Alzheimer's disease (AD) is the most common cause of dementia, affecting nearly 4 million older Americans (U.S. Department of Health and Human Services, 1996). Behavioral and psychological signs and symptoms of dementia (BPSD), especially agitated behaviors, affect nearly 80% of patients with AD (Jost & Grossberg, 1996). Researchers have speculated that BPSD, especially agitation, are the leading risk factors or triggers for nursing home (NH) admission in AD patients (Chenoweth & Spencer, 1986; Colerick & George, 1986). In this article, we review the literature on risk factors for NH placement in AD, and share preliminary data from an ongoing study at the Saint Louis University /Alzheimer's Association Brain Bank relative to the role of the BPSD as a risk factor for NH placement.

Suicide mortality among the elderly is high in most Western countries. We investigated the characteristics of suicide victims 65 years or older in a nationwide psychological autopsy study, the research phase of the National Suicide Prevention Project in Finland. This study population included all completed suicides (N = 1,397, of whom 211 were 65 years or older) that occurred in Finland during a 12-month research period in 1987-1988. The elderly suicide victims were found to have used violent suicide methods more often than the young. Although almost 70% of the elderly persons who had committed suicide had been in contact with health care services during the month before their death, their suicidal intentions were rarely communicated in these contacts. They had been referred to psychiatric services less often than the young, and only 8% had received adequate antidepressive medication. The fact that most elderly suicides have contact with health care services during their final month suggests a potential for suicide prevention. However, the major obstacle to this is the poor recognition of mental disorders and suicidal ideation among the elderly.

Objective: This study tests the hypothesis that integrated family support, in which patients and caregivers are both supported by one professional staff, is more effective in influencing behavior problems and mood of the dementia patient than nonintegrated support, such as psychogeriatric day care only. Design: A quasi-experimental pretest-posttest control group design with matched groups was applied. Setting: Psychogeriatric day-care centers of four community centers and three nursing homes. Participants: Fifty-six dementia patients living at home and their caregivers. Intervention: The patients in the experimental group (n = 33) participated together with their caregivers in an integrated family support program, whereas the patients in the control group (n = 23) received psychogeriatric day care only. Measurements: Behavior problems and mood were observed using standardized behavior observation scales. Results: After 7 months the experimental support program, compared to the regular psychogeriatric day care, showed a large positive effect on the total number of behavior problems (effect size .75), and also specifically on the degree of inactivity (effect size .66) and nonsocial behavior (effect size .61). No effect on mood was found. Conclusions: In influencing the total amount of behavior problems, as well as the degree of inactivity and nonsocial behavior, the integrated family support program proved to be more effective than psychogeriatric day care. Because behavior problems are an important determinant for admission of persons with dementia into a nursing home, integrated family support may contribute to the delay of institutionalization.

Background: The purpose of this study was to evaluate the utility (i.e., positive and negative predictive value) of the 7 Minute Screen in identifying patients with probable Alzheimer's disease (AD) in a primary care practice. A second objective was to estimate the number of undiagnosed AD patients in a typical primary care practice. Methods: One hundred thirty-seven successive admissions (96%) of patients over the age of 60 to a primary care practice over a 53-day period who completed informed consent documents were administered the 7 Minute Screen. All patients who screened positive (n = 13) and a random sample of those who screened negative (n = 26) returned for full diagnostic evaluation. Positive predictive value (PPV) and negative predictive value (NPV) of the 7 Minute Screen were determined using the criterion standard of clinical diagnosis established by examination, history, and laboratory studies. Test-retest reliability and time for administration were also determined. Results: Of the 137 patients evaluated, 13 screened positive and 124 screened negative. Eleven of the 13 patients who screened positive were willing to return to the primary care practice for follow-up evaluation. A random sample of 26 patients who screened negative all agreed to return for follow-up evaluation. Of the 11 patients who screened positive who returned for evaluation, 10 were subsequently diagnosed with probable AD. The remaining patient was diagnosed with mixed dementia. The caregivers of the two patients who refused to return were contacted and both indicated that the patients were having significant cognitive problems as verified by an activities of daily living scale. Of the 26 patients who screened negative, 25 were judged to be cognitively normal and the 26th was judged to have mild cognitive impairment. Discussion: In successive admissions of patients over the age of 60 in a primary care practice, the 7 Minute Screen showed a PPV of 91% and an NPV of 96% in identifying patients who were subsequently identified with AD or other dementing disorder. These data suggest that this may be a useful instrument in identifying patients who should undergo diagnostic evaluation for AD and other dementing disorders. Additionally, extrapolation from the data in this practice suggests that there may be between 75 and 100 AD patients in the typical primary care practice, many of whom may not be diagnosed.

