Multi-infarct dementia: diagnosis and management. Infarctions produce 20% to 35% of severe dementia cases

Depressive symptoms in late life: a 10-year follow-up

The objectives of this study were to describe the changes occurring in depressive symptomatology over a 10-year period among 75-year-old residents of Jyväskylä, Finland. It also addressed the question of whether the mood disturbances detected were a permanent phenomenon or whether they had a more episodic nature. In addition, various associations with and predictors of low mood were studied. Depressive symptoms were screened with the Center for Epidemiologic Studies Depression Scale (CES-D).The cut-off point of 16 was used to distinguish depressed individuals from those classified as non-depressed. A baseline study was carried out in 1989 (n = 337). A 5-year follow-up was carried out with the same cohort in 1994 (n = 222) and a 10-year follow-up in 1999 (n = 131). The permanent versus episodic nature of depressed mood was studied by comparing the three-wave longitudinal depression score findings of different individuals. In the follow-up settings, multivariate logistic regression models adjusted for sex were used to find predictors of depressiveness. Looking at the prevalence of depressiveness we found a statistically significant increase in the figures for women particularly from age 80 to 85 years. The much lower mean scores recorded for men in earlier measurements reached the same level as for women at age 85 years. Loneliness, a large number of chronic diseases, poor self-rated health, poor functional capacity, poor vision and perceived negative changes in life predicted depressive symptomatology. It seemed that minor depression among the elderly was most typically an episodic phenomenon.

Comparison of different diagnostic criteria for vascular dementia (ADDTC, DSM-IV, ICD-10, NINDS-AIREN)

BACKGROUND AND PURPOSE

Vascular dementia (VD) has been an ill-defined term thus far. Recently detailed criteria for the diagnosis of VD have been proposed (Alzheimer's Disease Diagnostic and Treatment Centers [ADDTC], 1992; Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV], 1994; International Classification of Diseases, 10th revision [ICD-10], 1992, 1993; and National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences [NINDS-AIREN], 1993). Until now the clinical feasibility of these diagnostic guidelines has not been evaluated.

METHODS

This study aimed to compare these criteria in an unselected sample of 167 elderly patients (mean age, 72.0 +/- 9.9 years) admitted with probable dementia.

RESULTS

The number of cases that could be classified as VD differed widely between the various diagnostic guidelines. According to DSM-IV criteria, 45 cases were diagnosed as VD. Twenty-one cases fulfilled the ICD-10 research criteria, but only 12 met the NINDS-AIREN criteria for VD. Twenty-three cases were classified as ischemic VD as defined by the ADDTC criteria. The concordance was very poor since only 5 cases met the criteria for VD of all diagnostic guidelines.

CONCLUSIONS

Our results show that the classification according to different diagnostic guidelines yields rather distinct groups of patients. The reasons responsible for these findings are as follows: (1) different criteria for dementia, (2) limitation to ischemic VD in the ADDTC criteria, (3) no further differentiation of VD into subtypes according to CT or MRI findings (DSM-IV), and (4) the multifactorial etiopathology of VD. Major diagnostic difficulties ensue from the very frequent cases with white matter lesions, since their etiology and classification remain widely unknown.

Dementia: diagnosis and emergency behavioral complications

Dementia is a relatively common syndrome seen in the elderly emergency department population. The emergency physician usually sees demented patients secondary to behavioral complications. Diagnosing the syndrome of dementia principally consists of ruling out treatable causes, which can be performed either in an in-patient or out-patient location. The emergency presentations of dementia include disturbances of activity, aggression, and psychosis. Complications that are primarily treated non-pharmacologically include circadian rhythm disturbance, catastrophic reaction (excessive emotional response), and wandering, as well as some mild verbal outbursts and delusions. Pharmacologic interventions are usually necessary for agitation, physical attacks, and significant delusions or hallucinations. Neuroleptic medication is the principal pharmacologic class with which to treat these symptoms, although benzodiazepines are also effective.

Clinical determinants of dementia related to stroke

Among 251 patients examined 3 months after the onset of acute ischemic stroke, we diagnosed dementia in 66 (26.3%) by using modified DSM-III-R criteria based on neuropsychological, neurological, functional, and psychiatric examinations. We used a logistic regression model to derive odds ratios (ORs) for clinical factors independently related to dementia in this cross-sectional sample. Dementia was significantly associated with age, education, and race. A history of prior stroke (OR = 2.7) and diabetes mellitus (OR = 2.6) was also independently related to dementia, but hypertension and cardiac disease were not. Stroke features associated with dementia included lacunar infarction compared with all other subtypes combined (OR = 2.7) and hemispheric laterality in relation to brainstem or cerebellar location. There was a predominance of dementia in patients with left-sided lesions (OR = 4.7), an effect not explained by aphasia. Dementia was especially common with infarctions in the left posterior cerebral and anterior cerebral artery territories. A major dominant hemispheral syndrome (reflecting size and laterality) was also independently associated with dementia (OR = 3.9). We suggest that dementia after ischemic stroke is a result of multiple independent factors, including both small subcortical and large cortical infarcts especially involving the left medial frontal and temporal regions, with additional contributions by demographic and vascular risk factors.

A population-based study of dementia in 85-year-olds

BACKGROUND

The aim of this study was to investigate the causes, severity, and prevalence of dementia in a representative sample of 494 85-year-olds living in Gothenburg, Sweden.

