Physicians and family members were compared on the roles played in surrogate decision-making and their views as to how choices should be made by surrogate decision-makers. Thirty-six family members of patients with Alzheimer's disease, 35 family members of patients with schizophrenia, and 34 physicians from a diversity of specialties were the respondents. There was general agreement that shared decision-making was preferred. Physicians seem to make surrogate decisions in accordance with contemporary views about their roles. Families believed they had a strong subjective appreciation of the patient's overall good. The burden of decision-making was geater for families, but that depended to some degree on the diagnosis of the patient.

The reliability, validity, and sensitivity to change of the Hierarchic Dementia Scale (HDS) were tested in two cross-sectional studies and one longitudinal study. Results prove the HDS to be a simple-to-conduct method, economical in terms of time, and possessing high reliability and high concurrent and criterion-related validity. The HDS appears capable of use at all stages of dementia and capable of permitting studies of the course well into the advanced stages of the illness.

Two reliability studies were performed on a recently developed cognitive assessment battery for severe dementia. The method, the Modified Ordinal Scales of Psychological Development (M-OSPD), is based on the Piagetian developmental model of sensorimotor functions. Procedures have been adapted from this test battery, which was originally applied to infants and small children, for the assessment of remaining cognitive capacity in severe dementia. Two independent interrater reliability studies were conducted. In these studies, two different raters simulataneously evaluated patients with severe dementia. One interrater reliability study was performed in a nursing home setting (Study 1), and the other reliability study consisted of a sample of community-residing patients (Study 2). The Global Deterioration Scale and the Mini-Mental State Examination were used to assess dementia severity. Study 1 (N = 22) resulted in an intraclass correlation coefficient (ICC) of .99 (p < .01) for the M-OSPD total score. Study 2(N = 19) resulted in an ICC of .96 (p < .01) for the M-OSPD total score. The M-OSPD proved to be a reliable instrument in these studies. This cognitive assessment measure can provide meaningful information regarding the cognitive abilities of late-stage dementia patients. Until recently, these late-stage dementia patients had been considered untestable in studies that utilized conventional psychometric and mental status evaluation measures.

Despite new developments in the concept of vascular dementia, the Hachinski Ischemic Score (HIS) and its modified versions continue to be widely used in the clinical differentiation of Alzheimer's disease (AD) and ischemic vascular dementia (IVD). The sensitivity of the HIS and two modified versions in the diagnosis of AD, IVD, and single infarcts in a large, geriatric population with mild cognitive impairment (N = 100) was evaluated. Sensitivity for identification of AD was greater than 90% but was less than 70% for IVD. Over one third of patients with one or more infarcts on computed tomographic brain scans and 63% of mixed cases were classified as having probable AD. It is concluded that ischemic scores may be useful at predicting prevalence rates if individual case accuracy is ignored. Despite being sensitive to identifying AD, ischemic scores are insensitive to both cerebral infarction and IVD and cannot reliably exclude IVD. Finally, patients with mixed dementia should not be expected to have intermediate scores.

Because dementia of the Alzheimer type (DAT) is commonly characterized by bilateral cerebral atrophy, we examined the issue of higher linguistic abilities lateralized to the right cerebral hemisphere (RH) in earlystage DAT. A modified version of an insertion task was administered to 14 patients with probable DAT, 8 right-hemisphere brain-damaged (RHD) patients, 8 left-hemisphere brain-damaged (LHD) patients, and 28 normal elderly (control, CTR) right-handed subjects. The task consisted of presenting the subjects with 53 well-formed sentences; in each a word or syntagm had to be inserted grammatically. Twenty-eight word/syntagm insertions required grammatical role reassignment of a lexical item in the stimulus sentence (shift, sensitive to RHD); 25 insertions implied only semantic reinterpretation of the target sentence (nonshift, sensitive to LHD). The three pathological groups were relatively and similarly impaired on standard aphasia assessment. The performances of the DAT patients, controlled for global cognitive verbal proficiency, verbal cognitive skills, and mood, were found to be significantly worse than the performances of the CTR group on both insertion subtests, whereas there were no significant differences between the DAT and RHD subjects on the shift items or between the DAT and LHD subjects on the nonshift items. Similarly, no differences were noted between the RHD and CTR nonshift scores, or between the LHD and CTR shift scores. On the other hand, the LHD group outscored the RHD group on the shift insertions. A comparison between the two insertion subtests revealed that only the RHD and DAT groups performed significantly worse on the shift than on the nonshift items. Results are consistent with other anecdotally reported RH-specific language-related disorders in early DAT and replicate previous findings of bihemispheric extralinguistic disturbances in these patients.

Psychiatric symptoms and behavioral disturbances in dementia (sometimes referred to as noncognitive features of dementia or neuropsychiatric symptoms) are important aspects of the clinical syndrome of dementia. Despite their significance, there have been few studies concentrating on these features from the viewpoint of therapy. This article reviews some of the studies that have been carried out. For more detailed reviews, the reader is referred to Schneider and Sobin (1994) and Burns (1994).

