Now is the Time to Improve Cognitive Screening and Assessment for Clinical and Research Advancement

Alzheimer’s disease (AD) is the only cause of death ranked in the top ten globally without precise early diagnosis or effective means of prevention or treatment. Further, AD was identified as a pandemic [1] well before COVID-19 was dubbed a 21st century pandemic [2]. And now, with the realization of the prominent secondary impacts of pandemics, there is a growing, widespread recognition of the tremendous magnitude of the impending burden from AD in an aging world population in the coming decades [3]. This appreciation has amplified the growing and pressing need for a new, efficacious, and practical platform to detect and track cognitive decline, beginning in the preliminary (prodromal) phases of the disease, sensitively, accurately, effectively, reliably, efficiently, and remotely [4–7]. Moreover, the parallel necessity of clarifying and understanding risk factors, developing successful prevention strategies [8–17], and discovering and monitoring viable and effective treatments could all benefit from accurate and efficient screening and assessment platforms. Modern recognition of AD [18] as a common affliction of the elderly began in 1968 with a paper by Blessed, Tomlinson, & Roth [19] in which two tests, one a brief assessment of cognitive function and the other a measure of daily function, demonstrated impairment which was associated with the postmortem counts of neurofibrillary tangles, composed mainly of microtubule-associated protein-tau (tau), in the brain, though not to senile plaques, composed mainly of amyloid-β (Aβ). Even in more recent analyses, the tangles correspond with the severity of dementia more than the plaques [20, 21]. Since 1960, a plethora of cognitive tests, paper and pencil [22, 23], simple screening models [24], and computerized [25–27], have been developed to assess the dysfunction associated with AD. However, there has been limited application of Modern Test Theory, which includes Item Characteristic Curve Analysis, used in the technological development of such tools [28–31], along with widespread failure to understand the underlying AD pathological process to guide test development [32, 33]. The lack of such development has likely been a major contributor to the failure of the field to develop timely screening approaches for AD [34, 35], inaccurate assessment of the progression of AD [36], and even now, failure to find an effective approach to stopping AD.

Genetic Risk of Alzheimer's Disease: Three Wishes Now That the Genie is Out of the Bottle

The availability and increasing popularity of direct-to-consumer genetic testing for the presence of an APOE4 allelle led the Alzheimer's Foundation of America Medical, Scientific and Memory Screening Advisory Board to identify three critical areas for attention: 1) ensure consumer understanding of test results; 2) address and limit potential negative consequences of acquiring this information; and 3) support linking results with positive health behaviors, including potential clinical trial participation. Improving access to appropriate sources of genetic counseling as part of the testing process is critical and requires action from clinicians and the genetic testing industry. Standardizing information and resources across the industry should start now, with the input of consumers and experts in genetic risk and health information disclosure. Direct-to-consumer testing companies and clinicians should assist consumers by facilitating consultation with genetic counselors and facilitating pursuit of accurate information about testing.

Undertreatment of patients with Alzheimer's disease in an elderly United States population

BACKGROUND

The aim of this study was to assess the undertreatment of elderly mild to moderate Alzheimer's disease (AD) patients in the United States utilizing baseline data from a community-based trial that has established comparability to national survey samples on demographic characteristics.

METHODS

Baseline data were used from an open-label, 12-week, postapproval study of compliance with galantamine, an AChEI and nicotinic receptor modulator, and vitamin E. A total of 2,114 patients from 406 community-based US practices in which physicians had previously treated patients with acetylcholinesterase inhibitors (AChEIs) were included in the study. This population reflects a large, ethnically diverse patient pool consistent with the demographics of the elderly population in the United States, atypical of those enrolled in most AD trials.

RESULTS

The majority of patients (64.5%) were described by either themselves or their caregivers as not having received prior AChEI treatment. Positive associations were found between past AChEI treatment and longer time since diagnosis, white race, higher education, medical care by a neurologist, and older caregivers. The likelihood of having received previous AChEI treatment was higher among white patients (61.9%) than among those from other ethnic groups combined (25.8%).

