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What a time it is for psychogeriatric research! This supplementary issue, drawing upon papers submitted for the 1991 IPA Research Awards in Psychogeriatrics, attests to the growth, vigor, and international reach of such studies. Also apparent are the depth and breadth of this field, as reflected in the papers published here— ranging in focus from dementia to depression, from biology to behavior, from cognition to culture. Especially exciting is the growing number of young investigators entering the field and contributing in an important way to the advancement of psychogeriatric knowledge.
One hundred and seven newly diagnosed, untreated patients with Parkinson's disease (PD) were divided into two groups according to their age at reported onset of symptoms. Of these, 79 patients were under age 70 (early-onset) and 28 patients were age 70 and over (late-onset). The group of 50 control subjects comprised spouses, friends of the PD patients, and community volunteers. The patients were participants in a multicenter drug study of Parkinson's disease. Each had received a detailed neurological and neuropsychological assessment in the baseline placebo phases of the study. Thirty-4 patients with early-onset and 12 patients with late-onset were reassessed 3 years after treatment with low-dose levodopa, with bromocriptine, or with a combination of the two drugs. The results of the baseline phase of the study revealed that 8% of the early-onset group and 32% of the late-onset group were classified as demented. The 3-year follow-up revealed that the prevalence of dementia had increased to 17% in the early-onset group and to 83% in the late-onset group. This study confirms that at least two distinct subtypes of Parkinson's disease exist. The subtypes differ both clinically and neuropsychologically. The age at onset of symptoms is a critical determinant of the rate and type of cognitive decline in Parkinson's disease.
Second Place (tie) 1991 IPA Research Awards in Psychogeriatrics
The Behavioral Syndromes Scale for Dementia (BSSD) is a new instrument that showed strong internal consistency and interrater reliability in an outpatient sample of 106 patients with probable Alzheimer's disease. Factor analysis provided support for a priori symptom groupings, particularly the syndromes of disinhibition and apathy-indifference. Dependency (87%), denial of illness (63%), and motor agitation (55%) were common, while sexual disinhibition (2.9%) and self-destructive behaviors (2.9%) were rare. Virtually all symptoms were predominantly minimal to mild in severity. Patients with longer illness duration were more apathetic. Disinhibited behaviors and apathy-indifference increased with greater severity of dementia. Catastrophic reactions, aggression, and agitation were associated with greater functional impairment. There was great heterogeneity in symptom presentation. In Alzheimer's disease, several behavioral changes might be direct manifestations of underlying brain pathology, rather than being solely secondary to cognitive impairment.
The purpose of this study is twofold: to estimate the prevalence of depressive symptoms among older adults in four culturally diverse groups (white Americans, black Americans, Japanese, Taiwanese), and to assess whether there are cross-cultural variations in the way depressive symptoms are manifest. Data from three recent nationwide surveys in the United States, Japan, and Taiwan reveal that the lowest overall levels of depressive symptoms are found among Japanese elderly, followed by Taiwanese, white Americans, and black Americans respectively. Based on previous cross-cultural research, it was hypothesized that the Japanese tend to express depressive symptoms as interpersonal complaints, whereas Taiwanese are more likely to manifest somatic symptoms. In contrast, Americans were expected to express depressive symptoms in the form of depressed cognitions. The findings failed to support these hypotheses. Instead, older Americans tended to have higher scores than Orientals on all three depressive symptom clusters.
Normative data were collected in a study population of 150 randomly selected elderly subjects. Using the SIDAM (Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, multi-infarct dementia, and dementias of other etiology according to DSM-III-R and ICD-10), both the dimensional and the categorical aspects of dementia and “mild cognitive impairment” are considered. With the SIDAM score (SISCO) [range 0 (minimum)-55 (maximum, no cognitive impairment)] and the SIDAM Mini-Mental State Examination (MMSE) (range 0–30), appropriate cutoffs for the category of DSM-III-R and ICD-10 dementia and “mild cognitive impairment” were defined. MMSE scores of 0–22 were found to be indicative of DSM-III-R and ICD-10 dementia. For “mild cognitive impairment,” MMSE scores ranged from 23–27 according to a DSM-III-R definition (ICD-10: 23–28). An MMSE score of 22 or less was found to differentiate between DSM-III-R/ICD-10 dementia and “mild cognitive impairment,” with a specificity of 92% (ICD-10: 95.6) and a sensitivity of 96% (ICD-10: 96%). With the SIDAM-based DSM-III-R/ICD-10 diagnoses of dementia as the criterion, the SISCO was 97.3% specific (ICD-10: 99%) and 94% sensitive (ICD-10: 94%) in detecting dementia. A SISCO of 0–33 was highly indicative of DSM-III-R and ICD-10 dementia. For “mild cognitive impairment,” a SISCO between 34–47 (ICD-10: 34–51) was found. The SISCO covers a broader range of cognitive functions that the MMSE and is more useful in detecting even very mild cognitive decline. Furthermore, the newly defined category of “mild cognitive impairment” could be validated successfully by means of GDS Stages 2–3 and CDR Stage 0.5. These findings confirm the value of the SIDAM as a short diagnostic instrument for measurement and diagnosis of dementia and “mild cognitive impairment.”
