In an earlier study, 31 healthy elderly volunteers had normal cognitive function as measured by the Mini-Mental State Examination. Twenty-seven returned for further memory testing using the Wechsler Memory Scale-Revised (WMS-R). The P2 latency of the flash visual evoked response was positively correlated with age (p = .0008), but was not significantly related to gender. Nine of these 27 putatively healthy subjects had a delayed P2, suggestive of dementia. Although unaware of any memory deficits, 5 of the 27 had WMS-R Visual Memory Span percentile scores 1 or more standard deviations less than age-matched controls. Four of the five also had a significantly delayed P2 component. This positive correlation, adjusted for age, between poor Visual Memory Span performance and a delayed P2 was statistically significant (p < .025). These findings suggest that a delayed P2 in putatively healthy subjects is indicative of a visuospatial deficit which might be a precursor of dementia later.

Cognitive impairment has been repeatedly shown to be a delirium risk factor. Much indirect evidence suggests that right-hemisphere dysfunction plays a particularly important role. This retrospective, case-controlled study, from a 148-patient memory loss clinic database, compared neuropsychological measures of hemispheric function in cognitively impaired elderly veterans with and without a history of delirium. Eleven study subjects had a history compatible with DSM-III-R criteria for delirium. Controls selected from the same database had no known history of delirium and were matched for Mini-Mental State Examination scores and Geriatric Depression Scale scores. Compared to the controls, subjects with a history of delirium had significantly lower scores on Object Assembly and Visual Reproduction (p < .05), tests that are predominantly right-hemisphere dependent. There were no significant differences in left-hemisphere measures. It is concluded that right-hemisphere dysfunction may prove to be an important risk factor for delirium.

Before evaluating behavioral distrubances of dementia (BDD), several factors should be considered. This includes the patient population, the properties of the rating scales to be used, and the assessor. The frequency of behavioral symptoms appears to vary between countries, making comparisons in multinational studies difficult. These variations may be caused by cultural differences, clinicians' attitudes to behavioral symptoms, and interrater variability. The psychometric properties of a rating scale may be affected by differences in clinicians' attitudes in different countries, which may, in turn, alter the frequency of diagnosis of BDD, causing problems in the interpretation of data in multinational studies. Consideration should be given to all these factors before initiating a multinational clinical trial.

The dynamic processes and the way they interact in shaping a care system for demented patients are analyzed and discussed. The development of disability/dependency, interpreted in a simulation model based on Katz's index of ADL and Berger's scale “Rating the severity of senility,” gave insight into the interplay of four care levels: psychogenatric long-term care for patients with severe behavioral disturbances, nursing-home care for patients with highly reduced ADL capacity who are often moderately to severely demented, group-living care for the demented with less dominating ADL dependency, and residential care for the elderly frail with or without symptoms of dementia. For each facility in this chain of care, characteristics in patients' symptomatology and behavior could also be identified. Resources necessary in order to fulfill goals in caring differed between each facility.

This article reviews longitudinal data collected from patients with Alzheimer's disease (AD) that are relevant to the design and interpretation of clinical treatment trials. Longitudinal data from patients tested with the Alzheimer's Disease Assessment Scale demonstrate that cognitive symptoms, including memory loss, dysphasia, and dyspraxia, worsen relentlessly over time with the rate of change depending upon baseline dementia severity. Noncognitive symptoms, such as agitation, depressed mood, and psychosis, are episodic, do not necessarily worsen over time, and tend not to be highly correlated with one another. The reliability of cognitive change measures increases with follow-up duration so that the likelihood of detecting drug effects on the rate of cognitive deterioration is greater with longer treatment trials. Functional measures of activities of daily living are difficult to standardize for AD patients but are important for determining the overall clinical and economic impact of AD treatments.

To address the development of studies for behavioral problems in patients with Alzheimer's disease (AD), a framework is used that includes the patient, the caregiver (formal or informal), the patient-caregiver interaction, the environment, the organization of care within institutions, and systems for the delivery of care to patients and caregivers. Within each of these components, there will be indicated the areas that are ready for testing using a clinical trial design and the areas that need further study using less controlled designs. Finally, recommendations will be made that address all components of the framework.

Behavioral disturbances of dementia result from both biologic and environmental factors. This article focuses on the biologic causes of behavioral problems in patients with dementia.

The IPA/Bayer Research Awards in Psychogeriatrics recognize unpublished original research of exceptional scientific value, interest, and clarity. The three papers that received the 1995 awards are the result of exciting, important research on (a) the health consequences in late life of earlier episodes of depression; (b) the diagnostic conception of noninfarct, single-infarct, and multiple-infarct vascular dementia as parts of a single entity; and (c) a comparison of the language deficits of patients with brain damage and those with early stage dementia of the Alzheimer type.