CONCLUSIONS

The similarity of patient demographic characteristics to the 2000 US Census figures for the population aged >65 years makes this data set a potentially powerful tool for planning public health initiatives. Findings suggest that patients with mild to moderate AD are undertreated and that specialist and nonspecialist organizations should discuss and implement ways to optimize management of this disease.

Morning or evening activity improves neuropsychological performance and subjective sleep quality in older adults

STUDY OBJECTIVES

Sleep disturbances and decline in neuropsychological performance are common in older adults. Reduced social and physical activity is likely a contributing factor for these age-related changes in sleep and cognition. We previously demonstrated that a program of structured social and physical activity, with 2 daily activity sessions, 1 in the morning and 1 in the evening for a relatively short period of 2 weeks, improved sleep and neuropsychological performance in community-dwelling older adults. The goals of this pilot study were to determine whether a single daily morning or evening activity session for 2 weeks would also improve sleep and neuropsychological function and whether these effects were dependent on the timing of the activity sessions.

DESIGN

We compared the effect of morning or evening structured activity sessions in a repeated-measures crossover design. Subjective mood, neuropsychological performance tasks, and subjective and objective measures of sleep were assessed at baseline and after the intervention.

SETTING

All procedures took place in the participant's residence.

PARTICIPANTS

Twelve older men and women (74.6 +/- 5.5 years of age).

INTERVENTIONS

Subjects participated in 14 days of structured activity sessions in the morning (9:00-10:30 am) or evening (7:00-8:30 pm). Sessions consisted of stretching, low-impact aerobics, and game playing.

MEASUREMENTS AND RESULTS

Exposure to either morning or evening activity significantly improved performance on a neuropsychological test battery. Morning activity sessions increased throughput on 4 of 8 performance tasks, while evening activity sessions improved throughput on 7 of the 8 performance tasks. Subjective sleep-quality ratings, measured by the Pittsburg Sleep Quality Index, improved following activity sessions in either the morning or the evening. Objective measures of sleep did not improve when measured by actigraphy or polysomnography.

CONCLUSIONS

These results suggest that short-term exposure to either morning or evening social and physical activity improves objective measures of neuropsychological performance and subjective sleep quality in the elderly. Increasing exposure to social and physical activity may be a useful intervention to improve sleep quality and daytime function in older adults.

Effects of rivastigmine on behavioral and psychological symptoms of dementia in Alzheimer's disease

BACKGROUND

The presence of certain behavioral and psychological symptoms (eg, paranoia, hallucinations, aggression, activity disturbances) in Alzheimer's disease (AD) may predict faster cognitive and functional decline; therefore, such symptoms represent an important treatment target. Behavioral and psychological symptoms of dementia (BPSD) may be caused at least in part by cholinergic deficits. Regulatory studies of rivastigmine in AD were not designed to evaluate effects on BPSD, but further investigation of rivastigmine in AD was prompted by later studies demonstrating behavioral benefits in other types of dementia.

OBJECTIVE

The primary aim of this article was to review available data on the behavioral benefits of rivastigmine in patients with AD.

METHODS

Relevant data were identified through a MEDLINE search for studies published in peer-reviewed journals through January 2004. The search terms were Alzheimer, behavior, psychosis, and rivastigmine. Data presented at international scientific congresses were also reviewed to ensure that the most recent data were considered.

RESULTS

A meta-analysis of three 6-month, placebo-controlled trials of rivastigmine in mild to moderate AD indicated that rivastigmine 6 to 12 mg/d may improve or prevent disruptive BPSD (P < 0.05 vs placebo). In patients with more advanced AD, 2 open-label studies of up to 12 months' duration found that improvements in BPSD were accompanied by a decrease in the use of psychotropic medications. Rivastigmine demonstrated behavioral benefits in patients with dementia with Lewy bodies (DLB) in a double-blind, placebo-controlled study (P < 0.05). In open-label extension studies, rivastigmine provided sustained effects (up to 2 years) in patients with mild to moderate AD or DLB.