Agitated behaviors in the nursing home pose a major problem for caregivers. Our data showed that the three syndromes of agitation—aggressive behaviors, physically nonaggressive behaviors, and verbally agitated behaviors—are differentially related to medical and psychosocial variables. Physically nonaggressive behaviors may be adaptive for a resident who presents a deteriorated stage of dementia, since these behaviors offer stimulation and exercise. Verbally agitated behaviors may be a form of help-seeking behaviors for residents with physical disease and depressed affect. Aggressive behaviors are those least understood, although these behaviors correlate with advanced stages of dementia and with poor interpersonal relationships. These findings should be a basis for further studies, with the ultimate goal being improved care for agitated elderly persons.
This paper addresses the questions of whether depression compromises cognition in the elderly and whether discernable patterns of cognitive performances could be differentiated between patients with severe depression and those with organic dementia. Published data on geriatric depression and cognitive functioning are divided in demonstrating a depression effect. Further examination and external validation by new data show that the depression effect on discrete cognitive tasks is (1) small, and (2) sensitive to the confounding of sampling and task variables. Future research must take these factors into account. Patterns of cognitive functioning in depression and dementia are different and can be differentiated using a variety of measures. This review finds the term pseudodementia inappropriate and misleading and recommends that it be abandoned.
The frameworks of Erikson (1963) and Butler (1963) were used to design this descriptive study that investigated the relationships among life review, ego integrity, and death anxiety in older adults. Three hypotheses were proposed: (a) the greater the life review, the higher the ego integrity; (b) the greater the life review, the lower the death anxiety; (c) the higher the ego integrity, the lower the death anxiety. The sample consisted of 115 female and male volunteers between the ages of 65 and 93. The participants filled out the Life Review Questionnaire, Adult Ego Development Scale, Death Anxiety Scale, Death Preparation Scale, and a Personal Information Sheet. Life review, while not positively correlated with ego integrity, was found to have a negative correlation with death anxiety. Also, religious subjects were found to be more prepared for death than those who did not practice. Implications for therapy and future research are discussed, as well.
This study examined the underlying variables of selected reminiscing processes to determine those that contributed to well-being. Two hundred and forty subjects randomly selected from nursing homes and high-rises participated in one of 10 different reminiscing modalities for eight weeks. Measures of life satisfaction (LSI-A), psychological well being (ABS), selfesteem (SES), and depression (BDI) were given pre- and postintervention to determine the most therapeutic treatment modalities. Results showed the most therapeutic way to reminisce was through a structured, evaluative life review performed on an individual basis. Thus, three variables contributed to successful reminiscing: individuality (one-to-one reminiscing), evaluation (a personal valuing of events), and structure (covering the whole life span).
Although the central cholinergic deficits are still considered to be of primary importance in Alzheimer's disease, there is great need for an expansion of the pharmacological approach in this illness beyond the simple cholinergic replacement hypothesis. This report focuses on the concept of “combination chemotherapy” in Alzheimer's disease as the next generation of therapeutic strategies. Based on earlier positive findings in Alzheimer patients with the monoamine oxidase B inhibitor, 1-deprenyl, the authors speculate that a combination of physostigmine, the short-acting cholinesterase inhibitor, and 1-deprenyl might be more beneficial than either agent alone. The authors outline a sample paradigm for such combination studies, report preliminary data on the first 16 Alzheimer subjects to have received an initial combination of physostigmine and deprenyl, and point to other possible “combination chemotherapy” strategies for future study.