Anxiety of Alzheimer's disease: prevalence, and comorbidity

BACKGROUND

Anxiety may be associated with psychiatric morbidity, disability, increased health care utilization, and mortality in Alzheimer's disease (AD) patients as it is in the general adult population. However, the phenomenology of anxiety symptoms in AD and its relationship to dementia progression, comorbid depression, and the presence of other problematic behaviors have not yet been examined.

METHOD

Data on anxiety symptoms and their coexistence with other factors were obtained in 523 community-dwelling AD patients through interviews with their caregivers and direct physical examination. The prevalence of anxiety symptoms and their association to patient depression, other behavioral problems, gender, and age was investigated.

RESULTS

Anxiety symptoms were common, occurring in 70% of subjects. Anxiety symptoms were significantly correlated with ADL impairment and other behavioral disturbances, including wandering, sexual misconduct, hallucinations, verbal threats, and physical abuse. Comorbidity of anxiety-depression was also prevalent: 54% of the sample had both anxiety and depression symptoms. ADL impairment and problem behaviors were significantly associated with comorbidity; however, the latter association was explained entirely by the presence of anxiety.

CONCLUSION

Anxiety symptoms were common and significantly related to ADL and additional neuropsychiatric problems in this sample. These results indicate the need for additional research into the phenomenology of anxiety and comorbid anxiety-depression in AD and for the development and investigation of effective assessment and treatment of anxiety in AD clinical practice.

Clinico-neuropathological correlation of Alzheimer's disease in a community-based case series

OBJECTIVES

Most clinico-neuropathological correlative studies of Alzheimer's Disease (AD) are based on research cohorts that are not necessarily generalizable to patients seen in the general medical community. In this study, we examine the accuracy of the criteria used in diagnosing AD in a community-based case series of patients with memory complaints.

DESIGN AND PARTICIPANTS

Clinical and neuropathological diagnoses were obtained from 134 patients evaluated for dementia who subsequently underwent autopsy.

SETTING

Subjects who exhibited new symptoms of dementia and were enrolled in the University of Washington/Group Health Cooperative Alzheimer's Disease Patient Registry were eligible for this study.

MEASUREMENTS

Clinico-pathological correlation was performed using NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and CERAD (Consortium to Establish a Registry for Alzheimer's Disease) criteria.

RESULTS

Ninety-five of the 134 cases studied met CERAD neuropathological criteria for AD. The sensitivity of NINCDS-ADRDA "probable AD" was 83% (diagnosing AD correctly) and overall clinical diagnostic accuracy was 75%. However, there was a high rate of additional neuropathological findings. Only 34 of the 94 cases had pure AD on neuropathology, whereas the remainder frequently had coexisting vascular or Parkinson's disease lesions.

CONCLUSIONS

This study of a large series of community-based incident dementia cases provides a way of judging the adequacy of currently available clinical diagnostic criteria. It also shows that co-existing neuropathological findings are common in community-based AD.

Alzheimer's disease symptom severity in blacks and whites

OBJECTIVE

In order to determine whether there are racial differences in Alzheimer's Disease (AD) symptom severity and vascular comorbidities, we compared African-American (black) and Caucasian (white) patients with AD from similar socioeconomic backgrounds at the time the disease was first recognized.

DESIGN

Cross-sectional observational study from a population-based dementia registry.

PARTICIPANTS

Patients were enrolled from an HMO base population of 23,000 persons more than age 60 in Seattle, Washington. This study examines 453 subjects with probable AD (38 blacks (mean age 76.5, SD 6.4), and 415 whites (mean age 79.7, SD 6.7)).

MEASUREMENTS

Measured were patient demographics, age at onset of AD, AD symptom duration, Mini-Mental State Exam (MMSE) score, Blessed Dementia Rating Scale, presence of psychiatric symptoms, and vascular comorbidities.

RESULTS

Blacks had significantly lower mean cognitive scores (MMSE = 17.2, SD 5.6) compared with whites (MMSE = 20.2, SD 5.2, unpaired t test P < .01). The significant racial difference in MMSE scores persisted after controlling for education, duration of AD symptoms, age, and ADL impairment. Blacks and whites did not differ significantly regarding gender distribution, education level, income, or percent with early age of onset of AD. No statistically significant race-related differences were found in impairments in activities of daily living or symptoms of paranoia, hallucinations, or agitation. Blacks had significantly higher rates of hypertension (56%) compared with whites (34%) (Fisher's exact test, P = .013), but the rates of stroke and ischemic heart disease were similar.