CONCLUSIONS

The available dats suggest that rivastigmine may be a well-tolerated treatment option for improving or preventing psychotic and nonpsychotic symptoms associated with AD. Prospective, double-blind studies are needed to evaluate these preliminary findings.

A randomized, placebo-controlled study of the efficacy and safety of sertraline in the treatment of the behavioral manifestations of Alzheimer's disease in outpatients treated with donepezil

OBJECTIVE

To examine the safety and efficacy of sertraline augmentation therapy in the treatment of behavioral manifestations of Alzheimer's disease (AD) in outpatients treated with donepezil.

METHODS AND MATERIALS

Patients with probable or possible AD, and a Neuropsychiatric Inventory (NPI) total score >5 (with a severity score > or =2 in at least one domain), were treated with donepezil (5-10 mg) for 8 weeks, then randomly assigned to 12 weeks of double-blind augmentation therapy with either sertraline (50-200 mg) or placebo. Primary efficacy measures were the 12-item Neuropsychiatric Inventory (NPI) and the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales.

RESULTS

24 patients were treated with donepezil+sertraline and 120 patients with donepezil+placebo. There were no statistically significant differences at endpoint on any of the three primary efficacy measures. However, a linear mixed model analysis found modest but statistically significantly greater improvements in the CGI-I score on donepezil+sertraline. Moreover, in a sub-group of patients with moderate-to-severe behavioral and psychological symptoms of dementia, 60% of patients on sertraline vs 40% on placebo (p = 0.006) achieved a response (defined as > or = 50% reduction in a four-item NPI-behavioral subscale). One adverse event (diarrhea) was significantly (p < 0.05) more common in the donepezil+sertraline group compared to the donepezil+placebo group.

CONCLUSION

Sertraline augmentation was well-tolerated in this sample of AD outpatients. In addition, post hoc analyses demonstrated a modest but statistically significant advantage of sertraline over placebo augmentation in mixed model analyses and a clinically and statistically significant advantage in a subgroup of patients with moderate-to-severe behavioral and psychological symptoms of dementia.

Behavioral and psychologic symptoms of dementia

Although tremendous strides with regard to identification and treatment of BPSD have been made over the last several decades, much work remains. Presently, BPSD research opportunities are at their greatest. The increasing worldwide social and economic impact of BPSD, however, requires that researchers, clinicians, and scientists develop a global network focused on collaboration and innovation. In particular, research must address cross-culturally applicable methods for assessment, exploration of the environmental relationships of BPSD and the underlying biologic and psychologic substrates, longitudinal evaluation, determination of the frequency and underlying pathogenic mechanisms, and development of a clearly defined treatment method profile with specific reference to different types of BPSD [134].

Dementia patients in primary care. Care managers offer a solution to providing ongoing care

The structure of our healthcare system does not take into consideration the many psychological and social needs of older patients. For a patient like Mr. G, who has mild-to-moderate dementia, a critical aspect of primary medical care is determining the patient's non-medical needs. These needs often bear directly on medical care. Cost is one reason primary care offices do not have more care managers. Yet, in the seven intervention sites participating in the Council for Jewish Elderly study, six have arranged to continue with the social worker or have made substantial efforts to come up with the funding to do so. As we continue to look at our changing demographics and the needs of our increasingly older population, public policy planners must look at care management in primary care settings as an important clinical provision of care. To find a care manager in your area, log on to www.caremanager.org, which is the web site of the National Association of Professional Geriatric Care Managers. Click on the "Find a Care Manager" link and fill out the search form.

