25-Hydroxyvitamin D, dementia, and cerebrovascular pathology in elders receiving home services

BACKGROUND

Vitamin D deficiency has potential adverse effects on neurocognitive health and subcortical function. However, no studies have examined the association between vitamin D status, dementia, and cranial MRI indicators of cerebrovascular disease (CVD).

METHODS

Cross-sectional investigation of 25-hydroxyvitamin D [25(OH)D], dementia, and MRI measures of CVD in elders receiving home care (aged 65-99 years) from 2003 to 2007.

RESULTS

Among 318 participants, the mean age was 73.5 +/- 8.1 years, 231 (72.6%) were women, and 109 (34.3%) were black. 25(OH)D concentrations were deficient (<10 ng/mL) in 14.5% and insufficient (10-20 ng/mL) in 44.3% of participants. There were 76 participants (23.9%) with dementia, 41 of which were classified as probable AD. Mean 25(OH)D concentrations were lower in subjects with dementia (16.8 vs 20.0 ng/mL, p < 0.01). There was a higher prevalence of dementia among participants with 25(OH)D insufficiency (< or =20 ng/mL) (30.5% vs 14.5%, p < 0.01). 25(OH)D deficiency was associated with increased white matter hyperintensity volume (4.9 vs 2.9 mL, p < 0.01), grade (3.0 vs 2.2, p = 0.04), and prevalence of large vessel infarcts (10.1% vs 6.9%, p < 0.01). After adjustment for age, race, sex, body mass index, and education, 25(OH)D insufficiency (< or =20 ng/mL) was associated with more than twice the odds of all-cause dementia (odds ratio [OR] = 2.3, 95% confidence interval [CI] 1.2-4.2), Alzheimer disease (OR = 2.5, 95% CI 1.1-6.1), and stroke (with and without dementia symptoms) (OR = 2.0, 95% CI 1.0-4.0).

CONCLUSIONS

Vitamin D insufficiency and deficiency was associated with all-cause dementia, Alzheimer disease, stroke (with and without dementia symptoms), and MRI indicators of cerebrovascular disease. These findings suggest a potential vasculoprotective role of vitamin D.

Multivitamin use and B vitamin status in a homebound elderly population

OBJECTIVE

Homebound elderly are at increased risk for micronutrient deficiencies and nutritional status in this population has not been adequately described. There is evidence for beneficial effects of multivitamin use and a greater understanding of their nutritional contribution could identify behaviors that may help alleviate excess chronic disease. The purpose of this analysis is to investigate, in a racially diverse group of homebound elders, the association of multivitamin use with measures of plasma B vitamin concentrations.

DESIGN

We examined the cross-sectional association between multivitamin use and plasma concentrations of B vitamins and homocysteine in 236 white and 182 black homebound elders (65-99y). Dietary intake was assessed and demographic and health information was ascertained.

RESULTS

White and black elders had a high prevalence of dietary intakes below the Estimated Average Requirement for folate (38.1 and 40.7%), vitamin B6 (16.9 and 19.2%.), and vitamin B12 (3 and 3.9%) respectively. Multivitamin use was associated with higher mean plasma B vitamin concentrations in each group. In whites, multivitamin users had higher concentrations of vitamin B6 (64.6 vs. 32.4 nmol/L; p < 0.001), vitamin B12 (398 vs. 324 pmol/L;p < 0.001) and folate (39.4 vs. 30.4 nmol/L;p < 0.001). Black multivitamin users had higher concentrations of vitamin B6 (53.7 vs. 29.5 nmol/L; p < 0.001), B12 (427 vs. 372 pmol/L; p < 0.05) and folate (35.7 vs. 25.4 nmol/L; < 0.001) than non-users.

CONCLUSIONS

Multivitamin supplementation was associated with higher mean plasma concentrations of vitamins B6, B12, and folate and lower prevalence of low plasma B vitamin status in a biracial homebound elderly.

[Micro-Mental Test - a short method of dementia screening]

Especially in outpatient settings, dementia is still an underdiagnosed syndrome. The Micro-Mental Test has been developed as a short version of the Mini-Mental-Status Examination (MMSE). We examined the reliability and diagnostic validity of a German version (Mikro-Mental Test). We administered the MMSE and the German version of the Micro-Mental Test to 20 inpatients of a geriatric psychiatry hospital (mean age 74.8+/-8.1 years), 55 patients from a cognitive clinic (mean age 71.9+/-9.1 years), and 27 healthy older adults (mean age 68.5+/-4.1 years). Diagnoses made by an experienced psychiatrist according to ICD-10 criteria served as external criteria. The mean duration for testing with the Micro-Mental Test was 8 min, and with the MMSE 15 min. Test-retest analyses showed satisfactory reliability. With regard to sensitivity and specificity, we found comparable diagnostic validity for the MMSE and the Micro-Mental Test. We suggest that, due to its brevity and diagnostic validity, the Micro-Mental Test is a useful tool for dementia screening in an outpatient setting.

Emotional distress in patients with retinal disease

PURPOSE

To investigate the prevalence of, and potential risk factors for, emotional distress among patients with retinal disease.

DESIGN

Cross-sectional study.

METHODS

Cases consisted of 86 consecutive patients at Wilmer Eye Institute Retinal Vascular Center. Fifty-one controls with normal visual acuity and no known ocular disease were frequency-matched to the cases by age, sex, and race. Subjects were interviewed using the Community Disability Scale, a functional status questionnaire, and the General Health Questionnaire, a questionnaire assessing emotional distress.

RESULTS

The prevalence of probable (General Health Questionnaire score 4 or greater and less than 10) or definite (General Health Questionnaire score 10 or greater) emotional distress was 59.3% among ophthalmic patients and 2.0% among controls. There were significant relationships between emotional distress, as assessed by General Health Questionnaire score, and degree of 1) visual impairment, as assessed by weighted bilateral average logarithm of minimal angle of resolution (logMAR), and 2) functional impairment, as assessed by Community Disability Scale score (P =.001). Univariate analyses identified significant predictors of emotional distress: shorter duration of ocular disease (P =.019), worse visual acuity (P =.001), increased systemic comorbidities (P =.001), and increased functional impairment (P <.001). Multiple regression analysis demonstrates that worse visual acuity, increased systemic comorbidities, and shorter duration of ocular disease each explain over 10% of the variability in General Health Questionnaire score (r(2) = 0.15, 0.12, and 0.11, respectively). Addition of Community Disability Scale score to the regression model eliminates the significance of visual acuity and systemic comorbidities; Community Disability Scale score explains nearly 30% of the variability in emotional distress, as assessed by General Health Questionnaire score (r(2) = 0.29).