CONCLUSIONS

Despite uniform detection methods and controlling for reported duration of dementia symptoms, measured cognitive impairment is significantly more severe when AD is recognized in blacks compared with whites. The significantly higher prevalence of hypertension among black AD cases was not associated with excess cerebrovascular disease comorbidity. This study highlights a need for normative measurements of cognitive function in minority AD groups in order to distinguish differential cognitive symptom severity from possible measurement bias.

Training families to provide care: effects on people with dementia

This paper addresses four questions concerning family training in dementia care: (1) What do we know about what works? (2) How do we know it? (3) What do we now need to know? (4) How should we go about trying to find this out? In addition, it provides some introductory information on the nature of family caregivers in dementia and the phenomenology of caregiver burden and behavioral problems in dementia, often the focus of family training. Training families to provide care to dementia patients has a long clinical history. In recent years, the amount and popularity of this kind of information has grown exponentially, as is evident in the proliferation of books, training materials and informational handouts. Even video and world wide web technology is now used to educate caregivers. Over a decade ago, reports showed that caregivers were able to learn specific behavioral techniques and successfully reduce problematic behaviors. More recently, controlled trials have suggested the effectiveness of caregiver training programs in reducing behavioral problems or delaying institutionalization in patients with dementia. There is much still unknown concerning family training in dementia care. Additional controlled clinical trials are needed, as are additional studies to understand the broader factors known to influence effective care, such as patient and caregiver physical health or family and social supports.

A comparison of the Cohen-Mansfield agitation inventory with the CERAD behavioral rating scale for dementia in community-dwelling persons with Alzheimer's disease

In a group of 242 community-dwelling patients with Alzheimer's disease (AD), a longitudinal comparison was made of two caregiver-administered instruments for assessment of behavioral disturbance; the Cohen-Mansfield Agitation Inventory (CMAI) and the CERAD Behavioral Rating Scale for Dementia (BRSD). We examined records of the 206 patients with baseline and 12-month follow-up data for the CMAI and the BRSD who also had tests of cognitive (Mini-mental State; MMSE) and global function (Clinical Dementia Rating; CDR and Functional Assessment Staging; FAST). Among 114 AD subjects, the correlation between total CMAI at baseline and 1 month readministration was 0.83 (p < 0.0001). In the same subjects, stratified into 5 groups by MMSE scores, the correlations between BRSD baseline and 1-month scores ranged from 0.70-0.89 (p < 0.0001). There was high correlation between total scores of both instruments at baseline and 12 months. In addition, all CMAI subscales except Verbally Aggressive correlated significantly with total BRSD score at both time points. At baseline, BRSD subscales for irritability/aggression, behavioral dysregulation and psychotic symptoms and at 12 months, irritability/aggression and behavioral dysregulation correlated with total CMAI scores. Neither scale changed significantly over 1 year, but there was wide individual variation. CMAI and BRSD scores correlated with 1-year change in the FAST, but not with MMSE or CDR (which weighs cognition heavily), suggesting that behavioral disturbance may be more strongly related to ability to manage activities of daily living (executive function) than to other aspects of cognition. The CMAI and BRSD appear to be interchangeable as measures of agitation, with the CMAI possibly more useful for patients who lack language and the BRSD more sensitive to apathy and depression.

Exercise and activity level in Alzheimer's disease: a potential treatment focus

This article provides information on the baseline health and physical function of 30 individuals with Alzheimer's disease (AD); describes a community-based program designed to increase balance, flexibility, strength, and endurance in these persons by the training of caregivers to facilitate and supervise exercise activity; and documents the adherence of these subjects and their caregivers to this intervention. Subjects were recruited from an ongoing, community-based Alzheimer's Disease Patient Registry, and met NINCDS-ADRDA criteria for probable or possible AD. Caregivers were family members living with the demented individuals in the community. Physical performance was measured using walking speed, functional reach, and standing balance. Health status was measured with the Medical Outcomes Study Short Form, the Sickness Impact Profile, and caregiver reports of subject's restricted activity days, bed disability days, falls, and exercise participation. Baseline data indicated that persons with AD were impaired on measures of physical performance and function, compared to published data on nondemented older adults. During a 12-wk treatment period, caregivers were taught to guide their demented charges in an individualized program of endurance activities (primarily walking), strength training, and balance and flexibility exercises. Adherence data indicated that 100% of the subjects were compliant with some exercise recommendations, and one-third completed all assigned exercises during the training period. Caregivers were able to learn and direct subjects during scheduled exercise activities. These findings indicate that the integration of exercise training into the care of persons with AD is both needed and feasible. Further research is currently underway to determine the efficacy of this approach for reducing additional physical disability in these individuals.

