Background: Activities of daily living (ADL) deficits are integral components of dementia disorders, and ADL measures are among the most robust markers of the course of Alzheimer's disease (AD). Despite this acknowledged importance, no clearly useful ADL instrument for cross-cultural application in pharmacologic trials in the early stages of AD had been available. Method: An international effort was launched to develop an ADL scale for pharmacologic trials in early AD. Steps taken from 1990 to the present included: (1) international scientific working group meetings and reviews, (2) reviews of existing measures, (3) collating of existent, nonredundant items, (4) querying experts for new items, (5) interviews with informants and subjects in the USA, France, and Germany, toward the identification of potential new items, (6) identification of an item pool based upon these procedures, (7) creation of a trial instrument, (8) piloting of this instrument, and (9) refinement of the scale based upon statistical analysis of the pilot data. Final item selection was based upon: (1) relevance for ≥ 80% of subjects in severity-stratified USA and German samples; (2) absence of gender and national biases; (3) significant (p < .05) discrimination between (a) normal versus mildly impaired and (b) mildly impaired versus moderately to moderately severely impaired subjects; and (4) Global Deterioration Scale (GDS) scores accounting for ≥ 12% of variance in the item after controlling for age and gender. Results: An ADL scale consisting of 40 items that correlate with the global and cognitive progress of AD is developed for international usage in pharmacologic trials in incipient, mild, moderate, and moderately severe AD. The scale contains 40 items falling within 13 ADL categories. The 40-item scale is shown to have .81 correlation with GDS staging,.81 with mental status assessment (Mini-Mental State Examination), and .81 with a psychometric test (the SKT) (p values < .001). Conclusion: This scale can be used to measure therapeutic response in AD.

This article discusses the potential of three assessments of language function in the diagnosis of Alzheimer-type dementia (DAT). A total of 115 patients (mean age 65.9 years) attending a memory clinic were assessed using three language tests: a picture description task (Boston Cookie-Theft picture), the Boston Naming Test, and a semantic and phonemic word fluency measure. Results of these assessments were compared with those of clinical diagnosis including the Global Deterioration Scale (GDS). The patients were classified by ICD-10 diagnosis and GDS stage as without cognitive impairment (n = 40), mild cognitive impairment (n = 34), mild DAT (n = 21), and moderate to severe DAT (n = 20). Hypotheses were (a) that the complex task of a picture description could more readily identify language disturbances than specific language tests and that (b) examination of spontaneous speech could help to identify patients with even mild forms of DAT. In the picture description task, all diagnostic groups produced an equal number of words. However, patients with mild or moderate to severe DAT described significantly fewer objects and persons, actions, features, and localizations than patients without or with mild cognitive impairment. Persons with mild cognitive impairment had results similar to those without cognitive impairment. The Boston Naming Test and both fluency measures were superior to the picture description task in differentiating the diagnostic groups. In sum, both hypotheses had to be rejected. Our results confirm that DAT patients have distinct semantic speech disturbances whereas they are not impaired in the amount of produced speech.

The Canadian Study of Health and Aging was a complex undertaking that faced management challenges not encountered by smaller-scale projects. The study followed 10,263 elderly people in 18 study centers spanning six time zones; it was administered in two languages, and over 70 investigators were involved. The data collected from each participant were not fixed, but varied according to the results of earlier testing. The data could include a screening interview, a self-completed risk factor questionnaire, an interview with a relative, a clinical examination, neuropsychological testing, blood samples, and neuroimaging.

This report describes the approach taken to organize the study, to track participants, and to monitor adherence to the study protocol. It also describes the human organizational aspects, including systems for staff training, for communicating among study centers, and for coordinating the publication of results. The discussion proposes some guiding principles for administering multicenter studies.

It is a privilege to announce on behalf of IPA the 7th Biannual IPA Research Awards in Psychogeriatrics. These awards are given for the best-submitted results of original, previously unpublished, research conducted in the field of psychogeriatrics. For the 2001 award competition, 35 submissions were received. These submissions came from 15 countries on five continents. Clearly, the review task is both rigorous and demanding, and I would like to commend the other referees who generously gave of their time and expertise for this competition. The referees were: Manfred Bergener from Germany; Henry Brodaty from Australia; Alistair Burns from England (UK); Vijay Chandra from India; Helen Fung-kum Chiu from Hong Kong; Edmund Chiu from Australia; Michael Davidson from Israel; Robin Eastwood from England (UK); Timo Erkinjuntti from Finland; Sanford Finkel from the United States; Mario Fioravanti from Italy; George Grossberg from the United States; Brian Lawlor from Ireland; Joao Carlos Barbosa Machado from Brazil; Burton Reifler from the United States; Karen Ritchie from France; Joel Sadavoy from Canada; and Michael Zaudig from Germany, in addition to myself, who also served as Chair of the IPA Research Awards Committee.

