We examined the factor structure of the 28-item Dementia Mood Assessment Scale (DMAS), an instrument to assess depressive symptoms in older adults with cognitive impairment, in a cohort of 165 community-dwelling elderly with varying degrees of cognitive impairment. Factor analysis using principal components analysis and varimax rotation was performed to explore the presence of subscales and examine construct validity. A five-factor structure involving all 28 items accounting for 63.2% of the variance in the DMAS scores was derived. Factors were named: Depressed Affect, Environmental Interaction, Diurnal Patterns, Agitation/Suspicion, and Somatic Indicators. This factor structure reflects the often differing presentations of depressive symptoms in older adults with varying degrees of cognitive function and established the construct validity of the DMAS in this population. We conclude that the DMAS may be used for differentiated clinical assessment of depressive symptoms along major dimensions of depressive illness in this cohort of elderly.

The purpose of this pilot study was to evaluate the usefulness of the Assessment of Motor and Process Skills (AMPS) as an outcome measure of instrumental activities of daily living (IADL) in pharmacologic studies of people with Alzheimer's disease. The AMPS simultaneously measures motor and process skills and their effect on the ability of the person to perform familiar IADL tasks. We administered the AMPS to 11 Alzheimer inpatients in a 31/2-month, double-blind, placebo-controlled, crossover study of fluoxetine and selegiline administered as single agents and in combination with physostigmine. Results indicated that there was a significant difference in IADL ability among study conditions for process skills, but not for motor skills, thereby suggesting that the AMPS is useful as a sensitive outcome measure of IADL ability in drug trials with this population.

Burns: It has been said that the Hachinski score is actually more an infarct score than an ischemic score. Dr. Erkinjuntti, what do you think?

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longer-term cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

Many nursing home residents are candidates for antipsychotic pharmacotherapy for dementia-related behavioral disturbances that include physical agitation and aggression, verbal outbursts, anxiety, and depression. These patients are often resistant to or intolerant of standard neuroleptics and are usually receiving multiple medications for concurrent psychiatric or medical conditions. New medications must be carefully considered because they may interact with concurrent medications or aggravate concurrent medical problems. Low doeses of risperidone may be better tolerated in the elderly because the drug poses little risk of extrapyramidal side effects or blood disorders. One hundred and nine patients with dementia-related behavioral disturbances were studied in 9 nursing homes; most initially received 0.25 to 0.5 mg of risperidone twice daily. Their behavior was recorded for up to 6 months on questionnaires completed by a nursing staff member at each home. Risperidone was well tolerated overall and nursing staff viewed it as helpful in 38 of 100 patients, moderately helpful in 26, slightly helpful in 17, and not helpful in 19.

Folie à deux is a rare, interesting disorder involving delusional beliefs shared by two persons. We report three cases of elderly couples referred to our service during an 18-month period with this disorder, and discuss the salient clinical features and the possible risk factors for folie à deux in the elderly.

A patient with delusional parasitosis has a strong conviction of being infested with parasites: for example, lice or worms. Such a patient is not satisfied with assurances or test results that no parasites are present, but is so convinced that he or she will go as far as to bring the parasites in “matchboxes” to a physician. Subjectively worried, the patient may try to pick the parasites out of the skin, causing cutaneous lesions and even ulcerations. The condition is classified as a delusional/paranoid disorder, somatic type according to DSM-III-R. Not much is known epidemiologically of this rare disorder, which usually affects older women who often are isolated socially. Therapy is regarded as difficult, and a wide variety of treatment methods have been attempted. In this article six female cases are presented, showing that a typical patient is an elderly woman who has suffered losses or is socially isolated. These patients lack deeper psychiatric insight into their problem, so they are mostly in the care of nonpsychiatric physicians. Treatment with a low dose of high-potency neuroleptics combined sometimes with antidepressants appears to be effective. Reducing social isolation is also important.

Many efforts have been made to trace the causes of Alzheimer's disease (AD). There are, however, many points of controversy among reports from the same country as well as among reports from different countries. The current study is a case-control study to determine the risk factors in the development of AD in Greece. Sixty-five patients with AD and 69 age-matched controls were examined. All patients with AD fulfilled the DSM-IV criteria for AD and NINCDS-ADRDA criteria for probable AD. Demographic characteristics such as gender, current marital status, who he/she is living with, education, main place of residence in childhood, adulthood, and late life, occupational hazards, patient's medical history (history of diabetes mellitus and hypertension), life habits like alcohol consumption and smoking, and a history of head trauma, heart attack, stroke, parkinsonism, or depression were collected from the subject or from an informant. A family history of selected diseases (hypertension, diabetes mellitus, dementia, Parkinson's disease, Down's syndrome, stroke) was also elicited. Ages of father and mother at birth were also recorded. Chi-square test, Kruskal-Wallis analysis of variance, cluster analysis, and logistic regression analysis were used for statistical analysis. The results (chi-square test) showed a statistically significant difference between patients with dementia of the Alzheimer type and controls as far as marital status (p = .04), the subject's history of major depressive episode (p = .02), and family history of dementia (p = .002) were concerned. Logistic regression analysis results produced a complex model of family aggregation of dementia, with patients with a history of depression and family history of dementia having an up to seven times higher risk of developing AD. These findings, especially a family history of dementia, are consistent with most of the literature.