CONCLUSIONS

Emotional distress is prevalent among patients with retinal disease; potential risk factors for emotional distress among such patients include shorter duration of ocular disease, worse visual acuity, increased systemic comorbidities, and increased functional impairment.

Visual hallucinations in patients with retinal disease

PURPOSE

To investigate the prevalence and phenomenologic nature of visual hallucinations among patients with retinal disease and to investigate whether presence of hallucinations is a significant predictor of functional status, quality of life, and/or emotional distress after adjusting for visual acuity.

DESIGN

Cross-sectional study.

METHODS

Eighty-six consecutive patients at the Wilmer Ophthalmologic Institute Retinal Vascular Center were interviewed using the Sickness Impact Profile, Community Disability Scale, General Health Questionnaire, Visual Phenomena Interview, Eysenck Personality Questionnaire, and Telephone Interview for Cognitive Status.

RESULTS

The prevalence of visual hallucinations was 15.1%. Most were formed hallucinations in clear consciousness that lasted for seconds to minutes. The majority of patients had been experiencing visual hallucinations for less than 1 year (61.5%) or for 1 to 2 years (23.1%). Only two of the 13 patients with hallucinations had informed a physician of their hallucinations. Univariate analyses revealed that variables significantly associated with experiencing hallucinations were female sex, worse visual acuity, bilateral visual impairment, emotional distress, decreased functional status, and decreased quality of life. Regression analysis demonstrated that among patients with relatively good vision, those who experienced hallucinations were more emotionally distressed and had a lower quality of life than patients without hallucinations.

CONCLUSIONS

Visual hallucinations among patients with retinal disease are common, underdiagnosed, and not associated with cognitive deficits, abnormal personality traits, or a family or personal history of psychiatric morbidity. Among patients with relatively good vision, hallucinations are associated with increased emotional distress and decreased quality of life.

Postmenopausal hormone therapy and cognitive function in healthy older women

OBJECTIVE

Accumulating biologic evidence suggests that estrogen is related to cognitive function. Several epidemiologic investigations have reported that hormone therapy may reduce the risk of Alzheimer's disease. However, fewer studies have examined the relation of postmenopausal hormone use to general cognitive function in nondemented older women. Thus, we examined the association of hormone therapy to performance on four cognitive tests among healthy participants of the Nurses' Health Study.

DESIGN

Cohort study.

SETTING

The Nurses' Health Study, an ongoing prospective cohort study begun in 1976.

PARTICIPANTS

From the Nurses' Health Study, 2138 women aged 70-78 years.

MEASUREMENTS

From 1995-1999 we administered four cognitive tests (Telephone Interview for Cognitive Status (TICS), immediate and delayed recall of the East Boston Memory Test (EBMT), and verbal fluency) by telephone. Hormone use was ascertained from biennial questionnaires beginning in 1976. Linear and logistic regression models were used to calculate multivariate-adjusted differences in scores and relative risks of a low score for never users compared to current and past hormone users.

RESULTS

After adjustment for confounders, neither current nor long-term hormone users demonstrated better performance on an overall measure of cognition (TICS), or on three tests of verbal memory (immediate and delayed recall of the EBMT, immediate recall of the TICS 10-word list) than never users. On the test of verbal fluency, current hormone users scored significantly better than never users (linear regression estimate of the difference in score = 0.78 points, 95% confidence interval (CI) 0.19-0.38, P = .01 for any current use; and 0.91 points, 95% CI 0.28-1.54, P = .005 for > or = 5 years current use). Current hormone users also had a 30% decrease (RR = 0.70, 95% CI 0.45-1.09) in their risk of a low score on the test of verbal fluency. These results were similar for women taking estrogen alone and estrogen combined with a progestin.

CONCLUSIONS

Verbal fluency may be enhanced among women taking postmenopausal hormones, however, there is little support for better overall cognitive function in hormone users than nonusers.

Pilot study on patients' and spouses' attitudes toward potential genetic testing for bipolar disorder

OBJECTIVE

The purpose of this pilot study was to gain information about attitudes of individuals with bipolar disorder and their spouses toward some of the ethical and social issues arising from rapidly advancing genetic research on bipolar disorder.

METHOD

Patients with bipolar disorder and their unaffected spouses were asked to answer questionnaires assessing their knowledge and attitudes about treatment response rates for bipolar disorder, probability of inheritance, genetic testing, disclosure of genetic information, abortion, marriage, and child-bearing.

RESULTS

The overwhelming majority of the patients and spouses said that they would take advantage of genetic tests for bipolar disorder if such tests were to become available. Most patients and spouses agreed that the benefits of knowing whether one carries a gene for bipolar disorder would outweigh the risks. The decisive majority of respondents also felt that they would not abort a fetus that carried a gene for bipolar disorder. Furthermore, most patients and spouses agreed that the knowledge that one of them carried a gene for bipolar disorder would not have deterred them from marriage or childbearing.

CONCLUSIONS

The results of this study suggest that most individuals believe that they would benefit from the use of genetic testing for bipolar disorder if it were to become available. Follow-up studies using a broader patient sample and nonclinical control groups would be useful in further evaluating the issues addressed in this pilot study.

Disability and psychiatric disorders in an urban community: measurement, prevalence and outcomes

BACKGROUND

The purpose of this analysis was to examine: (1) the prevalence of psychiatric disorders among disabled people, using seven different measures of disability; (2) variation in disability between and within psychiatric diagnostic categories; and (3) relationship of diagnosis and disability to health service utilization.

METHOD

Data were drawn from Phase I and Phase II of the Eastern Baltimore Mental Health Survey, part of the Epidemiologic Catchment Area Program (ECA) conducted in 1980-1 to survey mental morbidity within the adult population. A total of 810 individuals received both a household interview and a standardized clinical psychiatric evaluation. Estimated prevalence rates were computed using appropriate survey sampling weights.