Age-related changes in circadian rhythm (e.g., fragmented sleep-wake patterns) occur in many older persons but are particularly pronounced in patients with Alzheimer's disease. In these patients, disruptions of circadian rhythms can be severe enough to increase mental decline, agitation during the day, and restlessness at night. Moreover, patients whose nocturnal restlessness disrupts the sleep of the caregiver are more likely to be institutionalized than those who have cognitive impairment alone.

As people live longer, an increasing proportion of patients with schizophrenia and delusional disorder will be elderly. Little has been published on treatment response, effective treatment strategies, or the use of atypical neuroleptics in this group. This review of the literature explores documented response rate, route and dose of neuroleptic, indicators of poor response, and the use of novel drugs. Despite great variation in the neuroleptic dose ranges employed, patients with late-onset disease often continue to experience psychotic symptoms. Compliance with treatment is the most important determinant of outcome. Atypical neuroleptics are specifically indicated for patients with visual hallucinations or extrapyramidal symptoms. Elderly psychotic patients should be treated as vigorously and with as wide a range of neuroleptics as their younger counterparts. Physicians should not restrict drug doses to modest levels in all cases as long as patients are monitored frequently for the emergence of side effects.

In 1785, an anonymous author published what may be the first case report of a patient with dementia. This dramatic case report highlighted the distressing and disruptive behavioral manifestations that the patient suffered.

The prevalence of depression in persons with dementia is controversial. Among 288 outpatients with dementia, a prevalence of 7.4% was found according to the Hamilton Rating Scale for Depression (HRSD), 8.0% using the Geriatric Depression Scale (GDS), and 6.3% according to DSM-IV criteria. Rates and levels of depression tended to be higher in vascular than in Alzheimer's dementia according to the rating scales, but not according to the DSM-IV criteria. Greater cognitive impairment was associated with higher HRSD (but not GDS) scores. Cases of clinical depression did not persist over 12 months' follow-up. These results sugguest that clinically significant depression in dementia is less common than previously reported and tends to remit.

Although the essence of one's identity—one's self-esteem—is eroded and devastated by Alzheimer's disease, little attention has been paid to the regression and dissolution of the self experienced by patients with this disease. Investigations into the psychology of the self by psychoanalyst Heinz Kohut and others have provided new ways of understanding a demented patient's attempts to maintain some semblance of self-esteem and identity in the wake of progressive cognitive decline.

Alzheimer's disease (AD) is a progressive condition associated with a broad variety of clinical symptoms. These symptoms can, for the most part, be conceptualized as falling within three primary categories: (I) cognitive symptoms, (II) functional symptoms, and (III) behavioral (disturbance) symptoms. All of these symptom categories may potentially respond to specific behavioral intervention approaches to treatment and management. However, at this time, few behavioral approaches have convincingly been substantiated to be effective in treating any of the symptoms in any of these categories.

The purpose of this study was to examine the relationship between age-associated changes in central serotonergic function and abnormalities associated with major depression. Under randomized double-blind conditions, prolactin and cortisol responses to the serotonin-releasing agent d,l-fenfluramine hydrochloride (60 mg orally) and placebo were examined in 30 normal subjects (15 men, 15 women; age range 21–84 years) and 39 patients with major depressive disorder, endogenous subtype (14 men, 25 women; age range 29–72 years). In the normal subjects, a significant Age x Challenge x Time interaction was observed in the prolactin response (p = .03). This was primarily due to the elevated prolactin responses of the younger healthy women. Peak minus baseline (delta) prolactin responses were negatively correlated with age (women, p = .004; men, p = .06). In the depressed patients there was no age-related decline in prolactin response to fenfluramine. When depressed and healthy younger subjects were compared, delta prolactin responses to fenfluramine were significantly blunted in young patients with depression (p = .003) irrespective of the significant effect of gender (p = .01), but not in older depressed patients. Cortisol responses to fenfluramine did not reveal consistent effects of age, gender, or diagnosis. Age-related decline in central serotonergic function may make older individuals more vulnerable to depression and possibly render depressive episodes more frequent, more severe, and less amenable to treatment.

The levels of the monoamine metabolites 5-hydroxy-indoleacetic acid (5-HIAA), homovanillic acid (HVA), and 4-hydroxy-3-methoxyphenylglycol (HMPG) were determined in lumbar cerebrospinal fluid (CSF) of 56 patients with vascular dementia (VAD) and 57 healthy controls. Despite CSF sampling under standardized conditions, the variability in values was wide among both patients and controls. This suggests that yet unknown factors affect the lumbar CSF concentrations of monoamine metabolites. The VAD group showed significantly lower mean concentrations of 5-HIAA (p < .001) and HVA (p < .001) than the control group. These low concentrations appear to be no disease-specific phenomenon, but may be attributable to subcortical white-matter changes or a decreased production of monoamines, which are dependent on oxygen for their synthesis.