Cognitive screening in the primary care setting. The role of physicians at the first point of entry

There are many reasons why it is important to conduct the cognitive assessment and arrive at a preliminary diagnosis within the primary care setting. In addition to starting the patient on anti-cholinesterase medications, the physician must discuss with the family (and often the patient) issues related to financial matters and self-care. Alzheimer's patients who live alone may be targets for financial and personal exploitation, and are at risk for self-neglect. Community support or provision might be needed to assist with medication compliance, provide nutritional services by shopping for prepared foods or through Meals on Wheels, housekeeping to maintain cleanliness, adult day services to provide social and recreational activities, live-in companions, and assistance with other instrumental activities of daily living. Sometimes more structured or institutional living is necessary. Generally, the primary care practice is not set up to coordinate these additional services, as well as to provide ongoing care. We will discuss potential solutions to providing ongoing care in next month's column.

Behavioral and psychological symptoms of dementia. Assisting the caregiver and managing the patient

Behavioral and psychological symptoms of dementia cause many problems for patients and caregivers. Fortunately, physician intervention and pharmacologic and nonpharmacologic approaches to managing the patient provide hope for successful treatment. New antipsychotic agents and pharmacologic treatments are in development and may provide greater benefits to patients and their caregivers.

Behavioral and psychological symptoms of dementia: a current focus for clinicians, researchers, and caregivers

Behavioral and psychological symptoms of dementia are an important aspect of dementing illness. They represent a growing burden to caregivers and health care institutions and an increasing financial burden as the proportion of elderly patients, and consequently those with dementia, increases throughout the world. Behavioral and psychological symptoms of dementia can be recognized and assessed using a number of rating scales. Management of the symptoms is then possible for the benefit of patients, family members, caregivers, and the health care system.

Nimodipine potentiates the light-induced suppression of melatonin

In mammals the phase shifting response of the circadian clock to light can be enhanced by administration of the calcium channel antagonist nimodipine. In the present study we assessed the potential for nimodipine to affect the responsiveness of the human circadian clock to light by measuring the light-induced suppression of melatonin levels in plasma. Seven healthy young subjects (3M, 4F, 27.3 +/- 1.8 years old) were admitted on four occasions to the Clinical Research Center at Northwestern University Medical School. Blood was collected during the night to assess the effect of nimodipine (30 mg, orally, 01:30 h) on plasma melatonin levels in the presence or absence of light (500 lux, 2-3 am). Melatonin levels in plasma were measured by radioimmunoassay. Exposure to light for 1 h suppressed melatonin levels in plasma by nearly 38% relative to samples obtained at the same time in the absence of light (P = 0.013). Nimodipine administration did not modify plasma melatonin levels. However, combined treatment with nimodipine and light suppressed melatonin levels in plasma by 59%. Levels of plasma melatonin were significantly lower following treatment with nimodipine and light than following treatment with placebo/light (P = 0.014). Thus, the calcium channel antagonist nimodipine potentiated the suppressive effect of light on melatonin levels in plasma. These results suggest that the calcium channel antagonist nimodipine may also potentiate the response of the human circadian clock to light, and might thus be useful in combination with phototherapy for the treatment of sleep and circadian rhythm disorders.

Comparative efficacy of sertraline vs. fluoxetine in patients age 70 or over with major depression

Using data from a larger 12-week clinical trial, the authors evaluated the comparative efficacy and safety of sertraline (n=42) and fluoxetine (n=33) in patients over age 70 with a diagnosis of major depressive disorder. Similar improvement on measures of depression, including remission of depressive symptoms, was evident, although significantly more sertraline-treated patients achieved a criterion clinical response. Significantly greater improvement for the sertraline group was apparent on the Digit Symbol Substitution Test, but not on two other measures of cognitive functioning. Although there was no difference in the rate of adverse events experienced, fluoxetine-treated patients lost significantly more body weight over the 12-week trial than did sertraline-treated patients, whereas the latter group exhibited significantly more "shaking. "

Comparative efficacy and safety of sertraline versus nortriptyline in major depression in patients 70 and older

BACKGROUND

Few randomized, double-blind studies that examine antidepressant treatment in patients 70 years and older are available. To provide additional data on the safety and efficacy of antidepressants in this rapidly growing population segment, a subgroup analysis of a larger sertraline vs. nortriptyline elderly depression treatment study was performed.