RESULTS

Prevalence of disability ranged from 2.5 to 19.5%, varying with specific disability measure. Among those classified as disabled by any of the measures examined, 56 to 92% had a psychiatric disorder and serious chronic medical conditions were present in the majority of these cases (54 to 78%). Disability was expressed differently among the various diagnostic groups. Diagnostic category and disability were significant independent predictors of medical service utilization and receipt of disability payments.

CONCLUSIONS

The majority of disabled adults living in the community have diagnosable psychiatric disorders, with the majority of these individuals suffering from significant chronic medical conditions as well, thus making co-morbidity the norm.

Development and validation of a Structured Telephone Interview for Dementia Assessment (STIDA): the NIMH Genetics Initiative

As part of the NIMH Genetics Initiative Alzheimer's Disease (AD) Study Group, a brief structured telephone interview to distinguish individuals with normal cognitive functioning from those with changes in cognition and daily functioning suggestive of early AD was developed. The Structured Telephone Interview for Dementia Assessment (STIDA), yields a dementia score between 0 and 81 (higher scores indicating greater impairment). Subscales corresponding to the subscales of the Clinical Dementia Rating Scale (CDR) can be derived. The STIDA performed well as a screening instrument for mildly demented individuals. When a score of 10 or more (based on informant interview and subject testing) was used to identify mildly impaired individuals, the STIDA had a sensitivity of .93 and a specificity of .92 for a clinician-derived CDR of 0.5 or more. The STIDA was also capable of accurately assessing the level of dementia. STIDA-derived CDR ratings agreed with clinician-derived CDR scores in 23 of 28 cases, corresponding to an unweighted kappa of.71 and a weighted kappa of.81. A much-abbreviated short STIDA that could be administered directly to the subject was able to detect possible impairment with a sensitivity of .93 and a specificity of.77. These results suggest that the short STIDA provides a sensitive and fairly specific telephone screen for dementia, and that the full STIDA, consisting of an interview with a knowledgeable informant and subject testing, approximates the success of a face-to-face clinical interview, and provides reliable and valid screening and staging of dementia over the telephone.

Somatoform disorders in Caucasian and Chinese Americans

Somatization, broadly defined as the presentation of one or more medically unexplained somatic symptoms, refers both to the presentation of somatic symptoms in diagnosable psychiatric disorders such as major depression or anxiety as well as to the presentation of such symptoms in somatoform disorders. Although no comparative data exist, somatization is considered by many clinical investigators to be more common among Chinese than Caucasian patients, but it is unclear if this occurs because somatoform disorders are more prevalent among the Chinese or because Chinese patients with major depression or anxiety more often present with somatic complaints. We examined 85 consecutive Chinese American and 85 consecutive Caucasian American patients referred for psychiatric consultation and found the following: a) True somatization was significantly more common among Chinese American patients referred for psychiatric consultation; b) The somatoform symptom profiles of the two cohorts were different: Chinese American somatizers complained predominantly of cardiopulmonary and vestibular symptoms, whereas their Caucasian counterparts had symptoms that corresponded well with the categories listed in DSM-IV; c) In both cohorts of somatizers, a concurrent psychiatric disorder, most commonly major depression, was almost always present; and d) Among the Chinese American somatizers, pseudoneurological symptoms occurred most commonly in the form of abnormal sensations, whereas abnormal motor functions were more common among Caucasian Americans. Implications of the findings with respect to pathogenesis, treatment, and classification of somatization are discussed.

Differential diagnosis of dementia. The clinical process

Dementia as a syndrome must be differentiated from nondementing conditions. Dementia itself must also be differentiated as to cause, as in certain cases reversible conditions may be responsible. This article examines the clinical process of such differentiation, providing a decision free for diagnosis and a summarizing algorithm for thinking through individual cases, with a focus on the most frequent cause of dementia, Alzheimer's disease. Also outlined are the stages of Alzheimer's disease, with the admonition that variations from the expected progression may represent a dementia diagnosis other than Alzheimer's disease or the co-occurrence of some other contributing factors.

Cognitive functions in the informed consent evaluation process: a pilot study

Assessment of capacity to give informed consent in the general hospital setting usually rests on a clinical judgment made of a patient's understanding and appreciation of his or her illness, a process limited by its subjective nature, interexaminer variability, and relative deficiency of quantitative instruments available to provide collateral information. Inasmuch as identification of associated variables could strengthen this process, this study examines the association of cognitive functions to the capacity to give informed consent. Over a one-year period, 65 patients were evaluated independent of medical or psychiatric diagnoses. The study population consisted of medical and neurology inpatients seen for neuropsychiatric evaluation. All evaluations included assessment of capacity to give informed consent as it related to the reason for the admission to the hospital, followed by administration of the Hopkins Competency Assessment Test, the Mini-Mental Status Examination, the Trail-Making Test, Parts A and B, and the Executive Interview. Of 65 patients, 34 were excluded based on preset criteria. The remaining patients were assigned to either a "competent" or "noncompetent" group based on clinical evaluation. Number of patients, gender, and handedness distributions between groups were similar. The groups did not differ significantly in terms of age or education. Significant between-group differences were found on an empirical measure of competency, a general mental state measure, and on measures of attentional and executive cognitive functions. An analysis of classification rates indicated that a measure of executive cognitive functioning (Executive Interview) had the best sensitivity and specificity in correctly classifying competent and noncompetent patients. The results of this study support the association between the capacity to give informed consent in the hospital setting and measures of cognitive functioning, suggesting that utilization of cognitive function measures may strengthen the competency assessment process.

A controlled trial of idebenone in Huntington's disease

One hundred patients with clinically diagnosed Huntington's disease (HD) were randomized to either idebenone, an antioxidant and enhancer of oxidative metabolism, or placebo, in a 1-year, double-blind, parallel-group study aimed at slowing the rate of progression of the disease. Ninety-one patients completed the study. There were no significant differences between groups on the primary outcome measures of the Huntington's Disease Activities of Daily Living Scale (ADL-an index of functional status) and the Quantified Neurologic Examination (QNE). Sample size calculations based on progression of the ADL and QNE in this study group revealed that a larger study group is necessary to detect any differences less than an almost complete halting of the disease. This argues for multicenter efforts for future therapeutic trials in HD.