Objective: To investigate the effects of a systematic intervention with a case manager concept and rehabilitation periods compared to standard aftercare in elderly community-dwelling patients discharged from the hospital after a delirium episode. Design: Before/after intervention cohort study with 3-year follow-up. Settings: Acute geriatric wards of a city hospital and a private rehabilitation center. Subjects and Methods: The intervention group consisted of 51 community-dwelling people over 65 years of age without severe underlying disorders, who were consequently admitted as emergency cases to the hospital because of a delirious state or who were delirious immediately after admission. The intervention included continuous support and counseling by a nurse specialist and rehabilitation periods at a rehabilitation center. The control group consisted of 51 age- and gender-matched patients admitted to the same hospital for delirium fulfilling the same inclusion and exclusion criteria during preceding years. The main outcome measures were duration of community care, the use of long-term institutional care, the use of short-term hospitalizations during the follow-up, and the death of the patients. Results: Delirium even in the healthy community-dwelling subjects indicated a poor prognosis. After 3 years, 18 patients (35%) from the intervention group and 9 patients (18%) from the controls were in community care. The mean duration of community care was 671 days in the intervention group and 503 days in the control group, p = .025. A reduction of 19 years was achieved in the cumulative time spent in long-term institutionalized care. The use of short-duration hospitalization was similar in both groups. Conclusion: The institutionalization of elderly patients after a delirious state could be delayed using rehabilitation periods and systematic intervention with the case manager concept.

Background/literature review: The prevalence of agitated behaviors in different populations with dementia is between 24% and 98%. Although agitated behaviors are potentially disruptive, little research attention has been focused on the effects of these behaviors upon nursing staff. The objectives of this study of demented patients in long-term-care beds at an acute care community hospital were to determine the frequency and disruptiveness of agitated behaviors; to investigate the associations of patient characteristics and interventions with the level of agitation; and to explore the burden of these agitated behaviors on nursing staff. Method: The study sample comprised 56 demented patients in the long-term-care unit during the study period. Twenty-seven staff who cared for these patients during three shifts over a 2-week period were interviewed to rate the frequency and disruptiveness of agitated behaviors using the Cohen-Mansfield Agitation Inventory, and the burden of care using a modified version of the Zarit Burden Interview. Data on patient characteristics and interventions extracted from the hospital chart included scores on the Barthel Index and Mini-Mental State Examination, the use of psychotropic medication, and the use of physical restraints. Results: Ninety-five percent of the patients with dementia were reported to have at least one agitated behavior; 75% had at least one moderately disruptive behavior. A small group of six patients (11%) had 17 or more disruptive behaviors. The frequency of most behaviors did not vary significantly by shift. Length of stay on long-term care, Barthel Index score, and the use of psychotropic medications were significantly associated with the number of agitated behaviors. The number of behaviors, their mean frequency, and their mean disruptiveness were all significantly correlated with staff burden. Discussion: The prevalence of agitated behaviors in patients with dementia in long-term-care beds at an acute care hospital is similar to that reported in long-term-care facilities. These behaviors are associated with staff burden.

Education is correlated with cognitive status assessment. Concern for test bias has led to questions of equivalent construct validity across education groups. Following the work of previous researchers, we submitted Mini-Mental State Examination (MMSE) responses to external validation analyses. Subjects were older participants in the Epidemiologic Catchment Area study (age 50-98). Little evidence for test bias against those with low education was found. The correlation of MMSE scores and age was equivalent across high-and low-education groups (−.29 vs. −.27, p = .48), as was the correlation of MMSE scores and activities of daily living (ADL) functioning (−.23 vs. −.27, p = .42). The MMSE displayed significantly higher internal consistency reliability in the low-education group (.75 vs .72, p = .04). The MMSE did not predict functional decline over 1 year or mortality over 13 years differently by level of educational attainment. Evidence for sex bias was found. The MMSE was more highly correlated with age among women than among men (−.28 vs. −.21, p < .001). The MMSE was more highly correlated with ADL impairment among women than among men (−.30 vs. −.17, p = .01). The MMSE predicted mortality differently according to participant sex (p = 0.53). The lack of evidence for bias provides little support to proposals to adjust MMSE scores according to level of education.