METHODS

Outpatients (N = 76) who met DSM-III-R criteria for major depression with a minimum Hamilton Depression Rating Scale (HAM-D) severity score of 18 were randomized to 12 weeks of flexible dose treatment with sertraline (50-150 mg) or nortriptyline (25-100 mg).

RESULTS

Both treatments significantly improved depression as measured by the HAM-D and Clinical Global Impression scales. At Weeks 10, 12, and endpoint, sertraline demonstrated a significantly greater reduction in depression severity compared to nortriptyline as measured by improvement on the 24-item HAM-D (mean adjusted change score of 14.8 vs. 7.6, respectively, at Week 12; p = .001). Sixty-five percent of sertraline-treated patients were responders by Week 12 (50% or greater reduction from baseline in 24-item HAM-D score) compared to 26% of nortriptyline-treated patients (p < .05). Sertraline treatment had a significantly more positive effect, when compared to nortriptyline, across almost all associated measures of cognitive function, energy, anxiety, and quality of life and was better tolerated than nortriptyline, with a lower attrition rate/side effect burden.

CONCLUSION

The efficacy advantage of sertraline appeared to be even greater in this subgroup of older patients drawn from a larger treatment study of depression that included elderly individuals over the age of 60.

History and physical examination of elderly patients with dementia

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

Psychotherapeutic agents in older adults. Antipsychotics: old and new

As the number of older adults worldwide continues to increase markedly, the absolute increase in their numbers means that there also will be a substantial increase in the number of older people with mental disorders. These disorders include several that manifest psychotic symptoms. Many credit the substantial reduction in the number of older people in state mental hospitals over the past 40 years primarily to the advent of antipsychotic (neuroleptic) medication. Although the traditional neuroleptic medications often are effective, they also are associated with troublesome side effects. Newer neuroleptic medications appear to be just as effective but have fewer adverse side effects.

Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society

OBJECTIVE

A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research?

PARTICIPANTS

Consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy.

EVIDENCE

The expert presenters summarized data from the world scientific literature on the questions posed to the panel.

CONSENSUS PROCESS

The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached.

CONCLUSIONS

Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.

Managing the behavioral and psychological signs and symptoms of dementia

As the world's population ages, increasing numbers of patients with dementia can be expected, the signs and symptoms of which can be extremely disruptive. In particular, behavioral and psychological signs and symptoms of dementia reduce the quality of life of carers (usually family members) and increase the cost of care. Conventional neuroleptics have been used for many years in the management of disturbed and disruptive demented patients, although there are few well-controlled clinical trials demonstrating their efficacy. The use of the low-potency neuroleptics is associated with orthostatic hypotension, cardiac toxicity, anticholinergic side effects and daytime sedation. The high-potency neuroleptics tend to cause extrapyramidal side effects and akathisia. Clozapine although less likely to cause extrapyramidal symptoms than conventional neuroleptics, can cause orthostatic hypotension and requires continual blood monitoring. Early-phase open trials suggest that risperidone is efficacious in patients with behavioral and psychological signs and symptoms of dementia and that it has a low side-effects profile. Further trials are needed to confirm this, but it is likely that the newer antipsychotics, as typified by risperidone, will lead to safer and more effective management of patients with the disruptive and costly behavioral and psychological signs and symptoms of dementia. Non-pharmacologic interventions may also provide benefit, though controls are rare.

Psychogeriatrics, nursing homes, and lawsuits

Few pieces of American legislation evoke as many raised eyebrows and quizzical looks in non-Americans as does the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). Incorporated into this legislation is the Nursing Home Reform Act, which contains guidelines for establishing a better environment and better care for nursing home residents. Certainly, some of the provisions focusing on nutrition, improved staff education, and the collection and evaluation of data have resulted in improved care, but the provision that regulates the prescription of psychotropic medications has received mixed reviews.