Dementia is a relatively “new” disease in the medical field. Over the past few decades, neurologists, geriatricians, psychologists, and sociologists were keen to determine the causes of dementia. The prevalent picture of the scientific and theoretical causation of dementia, however, overshadows the lay perspective of dementia. To get a better understanding of the latter aspect, this study examined family carers' knowledge of dementia and how they made sense of the disease. Individual interviews were completed with 18 family carers. The interview data were analyzed based on grounded theory, which is characterized by a constant comparative method of analysis (Glaser & Strauss, 1967). This method of analysis is inductive in nature and allows the construction of a theory of the lay interpretation of dementia. The study revealed family carers' limited knowledge of dementia might be related to medical professionals' inadequate explanations of the multifaceted dimensions of dementia. Hence, the family carers tended to use external events and personal experiences to explain the occurrence of dementia. Findings suggested that the development of a lay understanding of dementia was a means for family carers to gain control of this abstruse disease and served as an adaptive strategy to cope with the loss experienced during the caring process. The study indicates a definite need for health care professionals to form partnerships with family carers in order to develop good dementia care.

Research suggests there has been a cultural change in the disclosure of diagnosis; most evidence relates to cancer and there is little knowledge of attitudes towards disclosing the diagnosis of Alzheimer's disease. A questionnaire was used to survey the current practice and attitudes of old-age psychiatrists and geriatricians in Nottingham, UK. The results of this pilot study suggest that only 40% of respondents regularly tell patients the diagnosis. Although physicians are aware of many benefits in disclosing, they have concerns regarding the certainty of diagnosis, the patient's insight, and potential detrimental effects. The advantages of disclosure and the ethical issues involved are discussed.

Alzheimer's disease (AD) is associated with a substantial reduction in life expectancy, and mortality has long been evaluated as part of the natural history of this progressive disease. Survival time also plays an important role in projecting the future public health costs of AD. There is now considerable evidence linking mortality in AD with the severity of cognitive impairment and the level of disability in common activities of daily living (Bowen et al., 1996; Jagger et al., 1995; Moritz et al., 1997); established predictors of mortality in AD are listed in Table 1. However, the relationship between mortality and other disease characteristics has received less attention.

We examined 510 subjects representing 83.2% of all citizens of a Finnish city aged 85 years or over. Mini-Mental State Examination (MMSE) scores, diagnosis of dementia by DSM-III-R criteria, and Apo-E genotype were determined. The prevalence of dementia was 38.6%. The odds ratio (OR) of the Apo-E ε4 carriers (with the reference population of people with the genotype ε3/ε3) for dementia was 2.36 (95% CI 1.58–3.58). There was a significant sex difference: The OR in women was 3.23 (95% CI 2.02–5.17) whereas among men it was insignificant. The mean MMSE score (± SD) among the Apo-E ε4 carriers (15.0 ± 10.0) and noncarriers (18.7 ± 8.6) (p < .001) differed among the whole population, but not within the demented or nondemented subjects analyzed separately. This study does not support the hypothesis that the Apo-E ε4 allele impairs cognitive functions of nondemented elderly, at least in those surviving to very old age.