Agitation is inappropriate verbal, vocal, or motor activity, which is common among older persons with dementia. Its assessment is complicated both by communication difficulties and by the complexity of the manifested behaviors. Three general approaches are used to assess agitation: informant ratings, observational methods, and technological devices. Within each category, several assessment instruments exist. The approaches differ as to time sampling, objectivity, and cost. Assessment of agitation in pharmacological studies should include consideration of the specific meaning to the agitated behavior for the older person and for the caregiver, along with an evaluation of the consequences of the behavior. At times, the agitated behavior seems to signal a specific need, and alternative methods for fulfilling that need should be considered. Evaluation studies of pharmaologic agents should include consideration of the impact of these agents on nontarget behaviors, as well as an awareness of the large intraperson and interperson variability in agitated behaviors.

Three hundred one patients were examined for suicidal plans during the acute hospital period following stroke and at 3, 6, 12, and 24 months' follow-up. It was found that 6.6% of patients developed suicidal plans during the initial in-hospital evaluation (acute-onset suicidal plans) and 11.3% of patients developed suicidal plans at 3, 6, 12, or 24 months' follow-up (delayed-onset suicidal plans). The development of both acute and delayed-onset suicidal plans was strongly related to the existence of depressive disorders, especially major depression, and to a prior history of stroke. Acute-onset suicidal plans were also related to premorbid alcohol abuse. Acute-onset suicidal patients had more anterior lesion location and delayed-onset suicidal patients had more posterior stroke lesions. Delayed-onset suicidal plans were not related to alcohol abuse but tended to be associated with greater physical impairment and poorer social support during the acute poststroke period. These data suggest that the etiology of these two types of suicidal plans may be different with acute onset related to biological mechanisms and delayed onset related to psychological mechanisms.

This article reviews the significance of the Geriatric Depression Scale (GDS) to practitioners and researchers in clinical gerontology, more than 10 years after the scale was introduced to the scientific community. This report summarizes findings from the most relevant validation studies in which this self-report for assessing depression in elderly people has been tested. Included is discussion of the use of the GDS with specific populations (elderly medical inpatients, nursing home residents, and dementia populations), with description of the scale's psychometric properties and its utility when used with them. This article also provides data on the use of the GDS from more recent studies, including additional information on psychometric properties, influence of source bias, and the international dissemination of the GDS. We conclude that the GDS is a relevant self-report for the assessment of depression in the elderly, given its advantage over other self-reports that are not as easily administered to this age group, its utility in the detection of depression, and its adequate psychometric properties. However, the GDS does not maintain its validity in demented populations because it fails to identify depression in persons with mild to moderate dementia. Finally, some suggestions for future research are made.

The aim of the study was to estimate the prevalence of major depression and to evaluate associated features in random age cohorts of 75, 80, and 85 years (N = 651). A clinical examination was made by experienced health center physicians, and major depression was diagnosed according to DSM-III criteria. The prevalence increased with age and was 1% to 4% in the age groups of 75 and 80 years, but 13% at the age of 85 years. No sex difference was found. The frequency of major depression was fourfold among institutionalized patients (16%) as compared to those living at home (4%). Major depression was strongly associated with objective health, intellectual functioning, and functional capacity. Depression was most common in subjects suffering from poor vision, urinary incontinence, or Parkinson's disease (odd ratios 4.2 to 4.9). Depression was also correlated with musculoskeletal disorders, coronary heart disease, and cerebrovascular diseases (odd ratios 2.5 to 3.4). The survey suggests that major depression is quite rare in healthy elderly people but common in disabled institutionalized patients.

A majority of patients with dementia of the Alzheimer type (DAT) display behavioral disturbances of varying degrees of severity. These disturbances include both behavioral excesses and deficits. The behavioral excesses reported in this population include physical aggression, wandering, and disruptive vocalization, to name but a few (Burgio et al., 1988b). Disruptive behaviors have been reported in at least 50% of individuals diagnosed with DAT (Cummings et al., 1987). Research has shown that individuals with dementia frequently display severe deficits in performing activities of daily living such as feeding, bathing, and dressing (Burgio et al., 1988b). Although these deficits are, in part, a natural result of the dementing illness, it has long been recognized by gerontologists that many demented individuals display “excess deficits” (Brody et al., 1971), i.e., symptoms of functional incapacity greater than those warranted by the actual organic impairment.

Are the behavioral disturbances of dementia a primary manifestation of a devastating degenerative brain disease or a consequence of a demented patient's inability to cope with a hostile environment that does not adapt to his or her needs? Our current state of knowledge regarding the origin of noncognitive symptoms in dementia does not allow us to neatly dichotomize behavioral disturbances into either syndromes that can be attributed to altered neurobiologic substrates or behavioral reactions to a change in social routine or environment. The best fit model is one that incorporates biologic (neurochemical, neuropathologic, or genetic); psychological (premorbid personality and behavior, and response to stress); and social (environmental change and caregiver factors) aspects. For any particular symptom or group of symptoms, the relative input from each causal source can vary and may change in the future as our knowledge and understanding grow. The importance of an interactive causal model is that is has direct and immediate relevance to the development of treatment strategies.