Efficacy and tolerability of antidepressant therapy in the old-old

As the number of elderly increases worldwide, there will be a concurrent increase in the absolute number of people over 70 years of age who suffer from major depressive disorders. There is a paucity of research in this old-old population, although each of the following drugs has been studied in at least one clinical drug trial: amitriptyline, bupropion, dothiepin, fluoxetine, mianserin, nortriptyline, paroxetine, and sertraline. The results to date, though limited, suggest similar efficacy and greater tolerability of serotonin selective reuptake inhibitors compared with tricyclic antidepressants in the elderly.

Clinical experiences and methodologic challenges in conducting clinical trials on the behavioral disturbances of dementia

With a world population increasing in size and age, the number of elderly people with behavioral disturbances in dementia (BDD) is becoming an increasing problem. The burden of caring for someone with BDD may be so great that it leads to premature institutionalization of the patient. Few clinical trials have focused on noncognitive behavioral symptoms in this group of elderly patients, and little is known about the efficacy of drugs against these symptoms. The pharmaceutical companies have recently begun to assess different medications, but clinical trials in the elderly present a variety of problems not encountered in other patient populations. This article describes how the administration, initiation, logistics, finances, and methodology of such trials must be carefully assessed. Consideration of these factors together with improved definitions of behavioral symptoms and the advances in medication in this area should lead to an improvement in the treatment and management of behavioral disorders in the elderly.

Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment

The behavioral (e.g., repetitive questioning, hitting) and psychological (e.g., delusions, anxieties) signs and symptoms of dementia can result in suffering, premature institutionalization, increased costs of care, and significant loss in the quality of life for the patient and his or her family and caregivers.

Nursing home research from investigators' perspective

The negative effects of behavioral disturbances of dementia on the quality of life of both the patient and caregiver have been recognized for some time. For family caregivers, behavioral problems increase stress and may lead to institutionalization of the patient. In nursing homes, professional caregivers may have difficulty managing behaviorally disturbed patients and avoid interactions with them.

Research methodologic issues in evaluating behavioral disturbances of dementia

Behavioral disturbances of dementia have been noted by early researchers in the field, including Esquirol (1838) and Alzheimer in his seminal case description (1907). Increasingly, family members, healthcare providers, and policy makers are realizing that neuropsychiatric symptoms and behavioral problems are an intrinsic component of Alzheimer's disease and result in caregiver psychopathology, early institutionalization, substantial societal costs, and detriment in the quality of life for the patient and caregivers.

Validity of the Severity of Psychiatric Illness rating scale in a sample of inpatients on a psychogeriatric unit

Previous efforts to define the case mix of psychiatric inpatients have generally relied on the use of psychiatric diagnosis, and have had little success elucidating the relationship between clinical outcome and resource utilization. The Severity of Psychiatric Illness (SPI) rating scale, a reliable chart-based system using nine clinical rating dimensions, has been developed by one of the authors for use in studying the case mix of psychiatric inpatients. This report is the first describing this scale. For a sample of 244 psychogeriatric patients, all but one of the dimensions were significantly correlated with at least one of the five baseline clinical assessments, and all but one of the SPI items were correlated with outcome assessment. Four dimensions of the SPI were related to clinical outcomes. The SPI also predicted length of stay (predicting 23% of the variance for patients discharged to their homes). This study provides strong evidence for the construct and predictive validity of the SPI among older adult psychiatric inpatients.

Research directions for treatment of depression

Late-life depression is an immense public health problem for which research on treatment interventions is very much needed. Between 1950 and 1990, average longevity worldwide increased from 46.6 years to 64.7 years (United Nations, 1993). With this surge in the elderly population has come an increased prevalence of late-life depression and its sometimes severe consequences. Older people with depressive symptoms have a threefold increase in mortality (Ashby et al., 1991). As many as 15% to 25% of nursing home residents in the United States have major depression (NIH Consensus Development Panel, 1992), and between 50% and 80% of elderly people who commit suicide have major depression (Clark, 1991; Conwell et al., 1991; Finkel & Rosman, 1995).