Lack of association of the apoE4 allele with hippocampal sclerosis dementia

We determined the apolipoprotein E4 (apoE) genotype in 12 cases of autopsy-confirmed hippocampal sclerosis dementia (HSD), a disorder characterized pathologically by neuronal degeneration, predominantly of temporal lobe structures, without senile plaques or neurofibrillary tangles. The frequency of the apoE4 allele in HSD was 12.5%, similar to that of a control population and significantly different from the approximately 40% found in Alzheimer's disease (AD) (P < 0.001). These observations suggest that apoE4 is not a risk factor for HSD.

Accuracy of clinical diagnosis of Alzheimer disease and clinical features of patients with non-Alzheimer disease neuropathology

Neuropathological examination confirmed the clinical diagnosis of possible or probable Alzheimer disease (AD) in 90 of the first 100 patients who came to autopsy at the Johns Hopkins Alzheimer's Disease Research Center. In 10 cases, postmortem brain examination did not confirm AD but revealed variable patterns of neuronal loss in neocortex and limbic structures without amyloid deposits. The most common pattern of degeneration was relatively isolated hippocampal sclerosis (HS). Despite the finding that the 10 patients with non-AD neuropathology were ill for less time and were less cognitively impaired at study entry than those patients with definite AD, they had shorter survival times and showed equal behavioral disturbance at study entry (on a standardized measure). The clinical case reports included here suggest early and progressive prominent behavioral disturbance and other indexes of rapid illness progression in three of the four HS patients and two other non-AD patients. We conclude that the criteria of the National Institute of Neurological Disorders and Stroke/Alzheimer Disease and Related Disorders Association for possible or probable AD are highly accurate and that misdiagnosis is most likely to occur early in the course of illness and in patients with prominent behavioral disturbance or other atypical features.

A randomized trial of dementia care in nursing homes

OBJECTIVE

To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia.

DESIGN

Randomized controlled clinical trial with 6-month follow-up.

SETTING

A 250-bed community nursing home.

PATIENTS

The nursing home was screened to identify patients with dementia and behavior disorders. A total of 118 patients were eligible for randomization. Of these, 89 (75.4%) were randomized, and 81 of these (91.0%) completed the trial.

INTERVENTION

The A.G.E. dementia care program consisted of Activities, Guidelines for psychotropic medications, and Educational rounds. The control treatment was usual nursing home care.

MEASUREMENTS

Behavior disorders, antipsychotic drug and physical restraint use, patient activity levels, and cognitive and functional status.

RESULTS

After 6 months, 12 of 42 (28.6%) intervention patients exhibited behavior disorders compared with 20 of 39 (51.3%) controls (OR = 0.38; 95% CI [0.15, 0.95]; P = .037). Controls were more than twice as likely to receive antipsychotics (OR = 2.55, 95% CI [0.96, 6.76]; P < .056), to be restrained during activity times (OR = 2.98, 95% CI [1.10, 8.04]; P < .028), and to be restrained on nursing units (OR = 2.14, 95% CI [0.9, 5.3]; P < .10). Intervention patients were much more likely to participate in activities (OR = 13.71; 95% CI [4.51, 41.73]; P = .001).

CONCLUSIONS

The A.G.E. program reduces the prevalence of behavior disorders and the use of antipsychotic drugs and restraints. It is practical, feasible, and appears to improve the lives of patients with dementia in nursing homes.

Alzheimer's disease in the National Academy of Sciences-National Research Council Registry of Aging Twin Veterans. III. Detection of cases, longitudinal results, and observations on twin concordance

OBJECTIVES

To detect cases of Alzheimer's disease (AD) in a large population of twins living throughout the United States and to examine concordance for AD in twins as a function of age and genotype for apolipoprotein E (APOE).

SETTING

Nationwide survey.

DESIGN

Multistage screening and field evaluation beginning with two telephone interviews and culminating with laboratory tests, longitudinal neuropsychological measures, physician examination, and diagnostic consensus among experts.

PARTICIPANTS

Membership in 1990-1991 of intact pairs in the National Academy of Sciences--National Research Council Registry of veteran twins, then aged 62 to 73 years.

MAIN OUTCOME MEASURES

Completeness of case detection was examined in collateral studies. Zygosity and APOE genotypes were determined by restriction mapping. Concordance was calculated by the proband method.

RESULTS

Ninety subjects who screened positively for AD were studied in person, and 60 whose differential diagnoses included AD were followed up, as were their co-twins. Sensitivity of screening was estimated at greater than 99%, but 24% of subjects refused participation after initial screening. Seven of 38 diagnoses of AD have been confirmed at autopsy, and 31 other subjects eventually met criteria for probable or possible AD (prevalence estimate, 0.42%, 95% confidence interval, 0.29% to 0.56%), with good interrater reliability (intraclass r = .86). Excluding one discordant pair with unknown zygosity, concordance rates were 21.1% (4/19) for monozygotic and 11.1% (2/18) for dizygotic probands. Concordance was 50% for twins sharing the epsilon 4/epsilon 4 genotype at APOE, but there were no affected co-twins of 15 probands with onset before age 70 years, no epsilon 4 allele, and no family history of AD. The mean (SD) period of discordance in the latter pairs was 11.3 (3.3) years.

CONCLUSIONS

The multistage case-detection approach achieved reliable and valid diagnoses of AD with high apparent sensitivity but substantial attrition after initial screening. Genetic influences in AD at this age are limited, except among homozygotes for allele epsilon 4 at APOE. Subjects with early-onset AD who lack the epsilon 4 allele are not rare, and their condition appears to have little genetic influence. They should be ideal for studies on environmental cause of AD.

Head injury as a risk factor in Alzheimer's disease

Several case-control studies have reported head injury to be more common among patients with Alzheimer's disease (AD) than healthy elderly controls. The present study sought to determine whether milder head injury is also a risk factor for AD. Furthermore, it was hypothesized that head injury would be more common among AD patients without a genetic risk for the disease. History of head injury in 68 consecutive cases of probable or definite AD and 34 non-demented control subjects was ascertained from their spouses. Head injury was reported in 20 of the AD patients (29%), and in only one control subject (2.9%) (odds ratio = 13.75). Twenty per cent of the familial and 43.5% of the sporadic AD cases reportedly had a premorbid head injury (odds ratio = 3.08). Head injury had no effect on age of dementia onset. The results indicate that head trauma may be a predisposing factor to AD, particularly in the absence of a clear genetic contribution.

