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.

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.

Since 1955, when I first became involved in the field, there has been much progress in geriatric psychiatry. I would like to add here some general, even philosophic, considerations to this very important discipline; I offer these as a series of messages to keep in mind as we approach the 21st century. While we pursue our specific interests as psychogeriamcians, we must also keep in mind these more general issues and work toward a philosophy of individual and societal aging and longevity, drawing on both Eastern and Western thought.

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

Patients with Alzheimer's disease (AD) have been reported to have a rate of nonsuppression on the dexamethasone suppression test (DST) comparable to that of patients with major depression. With symptoms of depression being increasingly recognized in patients with AD, studying their DST response may provide clues to the etiology of the abnormal response in both diagnostic groups. A correlation between dementia severity and post-dexamethasone cortisol was found within the group of male, but not female AD patients. Within the group of elderly depressives, a correlation between post-dexamethasone cortisol and ratings of depression was found. Serum dexamethasone levels were not significantly lower in the nonsuppressors as compared with suppressors in either diagnostic group.

Behavioral abnormalities and psychiatric symptoms were assessed in 178 patients diagnosed as having Alzheimer's disease by NINCDS/ADRDA criteria. The subjects were selected from a defined catchment area and therefore were representative of a group of patients with Alzheimer's disease of varying severity. Auditory hallucinations were found in 10%, visual hallucinations in 13%, and delusions in 16%. Symptoms suggestive of depression were reported by 39% of the patients and features of depression observed in 25%. Twenty percent were aggressive, and 7% were sexually disinhibited. Nineteen percent exhibited excessive walking behavior and 10% binge eating. Nearly 50% of the sample were incontinent. Patients in the hospital were more often aggressive, incontinent, and seemingly less depressed. Patients with severe dementia displayed excessive walking behavior, were more likely to be incontinent, and reported less depressive symptoms than those with moderate or mild dementia.

The Mini-Mental State Examination (MMSE) is a commonly used instrument for assessing mental impairment. Previous proposals for its underlying structure have focused on scores obtained from a single administration of the test. Because the MMSE is widely used in longitudinal studies, we examined the pattern of relations among the rates of chance of the items. Data were obtained from 63 subjects for 1.5 years or more. The relations among the rates of change of the MMSE items were described by a five-factor solution that accounted for 75% of the variance and comprised factors pertaining to orientation and concentration, obeying commands, learning and repetition, language, and recall. This was in contrast to the structure of the scores obtained from a single administration of the MMSE, which was best described by a two-factor solution. In order to provide a clinical validation, factor scores derived from the MMSE factors were used to predict scores on the Memory and Behavior Problems Checklist and the Brief Cognitive Rating Scale.

Abnormalities in calcium homeostasis have been reported in Alzheimer's disease (AD) and in the neurofibrillary tangle disorders of amyotrophic lateral sclerosis and parkinsonism-dementia occurring in the Pacific. In order to more fully evaluate calcium physiology in AD, we analyzed the size of pineal and choroid plexus calcifications, using X-ray computed tomography, in 23 patients with probable AD and 18 healthy age-matched control subjects. The area occupied by calcification was measured from hard copies of the data by two independent observers who were blind to the diagnosis. There were no differences in the areas occupied by pineal or choroid plexus calcifications between the two groups. These data suggest that AD is not accompanied by alternations in intracranial calcium deposition in pineal gland or choroid plexus.

We report here on the coexistence of dementia and depression in a community population aged 75 years and older. Complete information about mood and cognition was available for 286 cognitively intact subjects selected for assessment because of their low scores on the Mini–Mental State, and for 158 mildly and moderately demented subjects. Severely demented subjects, who were incapable of providing information, were excluded. Five percent (8/158) of demented subjects also fulfilled criteria for major depressive disorder Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) compared with 9% (27/286) of cognitively intact subjects. No substantial differences existed in the symptoms reported by demented depressives and nondemented depressives, but subjects who suffered from both disorders were so markedly apathetic that their depression might easily have been overlooked had specific enquiries not been made. Depression was particularly associated with dementia secondary to multi-infarct and Parkinson's disease. When reviewed one year later, 2 of the 18 surviving depressed, nondemented subjects showed evidence of dementia. Both presented unusual diagnostic difficulties, however, and no evidence emerged that large numbers of elderly people will be misclassified in community surveys that include a mental state examination, cognitive testing, and an informant interview.