We were asked to consider differential diagnosis. We decided that it really is different from the other diagnostic modalities and cannot be treated in the same way as, for example, global or neuropsychological measures. In the context of this meeting, we believed it would be appropriate to consider clinical criteria. Thus, clinical criteria for the dementia syndrome as well as for specific diseases were discussed. We recognized that in the future, an increasing number of patients will present with cognitive impairment who do not fulfill the clinical criteria for dementia. These patients may alternatively have an isolated memory impairment syndrome. Nevertheless, a diagnosis will still need to be made in these patients, at least in terms of the underlying molecular pathology, in order to implement potential treatments.

The recent literature on informal carers of dementia patients is reviewed. Families bear the major responsibility for such care. The production of “burden” in carers is a complex process, involving developmental and cultural factors, in addition to the stressors of dementia itself. Also influential are the carer's gender, coping style, social network, and the carer's level of inimacy with the elder. The interpretation of actual morbidity is complicated by methodologic problems. However, carers appear to suffer from at least moderate levels of psychological symptomatology. Carers tend to judge their own health to be poorer than that of controls. Some studies have also found aspects of caregiving to be associated with elder abuse, but this is controversial. Caregiving in dementia appears to be at least as stressful as that in chronic physical illness and depression. Finally, the implications for service provision and future research are considered.

The heterogeneity in severe mental illnesses means that although some persons exhibit a chronic course in later life, others may recover for long periods or have episodes throughout the lifespan. The challenge to mental health providers is to identify those people most at risk for a chronic or relapsing course in later life. Data described here come from a prospective study of course and adjustment in severe mental illness for persons over age 40. The sample of 313 people, residing in the community and both in treatment and not in treatment, is unique. Six 8-month course patterns were identified; nearly one third of the participants had course patterns that were unstable, and one third were well across the 8 months. Older participants were more stable and less depressed, but otherwise were very similar to those in middle age. Demographic and history variables that predict long-term outcomes were not useful for predicting short-term recovery or relapse.

Normal-pressure hydrocephalus (NPH) is a common cause of potentially reversible dementia. It can present with psychiatric manifestations that may hinder its diagnosis. A 68-year-old man presented with a paranoid psychosis and mild cognitive impairment, but no neurological signs or classic “triad.” Gait disturbance and urinary incontinence developed later in the course of illness after the diagnosis of NPH had already been made on computed tomographic (CT) scanning. A lumbo-peritoneal shunt was performed, followed by full remission of psychotic symptoms, as well as considerable improvement in functioning, continence, and gait. This case demonstrates the need to consider NPH when older patients present with psychotic symptoms, particularly in the presence of cognitive impairment, gait disturbance, or incontinence. The decision whether to perform a shunting operation is often difficult, because selection of patients with good prognosis is still inaccurate. CT scanning of the brain is an important investigation in older patients presenting with both functional and organic disorders.

Attitudes to death were explored in 125 community residents aged 81 and older. Those people who thought about dying had less frequent contact with their interview informant; those who thought about death more frequently showed less severe cognitive impairment, a greater severity of depressive symptoms, and were more likely to be unmarried and were more commonly reported to be depressed by their interview informant. Worries about dying showed no association with sociodemographic or clinical variables. The commonest category of response from spontaneous comments was concerning the circumstances of dying. The results are discussed in light of other research findings, and emphasize the influence of low mood and social factors on death attitudes. This may have implications for closer examination of such attitudes in the assessment of depression and suicidal risk as well as in the care of the dying.

The Mini-Mental State Examination (MMSE) is a widely used screening test for cognitive impairment in older adults. Because the guidelines for its application are brief, the administration and scoring of the test can vary between different individuals. This can diminish its reliability. Furthermore, some of the items must be changed to accommodate different settings, such as the clinic, home, or hospital. Because there are no time limits, it is not clear how long one should wait for a reply to a question. It is also not clear how one deals with answers that are “near misses.” The goal of the Standardized Mini-Mental State Examination (SMMSE) was to impose strict guidelines for administration and scoring to improve the reliability of the instrument. The reliability of the MMSE was compared with the reliability of the SMMSE in 48 older adults who had the tests administered by university students on three different occasions to assess the interrater and intrarater reliability of the tests. The SMMSE had significantly better interrater and intrarater reliability compared with the MMSE: The interrater variance was reduced by 76% and the intrarater variance was reduced by 86%. It took less time to administer the SMMSE compared with the MMSE (average 10.5 minutes and 13.4 minutes, respectively). The intraclass correlation for the MMSE was .69, and .9 for the SMMSE. Administering and scoring the SMMSE on a task-by-task basis are discussed.