Wandering: a significant problem among community-residing individuals with Alzheimer's disease

This study evaluated the frequency, predictors, and effects of wandering in a population-based sample of 193 individuals with Alzheimer's disease (AD). Although wandering occurred in subjects at all levels of cognitive impairment, analysis of variance indicated that for the group as a whole, greater frequency of wandering was associated with significantly more impairment in cognition, day-to-day functioning, and behavior. Caregiver distress also increased significantly with increased frequency of wandering. Logistic regression modeling identified functional impairment and disruptive behavior problems as the strongest independent predictors of wandering occurring within the past week. Cluster analysis revealed four characteristic groups of wanderers that represented a continuum of wandering frequency, each having a unique pattern of other behavioral disturbances. Based on this analysis, we recommend further evaluation and the development of possible treatment strategies that address the individual differences found among AD patients who wander.

Accelerated decline in apolipoprotein E-epsilon4 homozygotes with Alzheimer's disease

BACKGROUND

The apolipoprotein E-epsilon4 (APOE-epsilon4) allele is a powerful genetic risk factor for the development of Alzheimer's disease (AD). AD patients who are APOE-epsilon4 homozygotes have an earlier age at onset, increased amyloid burden, and decreased acetylcholine levels--findings that suggest differences in disease severity or rate of progression. Studies of genotype differences in rate of decline, however, have produced negative results that may be due to methodologic biases. The current study examined rate of decline in the largest sample of APOE-genotyped AD patients for whom longitudinal cognitive data have been reported.

METHODS

Newly diagnosed patients with probable AD (n = 201) comprised four genotype groups: epsilon2/3 (n = 14), epsilon3/3 (n = 75), epsilon3/4 (n = 82), and epsilon4/4 (n = 30). The Dementia Rating Scale (DRS) was administered at baseline and then annually for 1 to 6 years (mean, 2.5 years). For each subject, a DRS slope was calculated reflecting annual rate of decline. Rate of decline as measured by DRS slope differed according to genotype, with the effect modified by DRS score (p < 0.014). At the mean DRS score observed in our sample (DRS = 105), the epsilon4/4 group had an increased rate of decline (11.9 points per year) relative to the epsilon2/3 (5.8 points per year; p < 0.003), epsilon3/3 (9.3 points per year; p < 0.076), and epsilon3/4 (9.6 points per year; p < 0.055) groups. At a lower DRS score (DRS = 80), even larger differences were observed among genotypes; the epsilon4/4 group had a increased rate of decline (22.2 points per year) relative to the epsilon2/3 (9.7 points per year; p < 0.0006), epsilon3/4 (15.8 points per year; p < 0.020), and epsilon3/3 (18.2 points per year; p < 0.173) groups. The epsilon2/3 group had a significantly slower rate of decline than all other groups at DRS scores of 80 or 105.

CONCLUSIONS

APOE-epsilon4 homozygosity is associated with a faster rate of cognitive decline, whereas the epsilon2 allele slows disease progression. These findings suggest that APOE plays a mechanistic role in the progression of AD, and is not simply related to disease onset.

Successful behavioral treatment for reported sleep problems in elderly caregivers of dementia patients: a controlled study

Although sleep problems are common among dementia caregivers, there has been no research thus far describing treatment of such problems using behavioral techniques. In this study, 36 elderly dementia caregivers with disturbed sleep were randomly assigned to either a brief behavioral intervention or a wait list control. The active treatment consisted of standard sleep hygiene, stimulus control, and sleep compression strategies as well as education about community resources, stress management, and techniques to reduce patient disruptive behaviors. Caregivers in active treatment showed significant improvements in sleep at post-treatment and 3-month follow up. No significant differences between groups were observed for caregiver mood, burden, or patient behavior problems, suggesting that sleep improvements were not an artifact of depression treatment. Treatment responders tended to be younger and more compliant with treatment recommendations than non-responders. Results suggest that behavioral techniques may well be a viable alternative to medication for sleep problems in aging caregivers.