We investigated the relationship among gender of resident, staff social interaction, and agitation in 46 (31 male and 15 female) nursing home residents with clinically significant agitation. Direct observations were conducted of resident behaviors and environmental contextual events using a computer-assisted, real-time observational system. The system recored frequency, duration, and temporal sequencing of events. Results show that female residents displayed almost three times the amount of agitation as male residents (35% vs. 13% of total observation time, respectively), although men in the study were more likely to receive psychoactive drugs for their agitation. Staff spent similar amounts of time verbally interacting and touching male and female residents. Sequential analyses were conducted to examine the likelihood of staff verbal and touch interactions both preceding and following resident agitation using Bakeman and Quera's (1995) SDIS-GSEQ program. Results suggest that staff touch and verbal interaction elicit agitation in a significant proportion of residents. Once agitation occurs, staff were likely to respond by interacting verbally, but not physically, with the resident.

Background: Previous research on risk of delirium in acute hospital settings identified mainly patient variables (e.g., age) that are not amenable to intervention. The purpose of this study was to develop a model for new delirium in hospitalized older patients that included process of care and social variables. Methods: A prospective cohort study was undertaken in a community hospital in Ontario, Canada. Research paticipants included 156 hospitalized patients age 65+ years and without delirium on admission who were admitted to a medical or surgical unit. The measures included daily appraisal of delirium using a standardized and validated tool, and assessment of patient, process of care, and social variables. Results: Delirium developed in 28 of the 156 patients (17.9%). Older age and cognitive impairment were significant patient variables. Significant process of care variables included a high number of medications administered during hospitalization, surgery, a high number of procedures during early hospitalization (e.g., x-rays, blood tests), and intensive care treatment. Conclusions: Approximately one older patient in five developed delirium after admission to a medical or surgical unit. Risks not easily amenable to intervention included age, cognitive dysfunction, surgery, and intensive care requirements. Risk factors that are potentially modifiable included number of medications and number of procedures. Future research might focus on the efficacy of such intervention to reduce new-onset delirium in acute hospital settings.

Objectives: To estimate the annual rate of change scores (ARC) on the Mini-Mental State Examination (MMSE) in Alzheimer's disease (AD) and to identify study or population characteristics that may affect the ARC estimation. Methods: MEDLINE was searched for articles published from January 1981 to November 1997 using the following keywords: AD and longitudinal study or prognosis or cognitive decline. The bibliographies of review articles and relevant papers were searched for additional references. All retrieved articles were screened to meet the following inclusion criteria: (a) original study; (b) addressed cognitive decline or prognosis or course of AD; (c) published in English; (d) study population included AD patients with ascertainable sample size; (e) used either clinical or pathological diagnostic criteria; (f) longitudinal study design; and (g) used the MMSE as one of the outcome measures. Data were systematically abstracted from the included studies, and a random effects regression model was employed to synthesize relevant data across studies and to evaluate the effects of study methodology on ARC estimation and its effect size. Results: Of the 439 studies screened, 43 met all the inclusion criteria. After 6 studies with inadequate or overlapping data were excluded, 37 studies involving 3,492 AD patients followed over an average of 2 years were included in the meta-analysis. The pooled estimate of ARC was 3.3 (95% confidence interval [CI]: 2.9-3.7). The observed variability in ARC across studies could not be explained with the covariates we studied, whereas part of the variability in the effect size of ARC could be explained by the minimum MMSE score at entry and number of assessments. Conclusions: A pooled average estimate of ARC in AD patients was 3.3 points (95% CI: 2.9-3.7) on the MMSE. Significant heterogeneity of ARC estimates existed across the studies and cannot be explained by the study or population characteristics investigated. Effect size of ARC was related to the initial MMSE score of the study population and the number of assessments.