There is a paucity of research that examines the role of family members and friends in the lives of older schizophrenia patients. This study compared 66 middle-aged and elderly outpatients with 31 normal comparison subjects. Five dimensions of social network were assessed: (a) family composition, geographic proximity, and frequency of contact; (b) instrumental support; (c) emotional support and interpersonal difficulties; (d) role of friends; and (e) use of formal service providers as sources of support and assistance. As compared with normal subjects, the schizophrenia patients were less likely to be married, less likely to have children, more likely to live alone, and had fewer friendships. The patients were, however, similar to comparison subjects on the following family-relationship variables: frequency of contact, instrumental support received, presence of a family confidant, and extent of interpersonal difficulties. These findings do not support the stereotype of older schizophrenia patients as being estranged from family members. The need for developing interventions that use key family members to interface with service providers and to monitor treatment compliance and continuity of care is discussed.

Aggressive behavior among the elderly is a neglected area of research. An 18-week prospective study of aggressive behavior on a continuing-care psychogeriatric ward provided data to examine the relationship between two aggression scales (SOAS and RAGE). There was a strong and significant correlation between the SOAS and RAGE scales for the total and the subscale scores. Both these scales appear useful in measuring aggressive behavior among continuing-care psychogeriatric inpatients. Also, the nursing staff can be trained to complete these scales effectively.

The purpose of this study was to obtain information about the prevalence of depressive symptoms in a representative sample of elderly subjects aged 85 years and over. The study was carried out as a population-based interview study in the City of Vantaa in Finland. The Zung Depression Status Inventory (DSI) was used to evaluate various depressive symptoms in this study population. The DSI scores range from 20 to 80; the higher the score, the more severe the disturbance. In subjects interviewed (n = 467, 362 women, 105 men), the prevalence estimates of depression with cutoff scores used in earlier studies (40 and 48) were very low: 5.2% and 1.1%. Also, the mean DSI score (SD) was very low, 27.9 (6.4). The scores tended to decrease with age, although the differences were not statistically significant. The DSI means were 28.0 (6.1) for women and 27.3 (7.2) for men (p = .0349). Women had a greater risk of being classified as depressed on the DSI (odds ratio: 1.60, 95% confidence interval: 1.00-2.57, p = .049). Feelings of emptiness, personal devaluation, and depressive mood were the most common depressive symptoms. In conclusion, the present population-based study shows that subjective experience of depression is very rare in Finnish people aged 85+. Our results suggest that optimistic mood might give some protection against death.

Alcohol abuse and dependence are an increasing health problem among the elderly, but there is only scanty information about their prevalence and associated risk factors in developing countries. The authors set out to evaluate the prevalence and associated clinical/demographic features of alcoholism in a sample of male elderly subjects attending a Geriatric Primary Health Outpatient Clinic in a State University Hospital in the City of São Paulo-Brazil. Three hundred four patients were assessed with the Brazilian version of the Michigan Alcoholism Screening Test and a semistructured questionnaire designed to investigate associated features. Lifetime alcoholism was present in 15.1% of the sample, although only 4.3% were active drinkers. Patients classified as “cases” were younger than their nonalcoholic counterparts (70.61 vs. 73.31), and there was a mild, though not significant, excess of Blacks and Mulattos among the former (32.6% vs. 15.9%). Cases were also more likely to rely on their family for financial support (59.0% vs. 43.5%) and to acknowledge a positive family history of alcoholism (51.4% vs. 31.2%). Alcohol abuse or dependence was further associated with heavy smoking (58.7% vs. 44.0%). The authors concluded that alcoholism in this Brazilian elderly sample was likely to be associated with an earlier age at onset of medical problems, financial dependence, Black/Mulatto race smoking, and positive family history of alcohol abuse/dependence. The authors suggest that the use of standardized methods of assessment of alcoholism in general medical settings may increase the detection of case and contribute to improved health measures for the management of these patients.

Neuropsychological assessment involves the observation and measurement of an individual's behavior in relation to a given stimulus that has been selected for its likelihood to provoke an abnormal response in the presence of neurological damage. This approach incorporates a medical and psychological approach to diagnosis in that both pathology-specific signs and deviations from normal distributions are examined. In the case of Alzheimer's disease (AD), this methodology has assumed considerable importance. This is because behavioral indicators remain the principal basis for provisional diagnosis when there are no biological markers. Observations of elderly persons with and without senile dementia have led to the development of stimuli, or tests, that are able to assess the functioning of specific cognitive processes affected in AD as opposed to more common age-associated changes. Many of these tests have been found to be culturally portable. Diagnostic difficulties arise principally from the fact that many neuropsychological tests cannot be used in isolation, from uncertainty as to the limits of “normal” functioning and from the psychometric problems related to pathological thresholds and item-weighting. The usefulness of neuropsychological testing in the future could undoubtedly be enhanced by the use of measures derived from indices of decline in functioning rather than normative data and the development of functional testing in collaboration with cerebral imaging.