Nonsteroidal anti-inflammatory drugs in Alzheimer's disease

We reviewed the records of 210 patients in the Johns Hopkins Alzheimer's Disease Research Center to evaluate the role of nonsteroidal anti-inflammatory drugs (NSAIDs) on clinical features and progression of the disease. We compared patients taking NSAIDs or aspirin on a daily basis (N = 32) to non-NSAID patients (N = 177) on clinical, cognitive, and psychiatric measures. The NSAID group had a significantly shorter duration of illness at study entry. Even after controlling for this difference, the NSAID group performed better on the Mini-Mental State Examination, Boston Naming Test, and the delayed condition of the Benton Visual Retention Test. Furthermore, analysis of longitudinal changes over 1 year revealed less decline among NSAID patients than among non-NSAID patients on measures of verbal fluency, spatial recognition, and orientation. These findings support other recent studies suggesting that NSAIDs may serve a protective role in Alzheimer's disease.

Reliability and validity of NINCDS-ADRDA criteria for Alzheimer's disease. The National Institute of Mental Health Genetics Initiative

OBJECTIVE

To assess interrater reliability and validity of NINCDS-ADRDA (National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association) criteria for Alzheimer's disease (AD).

DESIGN

A multisite reliability and validity study in which clinicians from each site diagnosed 60 case summaries yielding a preconsensus estimate of reliability and validity. A consensus conference was conducted for each disagreement, leading to a postconsensus estimate of validity. The criterion standard was a diagnosis of AD by autopsy.

SETTING

Three academic medical centers.

SUBJECTS

A convenience sample of 60 detailed case summaries, 40 with AD and 20 with other dementing disorders.

MAIN OUTCOME MEASURES

The kappa coefficient, sensitivity, and specificity.

RESULTS

The kappa coefficient for preconsensus agreement on a diagnosis of probable or possible AD vs non-AD was 0.51; the sensitivity of a diagnosis of probable or possible AD for a pathological diagnosis of AD was 0.81, and the specificity was 0.73. The postconsensus sensitivity was 0.83, and the specificity was 0.84.

CONCLUSIONS

The results support the reliability and validity of NINCDS-ADRDA criteria and show that the consensus process may improve diagnostic accuracy. The cases are reviewed with a focus on the sources of diagnostic disagreements and errors and possible changes that might improve the accuracy of the criteria.

DSM-III personality disorders in the community

OBJECTIVE

The aims of this study were to estimate the prevalence and investigate the comorbidity and potential consequences of DSM-III personality disorders in the community.

METHOD

A total of 810 adults were examined in the second stage of the Eastern Baltimore Mental Health Survey in 1981, part of the National Institute of Mental Health Epidemiologic Catchment Area program. The subjects were directly examined by psychiatrists using a semi-structured method that allowed diagnosis of all DSM-III personality disorders as well as other DSM-III psychiatric disorders.

RESULTS

The prevalence of personality disorders in these adults was 5.9% (9.3% when provisional cases were included). Men had higher rates than women, and subjects who were separated or divorced had the highest rates. There was little comorbidity among specific personality disorders. Subjects with personality disorders were significantly more likely to have a history of sexual dysfunctions, alcohol use disorders, and drug use disorders as well as suicidal thoughts and attempts. In addition, they reported significantly more life events in the past year. Among subjects with any axis I disorder, those with personality disorders were judged by the psychiatrists to be more in need of treatment; however, only 21% were receiving treatment.

CONCLUSIONS

Personality disorders are relatively common in the community. They are associated with axis I disorders and life events. Only one-fifth of the individuals who qualify for diagnoses of personality disorders in the community are receiving treatment.

Obsessions and compulsions in the community

A total of 810 adults were examined by psychiatrists in the second stage of the Eastern Baltimore Mental Health Survey. A semistructured examination, the Standard Psychiatric Examination, was used. The relationships between obsessions and compulsions and personal characteristics, childhood behaviors, family history, and other psychopathology were evaluated. The estimated prevalence of obsessions and compulsions in this population was 1.5%. Cases were significantly more likely to report having had childhood fears, learning disabilities and a family history of alcoholism and suicidal behavior. There were significant positive relationships between scores on compulsive, borderline and histrionic personality disorder scales and the probability of obsessions and compulsions. These exploratory analyses in an epidemiologic sample may identify factors of etiologic importance in this condition.

Alzheimer's disease in the NAS-NRC registry of aging twin veterans. II. Longitudinal findings in a pilot series. National Academy of Sciences. National Research Council Registry

Over 3 years we followed 8 pairs of male twins one or both of whom had suspected Alzheimer's disease (AD) including 'mild/ambiguous' changes suggestive of incident AD. These pairs were screened in 1988 and 1989 from 339 pairs in the (US) National Academy of Sciences-National Research Council Registry (NASR) of aging veteran twins, then 61-72 years of age. Most of the suspected cases (10 of 12) had mild/ambiguous changes. Including these subjects, we had estimated the prevalence of AD in the NASR as about 2%. We now describe briefly the longitudinal evaluation of these 8 pairs. Only 1 of the 10 individuals with mild/ambiguous changes has progressed to show well-defined clinical symptoms of AD. Two others remain in their original research category, while 7 clearly do not have AD. Thus, we now estimate the 1988-1989 prevalence of AD in the NASR as 0.5%. These results contrast with other follow-up studies of mild cases from a university-based Alzheimer's clinic. We suggest that the contrasting findings reflect the nature of the samples studied, and we show that the present results are predicted by Bayesian reasoning.

Functional status and quality of life measurement among ophthalmic patients

OBJECTIVES

Assessment of the relationship between visual function and functional status/quality of life in clinical research involving patients with eye disease by investigating whether the scores of four existing functional status/quality of life patient questionnaires are sensitive to differences in visual acuity and studying whether selected subscales of the questionnaires provide similar information concerning the relationship between functional status/quality of life and visual acuity as do the respective full-length questionnaires.

DESIGN, SETTING, PARTICIPANTS

Case patients consisted of 86 consecutive patients seen at The Wilmer Ophthalmological Institute Retinal Vascular Center, Baltimore, Md. Controls consisted of 51 individuals with normal visual acuity and no known ocular disease and were frequency-matched to the case patients by age (+/- 5 years), sex, and race. Subjects were interviewed in person using each of the following questionnaires: the Sickness Impact Profile, the vision-specific Sickness Impact Profile, the Community Disability Scale, and the General Health Questionnaire.