METHODS

The study included a psychiatric interview, neuropsychological and physical examinations, comprehensive laboratory tests, electrocardiography, chest radiography, computed tomography (CT) of the head, and analysis of cerebrospinal fluid. A person close to each subject was also interviewed. Dementia was defined according to the criteria proposed in the Diagnostic and Statistical Manual of Mental Disorders (third edition, revised), Alzheimer's disease according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association, and vascular dementia according to recently proposed criteria that incorporate information from CT scanning and the patient's neurologic history.

RESULTS

The prevalence of dementia was 29.8 percent (147 subjects). The condition was mild in 8.3 percent, moderate in 10.3 percent, and severe in 11.1 percent. There were no significant sex-related differences in prevalence or severity. Of the subjects with dementia, 43.5 percent had Alzheimer's disease, 46.9 percent had vascular dementia (multi-infarct dementia in 34.6 percent, dementia related to cerebral hypoperfusion in 4.1 percent, and mixed dementia in 8.2 percent), and 9.5 percent had dementia due to other causes. The three-year mortality rate was 23.1 percent in the subjects without dementia, 42.2 percent in the patients with Alzheimer's disease, and 66.7 percent in the patients with vascular dementia. Infarcts detected by CT scanning were significantly more common in the subjects with dementia than in those without it (27.9 percent vs. 12.6 percent).

CONCLUSIONS

Dementia was present in nearly a third of unselected 85-year-olds in Sweden. Almost half these subjects appeared to have vascular dementia, which may currently be more amenable to prevention or treatment than Alzheimer's disease.

Clinical evaluation of the ICD-10 criteria for vascular dementia

The clinical feasibility of the ICD-10 criteria for subtypes of vascular dementia were examined in an investigation of 61 demented patients (74.4, SD 8.2 years) showing CT appearances of vascular lesions. Only 15 cases (24.6%) fulfilled the ICD-10 criteria of vascular dementia. Of these cases, 66.6% could adequately be classified in subtypes. The most frequent types of vascular dementia were multi-infarct dementia and subcortical vascular dementia. Our findings suggest that the ICD-10 criteria of vascular dementia are more selective than the classical 'ischaemic scales'.

Behavioural disturbances in the demented elderly: phenomenology, pharmacotherapy and behavioural management

Behavioural disturbances in the demented elderly cause a significant amount of distress both to the patients and their caregivers. This article first summarizes the phenomenology associated with these disturbances. It then deals with the pharmacological methods of reducing these disturbances. Finally, it deals with some of the more recent advances in combining the insights of behavioural modification with those of neuropsychology in finding non pharmacological methods of reducing problematic behaviours. It is stressed that a combination of the two approaches is most likely to be required, and most likely to be successful, in the individual case.

Prevention of mental disorder in the elderly: current perspectives and future prospects

This article reviews primary, secondary, and tertiary preventive strategies in the mental health field. Primary prevention is currently restricted to some forms of dementia, but secondary and tertiary prevention can significantly diminish both short-term and long-term morbidity. Improved professional and lay education, better use of existing knowledge and resources, and improved communication among practitioners in the medical, psychosocial, and mental health fields can all lead to improved care at the present time.

Tailoring adult psychiatric practices to the field of geriatrics

The United States' population is aging. Epidemiological surveys suggest significant rates of mental illness amongst the rapidly growing over-65 cohort. A burgeoning experience and data base related to the developing sub-discipline of geriatric psychiatry is now available. This article synthesizes key issues and concepts as an introduction to geropsychiatric practice-in particular, a) the interface between medical illness and psychiatric expression in the elderly, b) delirium, c) dementia, and d) depression-and considers their interactions. Finally, there is a brief overview of geriatric psychopharmacology, followed by clinically-oriented discussions of each of the major classes of psychotropics as applied to a geriatric population.

The epidemiology of dementia in North America

In this brief review, the epidemiology of dementia in North America is examined. The areas covered are prevalence and incidence studies, longitudinal studies, risk factors, distribution of types of dementia, cross-cultural factors and current research programmes.

Principles of geriatric care

The increase in the numbers of elderly in the United States, and their projected continued increase to 21% or more of the population by 2030, has provided impetus for the growth of geriatrics. Recognition of change that is age-related rather than disease-related, and the ways in which the elderly differ from their young counterparts is vital in the care of the elderly. A functional approach and appropriate geriatric assessment have been shown to be beneficial to the individual.

The picture absurdities test in the evaluation of dementia

Recognition of picture absurdities was found to be significantly impaired in a group of patients with dementia of Alzheimer type compared to patients with dementia syndrome of depression and cerebrovascular dementia, even when matched for age, education, and dementia severity. None of the other neuropsychological measures investigated, including visual recent memory, Raven's progressive matrices, geographic orientation, and copying of geometric figures, resulted in a similar pattern. Although uncertainty remains as to what the picture absurdities test measures, normal performance likely depends on the integrity of many independently assessable variables, in addition to cognition and judgment utilizing visual data.

Age at onset in geriatric depression: relationship to clinical variables

The significance of age at onset of first depressive episode was evaluated in an elderly depressed population. A prospective study of 71 consecutively admitted inpatients with a diagnosis of major unipolar depression examined the relationship between age at onset of illness and several clinical variables. Subjects divided into early-onset (EO) and late-onset (LO) groups, matched for current age, did not significantly differ in terms of symptomatology, cognitive impairment, physical illness, family history or treatment responsivity. These findings do not support a nosologic separation of EO and LO depression in geriatric patients.