Barriers to behavioral research are multifactorial. They include attitudinal, conceptual, financial, and administrative factors. In general, behavioral research and clinical research have received less support than basic science research (Marshall, 1994). The traditional emphasis has been on funding of basic research with the expectation that clinical research can be pursued without specific financial support. Although this might have been possible in the past, the increasingly tight control of clinicians' time and the need for cost-effective healthcare delivery have rendered this approach obsolete. Advances in clinically applicable information will require the type of research funding usually reserved for basic science endeavors.

The support group is an important means of providing help to families of demented elderly. In the Netherlands, the support group is widely used in mental health care. (Quasi-)experimental studies, however, have not established its effectiveness. In this article, an overview of the Dutch support groups and a review of the literature are given. In addition, a study among 110 participants of support groups is presented. Quantitative analyses show that the support group is especially effective in caregivers who are dissatisfied about their role as caregiver and have no job. Support groups are also more effective when the elderly person is more apathetic and lives in a nursing home. Interviews with caregivers show that the participants experience four forms of support: information, advice on how to cope with the situation, and moral and emotional support. These ways of support provide caregivers with a better perspective on their situation and help them to better cope with problems and emotions.

An impressive body of literature has been published on the relationship between psychotic symptoms in Alzheimer's disease and pathology demonstrated primarily by neuroimaging and biochemistry studies. Jacoby and Levy in 1980 and Burns and colleagues in 1990, for example, reported less severe atrophy in delusional patients with Alzheimer's disease than in nondelusional patients with Alzheimer's disease. The author and colleagues have found that smaller ventricle-brain ratios are associated with delusions of theft in Alzheimer's disease. Zubenko (1991) and Doty (1989) have reported that delusions and hallucinations in patients with Alzheimer's disease are associated with decreased amounts of serotonin.

The Hierarchic Dementia Scale is an instrument for measuring the severity of mental impairment based on Piagetian concepts, neuropsychological findings, and the hierarchic nature of decline in mental function. Performance of 20 specific functions such as orienting reflexes and comprehension can be rapidly pinpointed over a wide range of impairment. The scale is reliable, valid, responsive, safe, inexpensive, and easy to use.

This study examined the quality of emotional responsivity in mid-to late-stage dementia patients. Eighty-two nursing home patients with a DSM-III-R diagnosis of primary degenerative dementia of the Alzheimer type served as subjects. Patients were staged using the Global Deterioration Scale. The level and type of patient affectivity were assessed by family reports, aide reports, and direct observation and coding of patient facial expressions during a family visit. All three measures indicated that patients with Alzheimer's disease expressed a range of affective signals. Some showed an intact and functional emotion system even during the last stage of the disease; one third of end-stage dementia patients expressed sadness at the departure of their relatives as coded by an objective facial affect coding system.

Behavioral disturbances in dementia are some of the most burdensome features with which the caregivers must cope. These symptoms are particularly important because they are likely to be responsive to both pharmacological and nonpharmacological intervention strategies. Before the 1980s, rating scales for patients suffering from dementia did not separate cognitive features from noncognitive behavioral symptoms. This was a major problem because the evolution and course of behavioral symptoms in dementias, such as Alzheimer's disease, is different from the evolution and course of cognitive and cognition-related symptomatology. Before appropriate rating scales could be developed for the assessment of behavioral disturbances in dementia, the specific nature of these disturbances had to be described in the medical literature. Publications in the late 1980s described the specific behavioral diturbances occurring in dementia patients in detail for the first time. The rating scales that have been developed from these studies are as reliable as cognitive assessment measures. Instruments are now available that are based on information provided by the caregiver or that are based on observation of the patient made by the clinician. Construct validity, reliability, and the differences in methodology of these scales are compared in this overview. Using these scales will enable clinicians to assess pharmacological and nonpharmacological intervention strategies for behavioral symptoms in dementia with enhanced sensitivity.

Recent research suggests that affective disorder is associated with increased mortality and physical morbidity, but the reasons for this association remain uncertain. This report describes a 50-year prospective study of 240 men evaluated from the time they were university students in 1940–1942. A family history of mental illness was obtained and the men's habits, psychological adjustment, and marital and occupational satisfaction were followed every 2 years and their objective physical health was tracked every 5 years until age 70. Twenty-five men were identified as having affective spectrum disorder prior to age 53. Of the variables studied, the presence of affective spectrum disorder was the most powerful predictor of poor psychosocial outcome at age 65 and one of the most powerful predictors of poor physical health. Alcohol abuse and cigarette abuse accounted for the observed increased rates of heart disease and cancer. When alcohol abuse, smoking, and suicide were controlled for, affective disorder made a significant contribution to physical morbidity by age 70, but not to mortality from natural causes. Affective spectrum disorder, even in an educated population without antisocial trends, carries a profound negative risk to late-life physical and social adjustment.