RESULTS

Scores of all four questionnaires and their subscales were significantly associated with visual acuity. The vision-specific Sickness Impact Profile and the Community Disability Scale were independently significant predictors of visual acuity. Regression analysis revealed that in our study, selected subscales of the respective full-length questionnaires were able to demonstrate the association between vision and functional status/quality of life.

CONCLUSIONS

Ophthalmic patients are at high risk for decreased functional status/quality of life. Subscales of existing questionnaires potentially may be substituted for the full-length questionnaires, thereby increasing the efficiency of functional status/quality of life measurement in such patients.

EEG power spectra in Huntington's disease: clinical and neuropsychological correlates

Quantitative power spectral analysis (PSA) was applied to frontal (F3, F4, F7, F8), temporal (T5, T6), and occipital (O1, O2) EEGs of 16 Huntington's disease (HD) patients and eight healthy control subjects. PSA revealed HD patients' EEGs to be abnormal: (i) raw and percent Alpha power were reduced; (ii) raw and percent Theta power were reduced at F3 and F4; (iii) percent Delta and percent Beta power were increased; (iii) Theta frequency was reduced by approximately 1.0 Hz. Frontal and temporal EEG power measures and decreased EEG amplitude correlated with severity of neurological and cognitive impairment.

Assessment of DSM-III personality structure in a general-population survey

The object of this study is to assess the internal validity of DSM-III personality constructs and to explore whether the constituent elements are better explained by an alternate internally coherent classification. A two-stage stratified random sample of subjects identified at the Baltimore site of the Epidemiologic Catchment Area (ECA) program were examined by psychiatrists for DSM-III personality attributes using a semistructured instrument. Dichotomous factor analysis was used in the confirmatory mode to test whether a single factor explained each of the 11 DSM-III personality disorders. This approach rejected a single explanatory factor for all but compulsive personality disorder. Exploratory factor analysis showed that these DSM-III personality features are parsimoniously described by a five-factor model. These factors are warmth, animation, timidity, trust, and scrupulousness.

A new scale for comprehensive assessment of psychopathology in Alzheimer's disease

The Dementia Signs and Symptoms (DSS) Scale documents non-cognitive signs and symptoms (e.g., delusions, hallucinations, anxiety, depression, mania, and behavioral disturbances) in dementia. Patients, informants, and a clinical examiner rated signs and symptoms over the preceding month. Fifty-six Alzheimer's disease patients were administered the DSS, the BEHAVE-AD, the Cornell Scale for Depression in Dementia, the Young Mania Rating Scales, the Hamilton Depression Scale, the Hamilton Anxiety Scale, and the Psychogeriatric Dependency Rating Scale. DSS subscale scores correlated with corresponding scale scores, confirming construct validity. The DSS subscales were internally consistent (Cronbach's alpha, 0.3 7-0.75) and interrater reliability was high (ICC, 0.92-0.99).

A new bedside test of cognition for patients with HIV infection

OBJECTIVE

To compare the Mental Alternation Test, a new 60-second bedside test of cognition, with the Mini-Mental State Exam (MMSE) and the Trailmaking Test, parts A and B, in patients with human immunodeficiency virus (HIV) infection.

DESIGN

Cohort study.

PARTICIPANTS

Sixty-two inpatients with HIV infection.

SETTING

The AIDS service of a referral hospital.

MEASUREMENTS

Scores on the MMSE; the Trailmaking Test, parts A and B; and the Mental Alternation Test were compared using correlation calculations and analyses of variance. Receiver operating curves were constructed to identify the best cutoff score on the Mental Alternation Test for detecting impaired performance on the MMSE and the Trailmaking Test.

MAIN RESULTS

The Mental Alternation Test score correlated significantly with MMSE (r = 0.68, P < 0.01) and Trailmaking Test, part B, scores (r = -0.54, P < 0.01). The receiver operating curves showed that a Mental Alternation Test cutoff score of 15 yielded the best results for the detection of abnormal performance on the MMSE (sensitivity, 95% [95% CI, 90% to 100%]; specificity, 79% [CI, 69% to 89%]) and the Trailmaking Test, part B (sensitivity, 78% [CI, 68% to 88%]; specificity 93% [CI, 90% to 100%]). Patients making fewer than 15 alternations in 30 seconds were significantly more likely to have abnormal MMSE (P < 0.0001) and Trailmaking Test, part B, scores (P < 0.0001). The Mental Alternation Test had good reproducibility; analyses of reliability included test-retest correlation (r = 0.80) and inter-rater reliability (r = 0.85, kappa = 0.84). Time of administration was approximately 60 seconds.

CONCLUSIONS

The Mental Alternation Test of cognition has good sensitivity and specificity and is easily administered. It is a valuable test to identify patients who may need further cognitive evaluation.

Hereditary influences on cognitive functioning in older men. A study of 4000 twin pairs

OBJECTIVE

To determine the contribution of genetic factors to cognitive functioning in older men.

DESIGN

Cognitive testing by telephone interview in an epidemiologically defined population.

PARTICIPANTS

2077 monozygotic and 2225 dizygotic male twin pairs, all between the ages of 62 and 73 years, recruited from the National Academy of Sciences twin registry.

MAIN OUTCOME MEASURES

The Telephone Interview for Cognitive Status--Modified total score and factor scores were analyzed. The Falconer heritability statistic and maximum likelihood estimates of genetic and environmental components were computed.

RESULTS

Heritability of the total Telephone Interview for Cognitive Status--Modified score was estimated to be 30%. Shared environmental effects accounted for an additional 18% of the variance; most of this was related to years of education. Of the four cognitive factors derived, the language/attention factor had the highest heritability estimate.

CONCLUSIONS

Genetic factors and educational achievement together account for almost half of the variance in the cognitive functioning of older men. Studies of the genetics of dementing illnesses need to consider the degree to which cognitive capacities are themselves under genetic control.