There is a direct relationship between years lived beyond age 65 and the number of individuals diagnosed with dementia, primarily Alzheimer's disease (AD). The occurrence of AD has no socioeconomic, geographical, or ethnic limitations. The problem is worldwide. Its magnitude is demonstrated by the following facts: (a) approximately 6% to 8% of persons 65 years or older have AD, and the prevalence of the disease doubles each 5 years after 60 years of age; (b) 30% of 85-year-old individuals can be expected to have the disease; (c) AD affects an estimated 4 million people in the United States, and is expected to affect approximately 14 million Americans within the next few decades; (d) AD patients average 6 to 10 years of comprehensive treatment from symptom onset to death; (e) AD is the fourth leading cause of mortality among elderly Americans, more than 100,000 each year; (f) caregiver attempts at management of the behavioral and psychological symptoms of AD result in up to 50% developing significant psychological distress themselves; and (g) the cost for the management of AD patients is estimated to be between US $80 billion and US $120 billion annually. Primary care is essential for the appropriate diagnosis and treatment of the complex set of behavioral and psychological symptoms of dementia (BPSD) associated with AD.

Comprehensive Alzheimer's disease (AD) treatment should address caregiver well-being. We predicted that caregiver burden would be lower among caregivers of AD patients who received donepezil relative to caregivers of patients not treated with donepezil. A self-administered, nationwide survey of AD caregivers was used to match caregivers of patients treated with donepezil (n = 274) to caregivers of patients not treated with donepezil (n = 274). The Caregiver Burden Scale measured time demands and distress linked to commonly performed caregiving tasks. Respondents were three-quarters female, with an average age of 60 years. Results demonstrated that donepezil caregivers reported significantly lower scores on difficulty of caregiving. This difference remained when statistical controls for multiple patient and caregiver variables were imposed. However, selection factors must be recognized as a possible explanation for differences. The groups reported no difference on the time-demand subscale. In conclusion, better management of AD symptoms through donepezil treatment may reduce the burden of caregiving, providing physicians with a pharmacologic approach to improving quality of life for AD patients and their families.

Objective: To examine the hypothesis that chronic alcohol use causes accelerated aging of the brain. Methods: The auditory evoked potentials (EPs) were compared in three groups of 10 subjects each: (a) middle-aged individuals meeting DSM-IV criteria for alcohol dependence, (b) age- and gender-matched group of healthy individuals, and (c) an older (>65 years) group of gender-matched healthy individuals. Multiple levels of cortical information processing were examined using EPs. Early stages of information processing, related to sensory gating and stimulus classification (P50, N100/P200), were studied using a paired-click paradigm. Later stages of information processing associated with memory upgrading and identification of novel stimuli (P300) were studied using an oddball paradigm. Results: The amplitude and latency of the P300 of the alcoholic patients and the older healthy subjects differed significantly from those of the younger healthy group. Both groups showed changes that have been reported in association with aging. A tendency towards decreased sensory gating in later stages of information processing was noted in the aged healthy individuals. Conclusions: These data suggest that alcohol dependence may accelerate the aging process. The tendency towards a sensory gating deficit during the attentive phase of information processing in older healthy subjects requires further investigation because it may be a marker for an increased proneness to developing psychotic symptoms in that group.

Dr. Grossberg began the discussion by sharing preliminary data from a study designed to determine risk factors for institutionalization in patients with autopsy-confirmed Alzheimer's disease (AD). Initial findings from this study, which enrolled 100 patients, indicate that the principal predictor of institutionalization is behavioral and psychological symptoms of dementia (BPSD), principally agitation, aggressiveness, and problem wandering. Difficulty with activities of daily living, especially related to continence and hygiene issues, was the second most common predictor of institutionalization. The third most common predictor was lack of a caregiver, either because of death or because of other reasons.