Recent progress in the biochemical characterization of Alzheimer's disease (AD) neuropathology has led to the proposal of three hypotheses for the molecular etiology of AD. One focuses on calcium-activated neutral proteases or calpains (Nixon, 1989). Another focuses on protein phosphorylation (Saitoh & Iimoto, 1989). A third is centered on altered phospholipid metabolism (Pettegrew, 1989). Interestingly, all three hypotheses are mutually compatible, involving closely interlocking biochemical systems. Disturbances in any one of these systems might result in the same type of neuropathology, consistent with suggestions that AD could have multiple etiologies. Future investigations of the function and interrelation of these systems in the central nervous system in general and at the synaptic junction in particular are likely to have significant bearing on our understanding of AD.

A review of the first 144 patients to attend a Memory Disorders Clinic found not one case of treatable dementia. The use of a routine comprehensive battery of investigations was not supported: however, computerized tomographic brain scans and electroencephalograms were moderately useful in diagnosing dementia. Clinical features and historical data did not discriminate early- from late-onset Alzheimer's disease or Alzheimer's disease from multi-infarct dementia.

Alcohol use and use disorders in older people tend to be hidden and ignored by clinicians and scholars. Resulting misinformation about elderly alcohol problems can be found in such fundamental works as the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Yet, an extensive literature about the nature of geriatric alcohol problems has developed recently. This article reviews that literature, comments on current research at several North American centers, and offers some new information from the author's study of more than 300 older male alcoholics. Many findings remain to be replicated and further verified. Nonetheless, several coherent strands of information seem to be well substantiated: (a) problem drinking in the elderly constitutes a public health problem of moderate proportion, especially in men; (b) most signs predict increasing problem drinking in coming generations of elderly women and men; (c) many cases of geriatric alcoholism have late onset; (d) many geriatric cases are not properly identified; and (e) present screening and diagnostic methods for alcohol use disorders lack adequate validation for older persons.

Psychogeriatric medicine is a young discipline in Sweden as well as in other parts of the world. Patients with psychogeriatric diseases, however, have been cared for in different ways during the centuries. When Christianity was established in Sweden, the view toward the helpless and poor changed radically. The institutions that were built, however, so-called Houses of the Holy Spirit, housed all kinds of poor and sick people as well as mentally ill elderly persons. During the 17th and 18th centuries, hospitals consisted of large units for the care of the poor elderly, children, and physically and mentally ill people. In 1763 it was established that the local communities should be responsible for the social care, and the State be responsible for mental and somatic care of both young and old people. Further, it was decided that the big hospitals should be mental hospitals reserved for all patients with mental disturbances, young and old.

A review was conducted of the records of 147 patients above the age of 60 in a 350-bed general university hospital for whom a request for consultations was made over a two-year period by a geriatric psychiatry division in a department of psychiatry. Findings were compared with those obtained by Mainprize and Rodin and by Ruskin. Most referrals in the present study were from internal medicine as they were in the other two studies. The principal reason for referrals in this and in Mainprize and Rodin's study was depression (48% and 37%, respectively) but not in Ruskin's study (10%). The primary DSM-III-R diagnoses of the referred patients in this study were affective disorder (27%), adjustment disorders (26%), and dementia (22%). Affective disorder was also the most frequent diagnosis in Ruskin's study. Psychotropic medication was the most frequently cited recommendation in all three studies.

In 1989, the Netherlands had a total population of 14.5 million with 1.8 million people (12.3%) over 65 years old and 0.4 million (2.5%) over 80 years old. The 1989 total cost of health care was 35 billion guilders (19 billion U. S. dollars). Approximately 2.5 billion guilders (about 1.3 billion U. S. dollars) was spent on psychogeriatrics—largely on clinical facilities (96%), divided between 7,200 geriatric beds in psychiatric hospitals, and 22,600 beds in psychogeriatric nursing homes.