Legal and ethical issues in psychiatric genetic research

Genetic research may uncover the causes of severe mental disorders, and many projects have been undertaken to locate the genes responsible for schizophrenia, bipolar disorder, and Alzheimer disease. A number of sensitive legal and ethical issues have been raised, including 1) protection of confidential data concerning research subjects; 2) the assessment of types and degree of risk to subjects who participate in such studies; 3) the legal and ethical acceptability of substituted judgement on behalf of patients who may not be competent to provide informed consent; and 4) the separation of research and clinical roles in areas such as genetic counseling. Federal regulations and other guidelines are of limited value in dealing with such concerns, and many important human subjects issues will need to be dealt with by the investigator, subject to approval by a local Institutional Review Board. There does seem to be general agreement that informed consent must be obtained, potential risks of research need to be minimized, and confidentiality of sensitive data must be protected.

Memory complaint, memory performance, and psychiatric diagnosis: a community study

This study examined the prevalence of memory complaint and poor memory performance on brief screening measures within a community sample of 810 adults. All individuals received an extensive household interview and a clinical psychiatric evaluation. Overall, 22% indicated that they currently had trouble with their memory. This percentage increased with age, rising to 43% for those 65 to 74 years old, 51% for those 75 to 84 years old, and 88% for those 85 years of age and older; the percentage indicating memory problems decreased with educational attainment. The prevalence of poor memory performance was 11%, also increasing with less education and increased age, rising to 26% for those 65 to 74 years old and to 40% for those older then 75. Those who complained of memory trouble were twice as likely to show poor memory performance (29%) compared with those who did not complain (15%). Multivariate analysis found age, emotional distress, and physical illness to be independent predictors of memory complaint; age, functional disability, education, and physical illnesses proved to be independently associated with poor memory performance. A higher prevalence of complaints of memory trouble was found not only for those with affective disorders, as might be expected, but also among those with schizophrenic, cognitive, anxiety, and adjustment disorders. However, only individuals with cognitive disorders showed a higher prevalence of poor memory performance.

Use of twin cohorts for research in Alzheimer's disease

The causes of Alzheimer's disease (AD) remain a mystery despite the recent identification of several putative environmental risk factors and the discovery of several linked genetic loci and point mutations associated with the disease. Particularly uncertain is the generalizability of the genetic findings to the common forms of disease encountered in clinical practice or population research. Twin studies of AD can illuminate causal mechanisms, both genetic and environmental. This consensus document explores the rationale for such twin studies, as well as a number of methodologic problems that render them difficult to implement or interpret. We review existing twin studies of AD and note several ambitious new studies. Finally, we delineate several practical strategies for the near future of twin research in AD.

The relationship between personality and DSM-III axis I disorders in the population: results from an epidemiological survey

OBJECTIVE

The aim of this study was to assess the relationships between specific personality disorders and DSM-III axis I conditions in a community sample.

METHOD

A total of 810 subjects were examined by psychiatrists in the second stage of the Eastern Baltimore Mental Health Survey, part of the Epidemiological Catchment Area Program of the National Institute of Mental Health. A semistructured examination, the Standardized Psychiatric Examination, was employed to assess axis I and axis II conditions. Scales for compulsive and antisocial personality disorders were derived from DSM-III criteria. The relationships between scores on these personality disorder scales and the presence of generalized anxiety disorder, alcohol use disorders (alcohol abuse and alcohol dependence), and simple phobia were evaluated by using logistic regression.

RESULTS

Higher compulsive personality scores were associated with a greater odds of generalized anxiety disorder and simple phobia but a smaller odds of alcohol use disorders. In contrast, higher antisocial personality scores were associated with a greater odds of alcohol use disorders but a smaller odds of generalized anxiety disorder. There was no relationship between antisocial personality scores and simple phobia.

CONCLUSIONS

Personality disorders have specific relationships to axis I conditions, which suggests different vulnerabilities but also different protective influences.

The epidemiology of psychiatrist-ascertained depression and DSM-III depressive disorders. Results from the Eastern Baltimore Mental Health Survey Clinical Reappraisal

Psychiatrists used a semi-structured Standardized Psychiatric Examination method to examine 810 adults drawn from a probability sample of eastern Baltimore residents in 1981. Of the population, 5.9% was found to be significantly depressed. DSM-III major depression (MD) had a prevalence of 1.1% and 'non-major depression' (nMD), our collective term for the other depressive disorder categories in DSM-III, had a prevalence of 3.4%. The two types of depression differed by sex ratio, age-specific prevalence, symptom severity, symptom profiles, and family history of suicide. Analyses using a multiple logistic regression model discerned that both types of depression were influenced by adverse life events, and that nMD was influenced strongly by gender, marital status, and lack of employment outside the home. Neither type of depression was influenced by income, education, or race. This study validates the concept of major depression as a clinical entity. Future studies of the aetiology, mechanism, and treatment of depression should distinguish between these two types of depression.

Discriminant validity of a reduced set of Mini-Mental State Examination items for dementia and Alzheimer's disease

Linear discriminant analysis was used to construct a series of discriminant functions including subsets of demographic variables and Mini-Mental State Examination item responses for a case series and a population sample. A 9-item discriminant function including the variables for time orientation, recall, calculation, copying a figure, age, writing, 3-step command, naming, and race distinguished demented subjects from community controls with 91% sensitivity and 88% specificity. The same discriminant function classified Alzheimer's disease patients and controls with 96% sensitivity and 98% specificity. This discriminant function has been cross-validated as a potential screening instrument for Alzheimer's disease in a community-based sample.

Psychiatric diagnosis and uncooperative behavior in nursing homes

The prevalence of psychiatric disorders and behavioral disturbances in nursing homes is high, but the relationship between the two is unknown. We studied 454 new admissions who were diagnosed by research psychiatrists using DSM-III-R criteria and compared patients who nursing staff designated as cooperative or uncooperative by psychiatric diagnosis and use of restraints and neuroleptics. Uncooperative patients (n = 79; 17.4%) had a variety of psychiatric disorders (total, 87.3%) but particularly had dementia syndromes complicated by delusions, depression, or delirium (44.3%). Uncooperative patients were more frequently restrained and prescribed neuroleptics. Determining the origins of behavior disorders in patients with psychiatric disorders in nursing homes may reduce behavior disturbances.