Six elderly suicides in a 1-year period in a rural midwestern community

In a 1-year period, 6 of 11 suicides in a rural Wisconsin county were committed by people over the age of 60. At the request of the local coroner, the American Medical Association sent a team of investigators to perform psychological autopsies. Family member survivors, friends, and attending physicians were interviewed. The majority of suicide victims had evidence of major depressive episodes, delusions that they had a terminal physical illness, and knowledge of family/friends who had committed suicide. Most had seen their physician within 48 hours before their death. Continuing education efforts focused on increasing a physician's abilities to recognize depression and suicidal ideation have ensued, based on this experience.

A brief agitation rating scale (BARS) for nursing home elderly

OBJECTIVE

To determine the effectiveness of a brief agitation rating scale (BARS) derived from the Cohen-Mansfield Agitation Inventory (CMAI).

DESIGN

Test of reliability and validity of a new test.

SETTING

The Lieberman Geriatric Health Centre, a skilled nursing facility.

PARTICIPANTS

Forty members of the Lieberman Geriatric Health Centre nursing staff, 232 residents, and a sample of 40 randomly selected residents.

MEASUREMENTS

Observational agitation ratings by registered nurses and certified nurses' assistants; item to total correlations for the CMAI on each of the three shifts; Pearson correlations between the 10-item BARS and the BEHAVE-AD and the BSSAD scales.

RESULTS

Internal consistency reliability for the BARS was .74 (for the day shift), .82 (evening shift), and .80 (night shift), compared with .86, .91, and .87 for the full CMAI. Each of the 232 residents' scores on the BARS was correlated with a total score from the CMAI separately on each shift. Correlations were of .95, .94, and .95. Thus, across all shifts, the BARS accounted for approximately 90 percent of the variance of the total score of the CMAI. Concurrent validity of the BARS was supported by significant correlation with BEHAVE-AD and BSSD.

CONCLUSIONS

The BARS represents a brief and effective mechanism to assess the presence and severity of physically aggressive, physically non-aggressive, and verbally agitated behaviors in elderly nursing home residents.

May you live amidst interesting dichotomies--from manifest behavior to molecular biology

Research and practice amidst interesting dichotomies — such is the state of psychogeriatrics in the 1990s — a field that reflects interesting dichotomies, though often in a complementary manner. Alzheimer's disease (AD) is a case in point. Discoveries at the molecular level and in understanding neurobiological phenomena in AD have generated enormous scientific excitement and public hope about potential breakthroughs; findings involving chromosome 14, the amyloid precursor protein, synaptic changes, the tau protein, and the like are increasing chances of cracking the mystery that surrounds the etiology of AD. Meanwhile, neither cause nor cure is known. However, it would be incorrect to say there is no treatment for AD. While there are no treatments that can reverse or stop the progression of the disorder, there are a number of interventions that can alleviate many of the behavioral symptoms that compound the course of the disorder. These behavioral problems contribute significantly to excess disability in AD; treating these behavioral symptoms can alleviate patient suffering, improve patient coping at that point in time, and reduce family burden. Hence, while research on the molecular biology of AD offers hope for tomorrow, attention to the manifest behavioral problems of the disorder contributes to improved management today (Group for the Advancement of Psychiatry, 1988).

Aging and mental health: diagnosis of dementia and depression

In this second segment of a panel discussion on aging and mental health, panelists focus on the primary care evaluation and management of the patient with dementia, including differential diagnosis of depression. Other topics of discussion include the roles of psychiatric referral and psychotherapy in patient management, suicide prevention, and alcoholism in elderly patients.