Measuring behavior, mood, and psychiatric symptoms in Alzheimer disease

Behavioral disturbances, psychiatric symptoms, and mood disorders are prevalent, persistent, and debilitating aspects of the clinical course of Alzheimer disease. The authors discuss the phenomenology of these problems, their importance in understanding disease course and planning treatment, and the current state-of-the-art methods for assessment. Issues to consider in assessment of these problems also are discussed.

Behavior and caregiver burden: behavioral problems in patients with Alzheimer disease and its association with caregiver distress

Behavioral dysfunction in Alzheimer disease (AD) is a major influence on the morbidity and disability of patients and is central to decisions on patient institutionalization. Behavioral dysfunction ranges from withdrawal, apathy, and depression to hostility, anger, and aggression, with most patients exhibiting some symptoms during the course of the disease. Symptoms of depression are common in AD patients (17-30%) and are associated with broad behavioral dysfunction and increased functional disability. Furthermore, the occurrence of depression in patients correlates strongly with caregiver burden and depression. This report summarizes the relationship between caregiver distress and patient behavioral problems. Administration of the Revised Memory and Behavior Problem Checklist provided information on the frequency of behavioral problems and their association with caregiver distress. In one study of 201 patient-caregiver dyads, depression-related behaviors were confirmed as the most distressing to caregivers. In another, the rates of caregiver depression were high (75%) among those caring for clinically depressed AD patients. Indeed, in a third study, 100% of patients with depression had depressed caregivers. The vulnerability of caregivers to depression is linked to their own age, gender, physical ability, personality, and available social supports. Alleviation of caregiver distress, burden, and depression will be of great value in the improvement of AD patient care.

Memory, thinking, and aging. What we know about what we know

Cognition is the foundation that underlies all daily activities, from the most basic to the most complex. Successful aging depends, in large part, on maintaining a level of cognitive ability that allows a person to interact effectively and appropriately with the environment. In the following article we provide an overview of the effects of aging on cognition; discuss physical, social, and psychological factors that have been shown to influence cognition in old age; and review current literature on interventions that may optimize successful cognitive aging. We conclude with a discussion of abnormal cognitive aging and review current research on risk factors and treatments of Alzheimer's disease and other dementing illnesses.

Head injury and risk of Alzheimer's disease by apolipoprotein E genotype

Head injury and apolipoprotein E (APOE)-epsilon 4 (e4) genotype have each been associated with increased risk of Alzheimer's disease. If APOE-e4 affects neuronal viability and branching, and if response to head injury differs in e4 patients, then the association between head injury and Alzheimer's disease may vary with the presence of the e4 allele. The authors examined this association in a case-control study conducted between 1987 and 1995 among enrollees of the Group Health Cooperative of Puget Sound, a health maintenance organization in Seattle, Washington. Proxy informants reported prior head injury with loss of consciousness for 32 of 349 patients with probable Alzheimer's disease and for 16 of 342 control subjects of similar age and sex who had been randomly selected from the same population (odds ratio (OR) = 2.1, 95% confidence interval (CI) 1.1-3.8). Elevated risk was observed among men (OR = 4.2, 95% CI 1.5-11.5) but not among women (OR = 1.1, 95% CI 0.5-2.6). No significant variation in the head injury-Alzheimer's disease risk relation by APOE-e4 genotype was found among 230 cases and 309 controls (OR = 3.1 (95% CI 0.7-14.6) for persons with at least one e4 allele and OR = 2.0 (95% CI 0.8-5.2) for those without e4). Neither age, education, race, type of proxy informant, nor duration of relationship with the proxy confounded the association. Head injury with loss of consciousness, although uncommon in this sample, was associated with increased risk of Alzheimer's disease. APOE-e4 was an independent risk factor which neither modified nor confounded the association. Susceptibility to Alzheimer's disease as conferred by APOE-e4 does not appear to increase the risk associated with head injury.

Behavioral treatment of depression in dementia patients: a controlled clinical trial

The current study is a controlled clinical investigation of two nonpharmacological treatments of depression in patients with Alzheimer's disease. Two active behavioral treatments, one emphasizing patient pleasant events and one emphasizing caregiver problem solving, were compared to an equal-duration typical care condition and a wait list control. Seventy-two patient-caregiver dyads were randomly assigned to one of four conditions and assessed pre-, post-, and at 6-months follow-up. Patients in both behavioral treatment conditions showed significant improvement in depression symptoms and diagnosis as compared with the two other conditions. These gains were maintained at 6-month follow-up. Caregivers in each behavioral condition also showed significant improvement in their own depressive symptoms, while caregivers in the two other conditions did not. Results indicate that behavioral interventions for depression are important and effective strategies for treating demented patients and their caregivers.