The Hopkins Competency Assessment Test: a brief method for evaluating patients' capacity to give informed consent

The Hopkins Competency Assessment Test (HCAT), a brief instrument for evaluating the competency of patients to give informed consent or write advance directives, consists of a short essay and a questionnaire for determining patients' understanding of the essay. In a study to validate the instrument, 41 medical and psychiatric inpatients answered the questionnaire after reading the essay while bearing it read aloud. A forensic psychiatrist who was blind to the HCAT scores later examined the patients for competency. A subject's number of correct answers to the HCAT questionnaire was an accurate indicator of clinical competency as assessed by the psychiatrist. The results suggest that the HCAT is a useful tool for rapidly screening patients for competency to make treatment decisions.

Physostigmine in Alzheimer's disease: effects on cognitive functioning, cerebral glucose metabolism analyzed by positron emission tomography and cerebral blood flow analyzed by single photon emission tomography

The effect of acute, intravenous administration of physostigmine on measures of brain activity and cognitive functioning were investigated in 14 patients with Alzheimer's disease. Regional cerebral glucose metabolism was assessed using (18F)-fluoro-2-deoxy-D-glucose and positron emission tomography, and cerebral blood flow was assessed using 123I-iodoamphetamine single photon emission tomography. Although physostigmine enhanced cerebral blood flow in most patients, only one patient showed significant clinical improvement. This patient, however, also showed a very pronounced improvement in cerebral glucose metabolism. It is concluded that these preliminary findings hold considerable promise for our appreciation of the pathophysiology of dementing illness as well as our understanding of centrally acting compounds of interest in Alzheimer's disease.

Psychosis and physical aggression in probable Alzheimer's disease

OBJECTIVE

The purpose of this study was to determine the frequency and type of psychotic symptoms in patients with probable Alzheimer's disease and to test whether there is a relationship between specific psychotic symptoms and episodes of physical aggression.

METHOD

From 209 patients with possible or probable Alzheimer's disease who had been assessed in a research clinic every 6 months for up to 4.5 years, 181 subjects with probable Alzheimer's disease were selected for study. On the basis of the summary note for each visit in the patients' charts, the presence of delusions, hallucinations, misidentifications, and episodes of physical aggression was determined. Data regarding psychotic symptoms and aggression were available for 170 and 169 subjects, respectively.

RESULTS

Delusions had been reported for 74 (43.5%) of the patients and were the most frequent psychotic symptom; persecutory delusions were the most common type. Physical aggression had been noted for 50 (29.6%) of the patients. Delusions and misidentifications frequently preceded and were significantly associated with episodes of physical aggression. The presence of delusions was a significant predictor of physical aggression but accounted for only 3.5% of the variance.

CONCLUSIONS

This study suggests that delusions are a risk factor for physical aggression in patients with probable Alzheimer's disease who have moderate to severe cognitive impairment. As delusions accounted for only a small percentage of the variance, further research is needed to identify other variables that may be significant predictors of physical aggression in this population.

Dementia: case ascertainment in a community survey

The three-stage East Baltimore Mental Health Survey, conducted in 1981 as part of the Epidemiological Catchment Area Program, provided an opportunity to assess the prevalence of dementia and specific dementing disorders in a community-based, cross-sectional sample of the population. From the 3,841 households originally sampled, 810 individuals were selected for clinical psychiatric evaluation. Forty-one individuals were given a provisional diagnosis and referred to Stage 3 for differential diagnosis, with 32 individuals completing this evaluation. Thorough clinical evaluation of these cases resulted in an overall prevalence of dementia of 4.5% in those 65 years of age and older. The prevalence of specific dementing disorders was Alzheimer's disease (AD) (2.0%), Multi-Infarct Dementia (MID) (2.0%) and Mixed Dementia (MD) (0.5%). Prevalence increased with age for all dementias: Non-Whites had higher rates of dementia than Whites; females had higher rates of AD while males had higher rates of MID; and the prevalence of AD increased with increasing education, whereas the prevalence of MID decreased with increased education. Although this study includes only a small number of cases, necessitating some caution in interpreting the results, these figures do represent an estimate of the prevalence of severe dementing disorders and provide a basis for further community study.

Sleep disturbance and Alzheimer's disease: relationship to behavioral problems

We studied the sleep characteristics of 108 outpatients with probable Alzheimer's disease and found that sleep disturbance was significantly related to daytime behavioral disturbance but not to cognitive impairment. Possible treatment strategies and neuropathological and neurochemical mechanisms are discussed.

DSM-III compulsive personality disorder: an epidemiological survey

A two-stage probability sample of community subjects was developed with a full psychiatric examination employing DSM-III criteria in conjunction with the Epidemiological Catchment Area (ECA) survey conducted in Baltimore, MD. This report details the observation on those subjects diagnosed with compulsive personality disorder and compulsive personality traits. The results indicate that this condition has a prevalence of 1.7% in a general population. Male, white, married and employed individuals receive this diagnosis most often. Our data suggest a dimensional rather than categorical character for this disorder. The disorder imparts a vulnerability for the development of anxiety disorders.

Depression and mortality in nursing homes

To determine the prevalence rates of major depressive disorder and of depressive symptoms and their relationship to mortality in nursing homes, research psychiatrists examined 454 consecutive new admissions and followed them up longitudinally for 1 year. Major depressive disorder occurred in 12.6% and 18.1% had depressive symptoms; the majority of cases were unrecognized by nursing home physicians and were untreated. Major depressive disorder, but not depressive symptoms, was a risk factor for mortality over 1 year independent of selected physical health measures and increased the likelihood of death by 59%. Because depression is a prevalent and treatable condition associated with increased mortality, recognition and treatment in nursing homes is imperative.

Cognitive impairment and functional disability in the absence of psychiatric diagnosis

Data from the 1981 East Baltimore Mental Health Survey were used to examine the relationship between cognitive impairment and psychiatric diagnosis in an adult population. The Mini-Mental State Examination was administered to 3841 household respondents and a subset of 810 received psychiatric evaluations. Of the 810, 23% were found to be cognitively impaired. Over one-third of those with cognitive impairment, however, did not meet DSM-III criteria for a psychiatric diagnosis. Education, geographical background, race and neurological status were predictive of cognitive performance. There was no linear effect of age on cognitive performance with disease status and education controlled. In addition to their cognitive impairment these individuals, who ranged in age from 19 to 89, were found to have significant functional disabilities. Cognitive performance itself, along with physical and emotional health, predicted total functional disability.