and their interaction successfully explained cerebral (R2 = .51, p < .05) and cortical (R2 = .64, p < .05) atrophy in patients with probable AD. Age of onset may be a strong predictor of the rate of cerebral degeneration in AD, and our results suggest that controlling age and the age of onset is essential in the quantitative study of AD.

The wish to die in elderly persons is currently under debate. Experts are questioning whether it is natural for these individuals to show a wish to die, whether the right to eventually kill oneself should be respected, or whether suicidal intentions in old age are expressions of mental disorders that need intensive, professional care. A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview Geriatric Mental State Examination-Version A (GMS-A) and several self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R criteria and by clinical judgment. The goal of the study was to find examples of “pathology-free wishes to kill oneself.” A total of 115 out of 516 very old (70 to 105 years) persons, which represents 21.1% of the community population, said at the time of investigation that they wanted to die or felt life was not worth living (Hamilton Depression Rating Scale [HAMD] score 1, 2, or 3). Forty-three very old persons (6% of the community population) had the wish to be dead according to the HAMD or the GMS-A, and 11 persons (2% of the community population) had suicidal intentions. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as having psychiatric disorders and half to three quarters showed symptoms fulfilling the criteria of at least one specified psychiatric diagnosis. Acute suicidal intentions were in all cases associated with at least one specified diagnosis according to DSM-III-R. Thirteen persons out of 54 who actually wanted to die (GMS-A category 4, 5, 6 or HAMD category 2, 3) did not fulfill criteria for specified diagnoses. Seven individuals showed scores in self-rating and observer-rating scales that speak for mental disorders apart from pure suicidality. Six remaining persons are described in greater detail in short case vignettes. They showed either mild but chronic psychiatric disorders, fluctuating courses, or an atypical phenomenology of psychiatric disorders. The results of this study strongly suggest that the wish to be dead in the very old is most probable, and suicidal intentions are definitely associated with psychiatric disorders.