Correlates of nonparticipation in the community interview component of the Canadian Study of Health and Aging and their impact on bias in the results were analyzed. Characteristics of study subjects, their habitats, and encouragement techniques were analyzed to indentify correlates of variation in response rates across the 18 study centers. Refusal rates from 14% to 41% varied by age, gender, city size, number of subjects and length of time for enrollment, and method of approach. Cognitively impaired subjects had higher refusal rates which affected prevalence estimates. At one study site, efforts to “convert” subjects who initially refused to participate in the survey were successful with 26% of those who were recontacted.

Objective: To study the 12-month outcome of late-onset depression in elderly persons and the predictive factors affecting its outcome. Method: This is a prospective study of 50 patients who had their first major depressive episode (according to DSM-III-R) in old age (60 years and above) and attended the psychiatry services of a tertiary care hospital in India. These patients were assessed at baseline and after 12 months for clinical outcome. Stepwise logistic regression was applied to determine predictive factors for the clinical outcome. Results: Twenty-eight percent of the patients had recovered, 30% had partially recovered, 23% had relapsed, 6% had been continuously ill, 11% had died, and 6% had comorbid dementia. Factors predicting a good outcome (full recovery and continuously well for 1 year) were shorter duration of episode (adjusted odds ratio [OR] = 19.15, 95% confidence interval [CI] 2.12-172.82) and living in joint family system (adjusted OR = 4.88, 95% CI 0.80-29.74). Conclusion: Overall, the 12-month outcome was poor in elderly individuals with late-onset depression.

Background: Psychotic symptoms in subjects with Alzheimer disease (AD+psychosis, AD+P) are a marker for a distinct phenotype characterized by more rapid cognitive and functional decline and a liability to aggressive behaviors. We recently found that AD subjects homozygous for long alleles (l) of an insertion/deletion polymorphism in the promoter region of the serotonin transporter (5-HTTPR) had elevated rates of aggressive behavior. Objective: To examine whether the 5-HTTPR ll genotype confers an increased risk of AD+P, and of the combined AD+P/aggressive phenotype. Methods: The 5-HTTPR genotype was determined in 332 subjects diagnosed with possible or probable AD. All subjects received structured psychiatric assessments and were categorized with regard to their history of aggressive behaviors and psychotic symptoms. Results: Consistent with other reports, AD+P was associated with a significant increased risk for aggressive behavior. AD+P and aggression were both significantly associated with 5-HTTPR ll genotype and with an increased l allele frequency. Subjects with the combined behavioral phenotype (AD+P and aggressive behavior) had the highest rate of ll genotype and highest l allele frequency. Conclusion: The 5-HTTPR l allele appears to confer risk for the combined AD+P/aggressive phenotype. Confirmation of this association in a similar behaviorally well-characterized independent sample is needed.

Patients with dementia with lewy bodies (DLB) have progressive deficits in cognition, parkinsonism, and neuropsychiatric symptoms. Cholinesterase inhibitors have been used to ameliorate cognitive decline and neuropsychiatric symptoms in short-term trials. In this study, patients with DLB were treated with rivastigmine up to 96 weeks. Improvement from baseline was seen in cognitive function as measured by the Mini-Mental State Examination (MMSE), and neuropsychiatric symptoms as measured by the Neuropsychiatric Inventory (NPI) over the first 24 weeks of treatment. By 96 weeks, neither the MMSE scores nor the NPI scores were significantly worse than at baseline.

The Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, Multi-Infarct Dementia, and Dementias of Other Aetiology (SIDAM) includes the Mini-Mental State Examination extended by a number of additional items and allows the diagnosis of dementia according to ICD-10 and DSM-III-R criteria. The authors proposed to summarize selected items to form syndrome scores. These syndrome scores are supposed to measure different aspects of cognition. However, these syndrome scores have not been empirically confirmed. The present article presents a principal component analysis performed on the SIDAM test performances of 456 elderly subjects. The subjects were recruited in the course of a family study on dementia of the Alzheimer's type and depression in the elderly. One hundred four of these subjects met the criteria of dementia according to the ICD-10 criteria. Thus, the sample represnets the population in which the SIDAM is frequently used in routine clinical and epidemiological studies. We found a six-factor structure accounting for 57.1% of the variance with some similarities to the predefined structure of different syndrome scores proposed by the authors of the SIDAM. The first factor found in principal component analysis represented different higher cortical functions that all depend on language and comprehension. Three factors covered three different aspects of memory, i.e., orientation for time, orientation for place, and short-term memory. One factor represented visuoconstructive skills and, finally, there was a factor representing intellectual abilities and education. This empirically found factor structure characterizes the dimensions of cognitive deficits in demented subjects measured by the SIDAM. Syndrome scores should reflect these dimensions. Consequently, we propose to consider the empirically found factor structure in a new version of the SIDAM.