Progression to dementia in patients with isolated memory loss

BACKGROUND

The diagnosis of dementia requires both memory loss and at least one other type of cognitive impairment. The natural history of patients with severe memory loss but no other type of cognitive impairment is poorly understood. We studied progression to dementia in patients with isolated memory loss.

METHODS

From a registry of 811 patients with cognitive complaints, 21 patients with severe isolated memory loss of unknown cause were identified and followed up for a mean of 48 months. A comparison group of 198 patients on the same register was identified with newly recognised cognitive complaints but without dementia or isolated memory loss (mean follow-up 31 months). We did a range of neuropsychological tests at intake.

FINDINGS

During follow-up, 48% (n = 10) of patients with isolated memory loss-developed dementia compared with 18% (n = 36) of the comparison group. Life-table analysis showed the mean times to a diagnosis of dementia was 3.77 years (95% CI 2.99-4.56) and 5.96 years (5.60-6.31), respectively (p = 0.01). The neuropsychological tests did not predict which patients would progress to dementia.

INTERPRETATION

Patients with severe isolated memory loss have an increased risk of developing dementia and should be closely followed-up.

The Pleasant Events Schedule-AD: psychometric properties and relationship to depression and cognition in Alzheimer's disease patients

The Pleasant Events Schedule-AD (PES-AD) has been described as a useful tool for identifying pleasant activities for Alzheimer's disease patients. The current investigation provides psychometric data on the PES-AD, introduces a shortened, 20-item version, and examines the relationship between pleasant events, cognitive functioning, and depression. Both versions of PES-AD had good reliability and were significantly correlated with each other and with other relevant measures. As hypothesized, both depression and decreased cognitive functioning were associated with reduced frequency of enjoyable activity, and the reduction was significantly greater in AD patients who were depressed than in those who were not depressed, regardless of cognitive level.

Alzheimer's disease and history of blood transfusion by apolipoprotein-E genotype

Some dementias, such as Creutzfeldt-Jakob disease, may result from transmissible agents. To assess the possibility of a blood-borne transmissible agent in Alzheimer's disease (AD), we compared informant-reported history of blood transfusions among 326 newly recognized probable AD cases and 330 control subjects of similar age and sex, randomly selected from the same health maintenance organization population. Since risk of AD is increased in persons with apolipoprotein E epsilon 4 (APOE-e4) alleles, we examined whether the transfusion-AD relationship varies by APOE genotype. Transfusion was more frequent among controls (17.9%) than cases (12.0%) in the overall group (crude odds ratio = 0.62; 95% confidence interval = 0.40, 0.97). Similar risks were seen for transfusions occurring < or = or > 10 years before the reference year. Stratified analysis by APOE-e4 genotype showed no effect modification. Logistic regression adjusting for age, sex, education, and presence of e4 did not change the transfusion-AD association. We conclude that a history of blood transfusion is not associated with increased risk of AD, nor does consideration of APOE-e4 status modify that conclusion.

Apolipoprotein E in Alzheimer's disease risk and case detection: a case-control study

The objective of this study was to describe the association between the epsilon 4 allele of the apolipoprotein E gene (APOE E4) and Alzheimer's disease (AD) and to evaluate APOE E4 genotyping as a test for AD. The study base of this case-control study included about 23,000 persons 60 year of age or greater (a large health maintenance organization); the demographic characteristics of this group are similar to those of the surrounding area. Analysis focused on 234 Caucasian probable AD patients first identified between 1987 and 1993; and 304 cognitively intact controls of similar age, sex, and race who were randomly selected from the same study base. All cases were examined and diagnosed by study physicians using standard protocols. All subjects participate in continuing annual follow-up testing to verify their cognitive status. APOE genotypes were determined from blood samples using standard laboratory methods. Subject characteristics and diagnoses were obtained from interviews, diagnostic examination, or medical record review. Heterozygous E4 individuals had a crude odds ratio of 3.1 (2.1-4.5) for AD compared to those with no E4, while homozygous E4 subjects had an odds ratio of 34.3 (8.0-146.3) for AD. As an indicator of AD, having one E4 allele showed a sensitivity of 0.52 and a specificity of 0.74. Homozygous E4 genotype had a sensitivity of 0.23 and a specificity of 0.99 (when compared to non-E4 genotypes). Cardiovascular disease differed in cases and controls, but did not confound or modify the APOE E4-AI) association. In this study base, the APOE E4 allele was a significant risk factor. However, considering either homozygous or heterozygous E4 genotype as a screen or diagnostic marker for AD would miss many true cases and could misclassify many normals as AD.