To evaluate nonpharmacologic interventions, caregivers (65 women, 38 men) and their dementia-diagnosed spouses (patients) were randomized to one of four treatment programs (cognitive stimulation, dyadic counseling, dual supportive seminar, and early-stage day care) or to a wait-list control group. Assessments occurred initially and at postintervention (3 months). Patients were evaluated on memory, verbal fluency, and problem-solving ability, and caregivers were assessed on marital interaction, emotional status, and physical health, along with stress, coping, and social support. Caregivers also completed a program evaluation. Repeated measures procedures showed that patients in the cognitive stimulation group demonstrated more improvement over time in cognitive outcomes, and caregivers decreased in depressive symptoms. Early-stage day-care and dual supportive seminar group caregivers reported a decrease in hostility and a decrease in use of negative coping strategies, respectively. Although qualitatively derived benefits differed across groups, similarities in program content reduced the potential for quantitative differentiation among the groups.

Introduction: Negative symptoms such as diminished initiative, drive, motivation, and emotional reactivity have been described in patients with Alzheimer's disease (AD). The purpose of this study was to retrospectively analyze the efficacy and tolerability of risperidone for the treatment of clinically significant positive and negative symptoms in AD. Methods: We reviewed the charts of 50 community-residing AD patients who had been treated in a specialized university-based dementia management clinic. Clinical data comparing baseline and 12 weeks of treatment were obtained by reviewing a series of rating scales that were recorded as part of a comprehensive behavioral assessment. Results: Reviewed subjects had a mean age of 79.7±6 years and a mean of 12±3.6 years of school. Seventy percent of the subjects were female and the majority was White. The mean dose of risperidone prescribed was 1.3±0.6 mg per day (range from 0.5 mg to 3.0 mg). After 12 weeks of treatment, the severity of positive and negative symptoms was significantly reduced. Importantly, improvement in negative symptoms with the use of risperidone appeared to be independent of a positive treatment effect on positive symptoms. Risperidone had insignificant effects on both cognitive status and the emergence of extrapyramidal symptoms. Conclusion: This retrospective study demonstrates that risperidone appears to be efficacious in the treatment of clinically significant positive and negative symptoms in patients with AD.

The Clinician Interview-Based Impression of Change, plus carer interview (CIBIC-Plus), is widely used in antidementia drug trials. It comprises Likert scales for disease severity and changes, and written accounts summarizing semistructured interviews evaluating behavior, cognition, and function. Studies using the CIBIC-Plus have focused on the numeric scores to the exclusion of the textual data. Our study explored both sets of data to evaluate whether the CIBIC-Plus written data supported (a) the clinicians' global evaluation of patients' changes during treatment, and (b) the emergence of consistent treatment effects. The global (numeric) scales of change were inconsistently supported by the textual data provided in the CIBIC-Plus. No consistent treatment effects were noted. Methodological problems presently limit the retrospective use of the CIBIC-Plus textual data. Improved standardization of note-taking in the CIBIC-Plus textual data may allow for a better understanding of the typical profiles and clinical importance of changes seen in the course of dementia treatment.

It is well known that abnormalities in the brain serotonin system exist in patients with dementia. The present study was performed in order to investigate whether a peripheral serotonin system marker, the platelet 5-HT2A receptor, is affected in dementia. Thirty-eight patients with Alzheimer's disease (AD), 13 patients with vascular dementia, and 40 healthy controls were included in the study. There were no significant differences in receptor density for 5-HT2A receptor binding between the groups. Affinity of the radioligand to the receptor was significantly lower in AD than in vascular dementia and in the controls (p = .006 and p = .003, respectively), whereas there was no significant difference between the vascular dementia group and the control group. In 12 patients, treatment with citalopram was started due to depression or agitation. This treatment significantly reduced the Behavioral Pathology in Alzheimer's Disease Rating Scale scores (p = .001), but did not affect the platelet 5-HT2A receptor status. There was no correlation between 5-HT2A receptor status before treatment and the therapeutic effect of citalopram. The study indicates that platelet 5-HT2A receptor status is of limited value as a peripheral marker in dementia.