Background: Depression is the most prevalent disabling psychiatric syndrome of aging and may lead to important decrements in the elderly depressed patient's health-related quality of life (HRQL). The goal of this study was to determine whether severity of chronic illness at admission, severity of depressive symptoms at admission, or living alone before admission was associated with lack of improvement in HRQL at 3 months postdischarge among elderly depressed inpatients. Methods: Subjects were 100 consecutive patients admitted to a 26-bed inpatient geriatric psychiatry unit from 1994 through 1997, who were residing in the community and were not demented. At admission, severity of depressive symptoms was assessed using the Geriatric Depression Scale and severity of chronic physical illness was measured using the Cumulative Illness Rating Scale (Geriatrics). HRQL was assessed at admission and again at 3 months postdischarge using the Medical Outcomes Study (MOS) 6-Item General Health Survey. Results: This study found large improvements in all MOS items between admission and 3 months postdischarge. Severity of chronic physical disease was negatively associated with the probability of improvement in three MOS items (role functioning, psychological functioning, and general health perceptions) whereas the severity of depressive symptoms on admission was negatively associated with the probability of improvement in role functioning, social functioning, and bodily pain. Living alone was negatively associated with social functioning but not with any of the other MOS items. Conclusion: The results of this study suggest that the inpatient treatment of depression in the elderly brings about improvements in quality of life that persist for at least 3 months follwing discharge. The patient's initial level of depression and initial level of physical health may be important factors to be considered when evaluating a patient's prognosis.

Introduction. The aim of the study was to investigate whether the preclinical stage of Alzheimer's disease (AD) can be diagnosed in a clinical setting. To this end we investigated whether subjects with preclinical AD could be differentiated from subjects with nonprogressive mild cognitive impairment and from subjects with very mild AD-type dementia. Methods. Twenty-three subjects with preclinical AD, 44 subjects with nonprogressive mild cognitive impairment, and 25 subjects with very mild AD-type dementia were selected from a memory clinic population. Variables that were used to differentiate the groups were demographic variables, the Mini-Mental State Examination score, performance on cognitive tests, measures of functional impairment, and measures of noncognitive symptomatology. Results. Age and the scores for the delayed recall task could best discriminate between subjects with preclinical AD and subjects with nonprogressive mild cognitive impairment. The overall accuracy was 87% The score on the Global Deterioration Scale and a measure of intelligence could best discriminate between subjects with preclinical AD and subjects with very mild AD-type dementia. The overall accuracy was 85% Conclusions. Subjects with preclinical AD can be distinguished from subjects with nonprogressive mild cognitive impairment and from subjects with very mild AD-type dementia. This means that preclinical AD is a diagnostic entity for which clinical criteria should be developed.

In studies of dementia, the age at onset (AAO) of the disease is often described without indicating how it was obtained. We used the “CAMDEX algorithm,” an ad hoc procedure, to compute the AAO of dementia form the CSHA database. An AAO could be calculated for 983 of 1,132 subjects with dementia. A similar procedure (the “clinical algorithm”) was used to calculate a second AAO, which was compared to that obtained by the first algorithm. The CAMDEX and clinical algorithms produced mean AAOs of dementia of 80.5 years (SD = 9.2 years, n = 983) and 79.6 years (SD = 9.7 years, n = 829), respectively. The sample correlation coefficient between the CAMDEX and clinical algorithms was .899 while the intraclass correlation coefficient, ICC(2,1), was .898. This method could prove useful for researchers using the CSHA data who need an AAO for those subjects with dementia.

The reliability and validity of the Chinese vesion of the Cohen-Mansfield Agitation Inventory (CCMAI) were studied in 164 demented patients. The agitation pattern in Chinese elderly was also examined in this study. The CCMAI demonstrated high validity, test-retest reliability, and interrater reliability. Eighty-five precent of demented patients manifested one or more agitated behaviors at least once a week. Factor analysis yielded three subtypes of agitation: physically aggressive behaviors, physically nonaggressive behaviors, and verbally agitated behaviors. There was a linear upward trend in physical aggression as one progressed from one Global Deterioration Scale stage to the next. Community-living patients showed higher physically nonaggressive and verbally agitated behaviors, whereas institution residents exhibited a significantly higher level of physical aggression. The differences between residential and institutionalized patients need further research. Future study should focus not only on the behavioral disturbances; medical, psychological, and environmental factors should be taken into account to provide a more accurate profile.