Aging and mental health: primary care of the healthy older adult. A roundtable discussion: Part I

Dementia, depression, alcoholism, and suicide are some of the most important mental health issues for the aging population. Among the factors that affect the physician's ability to evaluate and manage these disorders are drug-induced side effects, the ability and willingness of patients to communicate their feelings, the level of caregiver cooperation, and limitations imposed by federal regulations and reimbursement policies. In this first of three installments of a panel discussion, experts in geriatrics and geropsychiatry discuss healthy aging, age-related memory and sensory loss, changes in mentation postanesthesia, sexuality in the elderly, and side effects of common psychoactive medications.

Late-life suicide

Suicide rates for older people are increasing worldwide, thereby creating a major public health concern. There has been an absence of public policy and research interest in this area, although the needs are pressing and promise to be even more so.

Psychogeriatrics--an interdisciplinary specialty

Increasing numbers of people in absolute terms, and even more so in relative terms, are reaching an age in which psychogeriatric illness, as well as geriatric illness, frequently is manifested. This unprecedented increase in average individual lifespan is due largely to advancement in life standards of the population as a whole, the enormous improvement in hygiene, and the progress made by preventive and curative medicine in controlling acute and fatal disease, in addition to advancements in available treatments of chronic disease in old people.

Psychogeriatrics and medical informatics

The rapid growth of the field of psychogeriatrics, spurred on by aging populations, substantially increased funding, and growing interest by professionals, government, and society, has led, in turn, to a rapid growth of medical information. The management of this information poses a significant challenge to health care professionals and scientists. This rapid growth of knowledge has spawned a whole new field, “Medical Informatics.” This field concerns itself with the “cognitive, information processing, and communication tasks of medical practice, education and research, including the information science and the technology to support these tasks” (Greenes & Shortliffe, 1990).

Psychogeriatrics in the 1990s

This issue of International Psychogeriatrics is the first in the last decade of this century. If progress in the field of psychogeriatrics during the 1980s is any indication, the 1990s should be all the more impressive. The 1980s witnessed a remarkable upsurge of psychogeriatric research and clinical interest in working with older patients. There was a geometric growth of scientific publications and a new infrastructure fostered by the growth and development of national and international professional societies emphasizing psychogeriatrics.

House calls in the 1990s: new concepts and categories of home visits. A call for new research and reports

Where ill or frail older adults might reside is still too narrowly viewed, as if there are but two choices—home versus nursing home. But the choices are expanding, and, in the process, new treatment challenges and opportunities are emerging. This is especially the case from a psychogeriatric perspective.

Learning mnemonics: a preliminary evaluation of a computer-aided instruction package for the elderly

Sixty-two normal elderly subjects averaging 71 years old were taught a common mnemonic device for recall of lists using a Computer-Aided Instruction (CAI) package. Improvement in list-learning after CAI training was not statistically different from a separate group of 218 elderly subjects who received instruction from a trainer in a normal classroom situation. Improvement in the CAI group was significantly related to higher scores on the Openness to Experience subscale of the NEO-Personality Inventory. CAI devices for memory training in the elderly may find a place in training selected elders on specific areas of memory loss.

Subdiaphragmatic bronchogenic cyst with gastric communication

Upper gastrointestinal series and computed tomography of the abdomen in an elderly women demonstrated a large multiloculated mass in the left subphrenic space that communicated with the fundus. The resected specimen showed histopathological features of bronchopulmonary foregut malformation.

Mental health services for the elderly: current policies & future directions

The changing demography of this country shows an ever increasing percentage of elderly Americans within the population. Changing public policies will tend to shift the health and mental health care of the elderly more toward the private sector. However, work with the elderly mentally ill has many rewards in the professional, intellectual, and personal spheres. Currently, according to 1982 data, a number of NAPPH member hospitals have services in place to face the coming challenge that will accompany the "greying of America." These, however, will be insufficient. We must use our creative resources to develop more effective approaches to the psychiatric problems of later life.