Behavioral disturbances are a prevalent and important aspect of dementia of the Alzheimer type, but they have been relatively neglected by researchers. To characterize patients as having dementia, at least two goals should be addressed: first, determining a reliable definition and categorical diagnosis of dementia using such criteria as the Diagnostic and Statistical Manual of Mental Disorders (DSM)–IV and the International Classification of Diseases (ICD)–10; second, establishing a reliable and valid measurement of the severity of cognitive and noncognitive impairment by means of rating scales. DSM-IV and ICD-10 do not provide definitions of behavioral disturbance, whereas more than 100 geriatric rating scales exist that include some measurement of behavioral disturbances of dementia. There is a need for consensus on the term for these noncognitive symptoms. Some authors prefer the subdivisions of (a) psychiatric and noncognitive symptomatology into psychiatric symptoms, or syndromes and behavioral distrubances; and (b) cognitive syndromes. Given the frequency and clinical significance of behavioral and psychiatric disturbances in dementia, a standardized assessment procedure is needed for reliably and comprehensively describing psychiatric phenomena and behavioral disturbances in patients with dementia.

Dementia is a major public health problem in the United States and the world, requiring the expenditure of enormous economic and human resources. Dementia is common in the elderly, and, as the size of the aged population increases, the number of dementia victims will rise. Many dementias are fatal, producing the gradual erosion of intellectual abilities and eventual death of the patient. Demands made on family members and caregivers of dementia patients are extraordinary and often result in their emotional and financial exhaustion. Although basic science efforts are devoted to finding a cure for Alzheimer's disease (AD) and other dementing illnesses, there is an urgent need for research that has immediate applicability to the 4 million current dementia patients.

This article focuses on some of the long-standing problems that exist in the classification of the vascular dementias. To clarify the definition of vascular dementia, mental status and other cognitive processes were investigated in 12 patients with a single cerebral infarct (mean age, 74.8 years), 17 patients with multiple cerebral infarcts (mean age, 71.4 years), 21 vascular patients with no cerebral infarcts (mean age, 76.9 years), and 16 demographically equivalent normal elderly persons (mean age, 70.4 years). The following null hypotheses/hypotheses were tested: (a) The cognitive impairment of single-infarct, multiple-infarct, and noninfarct vascular patients is not/is significantly greater than and outside the range of that in normal aging, and (b) there are/are not significant differences between single-infarct, multiple-infarct, and noninfarct vascular patients on mental status and other cognitive measures. Measures used included the Mini-Mental State Examination, Dementia Rating Scale, Western Aphasia Battery, and Boston Naming Test. Results indicate that vascular disorders involve a decrement in mental status and other cognitive functions that is significantly greater than the age-associated cognitive impairment of normal aging. Also, results from the study indicate that there were no robust, reliable significant differences between single-infarct, multiple-infarct, and noninfarct patients. The validity of the distinction of focal versus generalized or diffuse cerebral lesions is questioned. The nosologic entity of noninfarct vascular dementia is introduced. The future nosology of vascular dementia should provide for noninfarct vascular dementia, defined as vascular dementia caused by underlying vascular mechanisms other than cerebral infarction.

Neuroimaging studies have contributed greatly to our understanding of Alzheimer's disease and other dementias. Computed tomography and magnetic resonance imaging reveal brain structure and aid in the diagnostic evaluation of patients with cognitive impairment. Functional neuroimaging studies use positron emission tomography, single-photon emission computed tomography, and other methods to measure regional cerebral activity, including metabolic rate, blood flow, and neuroreceptor density. Functional neuroimaging results can be useful clinically and have also been used in a variety of research applications to examine physiologic variables in neuropsychiatric illnesses.

Tests used as outcome measures in clinical trials of antidementia agents are not typically employed as part of diagnostic evaluations, and little information exists as to the sensitivity of these tests in terms of either differentiating demented patients from normal individuals or in distinguishing dementias of various types and etiologies. Sensitivity to mild dementia and sensitivity to impairment of various neuropsychological domains are, however, prerequisites for valid use of an instrument as an outcome measure in this context. The present study was undertaken to directly compare six different tests (three traditional psychometric tests and three clinical trial batteries) in terms of their sensitivity to detect and distinguish between mild dementia in patients with either Alzheimer's disease (n = 15) or Huntington's disease (n = 15), when compared to normal controls (n = 15). Tests included the Mattis Dementia Rating Scale, the Mini-Mental State Examination, the Wechsler Memory Scale-Revised, the Alzheimer's Disease Assessment Scale-Cognitive Subscale, the Computerized Drug Research (CDR) Cognitive Assessment System, and the Repeatable Battery for the Assessment of Dementia (RBAD). All of the tests were roughly equivalent in terms of their ability to discriminate normal subjects from mildly demented patients. Only the CDR and RBAD, however, were able to reliably discriminate between the two patient groups. The results are discussed in terms of the applicability of these tests as outcome measures for clinical trials in dementing disorders.