Objective: To investigate the effects of light to moderate alcohol consumption on cognitive performance. Design and Setting: A cross-sectional analysis including older Japanese Americans in King County, WA, enrolled in the Kame Project, a population-based study of cognition, dementia, and aging. Participants: 1,836 cognitively intact participants aged 65 and older who participated in the baseline (1992-1994) examination. Measurement: Cognitive performance was measured using the Cognitive Abilities Screening Instrument, reaction time (simple and choice), and a measure of vocabulary (North American Adult Reading Test). Results: Multivariate analyses were used to examine the relationship between cognitive performance and alcohol consumption at baseline with men and women together and then separately controlling for age, education, smoking, history of stroke, angina, hypertension, diabetes, and coronary heart disease. Findings showed lower cognitive test scores were observed for men who were either abstainers or in the heavy drinking group. For women, a linear relationship between alcohol consumption and cognitive performance was seen on two of the four measures of cognitive functioning. No significant difference in the association of drinking and cognitive function was identified within the different Japanese American subgroups. Conclusion: Results suggest a possible positive relationship between light to moderate drinking and cognitive performance in an aging Japanese American population. Additional long-term prospective and cross-cultural studies are needed to determine the generalizability of these findings to other aging cohorts.

This study compared the efficacy and tolerability of 150 mg/day imipramine and 50 mg/day sertraline for the treatment of a major depressive episode (DSM-IV) in older adults (N = 55) in an 8-week, randomized, double-blind, controlled clinical trial. Intention-to-treat analysis (last observation carried forwards) showed a reduction of 50% or more on the baseline scores of the Montgomery-Åsberg Rating Scale (MADRS) in 60.7% and 55.6% of patients receiving imipramine and sertraline, respectively (p = .698). Full remission of symptoms (MADRS < 9) was observed in 50.0% and 51.8% of patients, respectively (p = .891). Side effects were more frequent among patients treated with imipramine (86.7%) than among patients treated with sertraline (42.1%) (p = .008). Dropout rates were high in both groups (46.4% and 29.6% respectively, p = .200). These results indicate that imipramine and sertraline are equally effective for the treatment of major depression in later life, although adverse reactions are more frequent among subjects treated with imipramine than with sertraline.

Objective: Until now, prospective studies of aging have begun with 50- to 60-year olds, not adolescents. Premature deaths, childhood variables, and alcohol abuse have been often ignored. So has positive aging. As people live longer, gerontology needs to understand the determinants of health as well as illness in the later years. Method: The present study follows a cohort of adolescent boys (332 inner-city youths) for 60 years or until death. Complete physical exams were obtained every 5 years and psychosocial data every 2 years. Predictor variables assessed prior to age 50 include six variables reflecting uncontrollable factors—parental social class, environmental strengths, number of family problems, major depression, ancestral longevity, and premorbid physical health at age 50—and six variables reflecting (at least some) personal control: alcohol abuse, smoking, marital stability, body mass index, coping mechanisms, and education. The four outcome variables chosen to assess healthy aging at 70 reflected both “mind” and “body”. They included objectively assessed variables (death and/or disability prior to 70, and objectives mental health) and two subjectively assessed variables (perceived instrumental activities of daily living and life enjoyment). Results: Multivariate analysis suggested that positive aging at 70 could be predicted by variables assessed prior to age 50. More hopeful still, if the six variables under some personal control were controlled, depression was the only uncontrollable variable that affected the quality of subjective and objective aging. Conclusions: First, we may have greater personal control over our biopsychosocial health after retirement than previously recognized. Second, in this cohort, psychiatric rather than sociological predictors appeared more important.

We examined the degree of interrater agreement on the Modified Mini-Mental State Examination (3MS), administered both in the home and at the clinical examination, to determine the boundaries of reliable individual changes for 257 community-dwelling older persons who received a diagnosis of dementia at CSHA-1. Individual score differences were approximately normally distributed (mean of differences 0.2; SD 8.0; 95% confidence interval -16 to 16). The intraclass correlation coefficient was 0.85. Except for the language of testing, there was no relationship between score differences and the determinants investigated (i.e., age, education, type and severity of dementia). This study provides evidence that, in a time frame compatible with no change in cognition, the discrepancy between repeat 3MS scores can be as large as ± 16. These limits represent the range of variability consistent with no change and should be considered when interpreting individual change scores.