Predictors of mortality in patients diagnosed with probable Alzheimer's disease

OBJECTIVE

We sought to identify factors associated with mortality in persons recently diagnosed with probable Alzheimer's disease (AD).

BACKGROUND

Predicting mortality in AD in needed both in patient care and public health planning. Previous studies have identified several factors which contribute to mortality in AD, but few longitudinal studies of population-based cohorts exist.

METHODS

In a longitudinal follow-up study 327 patients with newly diagnosed probable AD (mean Mini-Mental State Examination [MMSE] score of 20) from a large, stable health maintenance organization were identified. Demographic characteristics, dementia severity, and comorbid conditions were identified at enrollment. Patients were followed longitudinally (median 3.3 years, total 898 person-years). Baseline characteristics were used to predict survival in univariate and multivariate models.

RESULTS

Increased mortality was seen in patients with probable AD (9.0 deaths per 100 person-years) compared with the community population adjusted for age and gender (4.3 deaths per 100 person-years). On univariate analysis we found increased age, male gender, impairment on MMSE or Blessed dementia rating scale (DRS), rate of MMSE decline, wandering or agitation, vascular disease, and sensory impairment affecting the ability to read or hear to be moderately associated with decreased survival. After adjusting for age and gender in a multivariate model, Blessed DRS score and sensory impairment affecting the ability to read were independently associated with decreased survival.

CONCLUSIONS

Short-term mortality is increased in patients newly diagnosed with probable AD. Measures of dementia severity, measures of general debility, and vascular disease are associated with increased mortality. Of these, general debility and sensory impairment were more strongly associated with shortened survival.

Selecting outcome measures for clinical trials of behavioral disturbances of dementia

The usefulness of data generated by clinical trials of patients with behavioral disturbances of dementia depends heavily on the study design and the measures used to determine patient outcomes. Several rating scales are available to assess general behavioral problems, agitation, and depression in patients with dementia. The appropriate rating tool depends not only on the purpose of the study but also on whether the measure meets the criteria discussed subsequently.

Geographically overlapping Alzheimer's disease registries: comparisons and implications

In the medical and epidemiologic literature, a registry denotes a data base in which registrants share some common characteristic such as disease category. One criticism of registries is that they frequently collect subjects in a haphazard fashion and, hence, are "nonrepresentative of the population purportedly being represented." In this report, we compare two registries: an incident-based Alzheimer's Disease Patient Registry (ADPR) recruiting subjects for epidemiologic studies from a large health maintenance organization; and an Alzheimer's Disease Research Center (ADRC) registry recruiting subjects for phenomenologic, biologic, and pharmacologic studies. While these registries share personnel, overlap geographically, and use similar diagnostic procedures, they differ substantially in their missions and resulting recruitment strategies. We compared these registries with respect to demographic characteristics and cognitive features at subject entry. Subjects enrolled in the incident-based registry are older and report shorter time between symptom onset and recruitment. They are less demented and mirror the general population demographically more closely than do subjects in the other registry. The ADRC registry contains a much greater proportion of subjects with higher educational attainment.

Methodologic issues regarding outcome measures for clinical drug trials of psychiatric complications in dementia

Selecting outcome measures that are both psychometrically sound and sensitive to change is a very important aspect of clinical outcome research. A variety of measures have been introduced in recent years to assess behavioral complications in dementia, but few have been adequately tested in clinical trials. This article provides a discussion of factors to consider in selecting measures, including psychometrics, item content, assessment source, and sensitivity to change. A review of behavioral and psychiatric measures for dementia patients is provided, including measures of general behavioral disturbance, and measures specifically developed for agitation and depression. Each measure's psychometric characteristics, prior use with demented patients, and strengths and weaknesses with regard to treatment outcome research is summarized. The importance of linking measures to the investigators' hypotheses is discussed, along with recommendations for evaluating and selecting outcome measures depending on the needs of the specific investigation.