Several investigators have examined the relationship between a patient's premorbid personality and behavioral disturbances of dementia. Dr. Swearer described a study in which she examined whether premorbid personality was a predictor of disordered behaviors in dementia. Specifically, she considered whether premorbid aggression predicted subsequent aggressive behaviors, whether premorbid suspiciousness predicted disordered ideation, and whether premorbid restlessness predicted hyperkinesia. She found a relationship only between premorbid aggression and subsequent dementia-related aggressive behaviors. However, this finding appeared to be due to recall bias of caregivers of patients who were aggressive at the time of evaluation. This suggests that premorbid personality traits do not predispose to subsequent behavioral disturbances in dementia. On the other hand, in retrospective analyses, Drs. Whitehouse and Strauss and colleagues have found that premorbid personality predicts subsequent psychopathology.

Delirium is a recognized cause of behavioral disturbances of dementia. Yet the proportion of cases of behavioral disturbances resulting from delirium is difficult to determine. In many epidemiologic studies, delirium is excluded as a causal factor. In the few studies that describe delirium as an underlying cause of behavioral disturbances, the mechanism by which delirium is diagnosed and the extent of the diagnostic workup are rarely delineated.

Patients with dementia may be treated with several drugs because of comorbid conditions or symptoms related to the dementia itself. Such drug treatment can complicate patient management because many drugs may cause side effects, such as depression and Parkinsonism, that also are considered behavioral disturbances of dementia. Distinguishing between drug side effects and behavioral problems is difficult but necessary for several reasons. Attributing the behavioral disturbance to an incorrect cause can affect the type of treatment selected and the patient's response to it. It also can increase the overall cost of care and adversely affect the patient's quality of life. Making this distinction has theoretical importance as well, including the development of new drugs that have fewer behavioral side effects.

In the early part of this century, Alzheimer described a 51-year-old woman who experienced a rapidly increasing loss of memory. She could no longer find her way around her home. She carried objects back and forth, and hid them. At times, she thought someone wanted to kill her and began shrieking loudly. This type of behavior certainly would have been a strain for the woman's husband. If he could no longer care for his wife, his principal option was to place her in a mental hospital. Today, patients with Alzheimer's disease who require institutionalization are more likely to be admitted to a nursing home. However, because most patients in nursing homes have some type of mental illness, nursing homes, by default, serve as mental hospitals. The increasing number of nursing home residents with dementia prompted the author and colleagues to examine behavioral disturbances in this patient population.

Behavioral disturbances are a primary reason elderly patients with dementia are admitted to long-term care facilities. Blackwood and colleagues found that 58% of 130 consecutive patients admitted to a nursing home because of a behavioral disorder had a principal diagnosis of dementia. Similarly, in a study of long-stay institutional care for persons with dementia in France, the author and colleagues found that 67% of 352 patients had been admitted because of a social or behavioral problem. Thus, outpatient management of behavioral disturbances would appear to play a central role in determining whether a patient with dementia can remain in the community.

The recognition that behavioral disturbances of dementia are an entity that deserves study raises the question of exactly how these behaviors should be investigated. To obtain useful and relevant data, researchers must carefully design their studies, considering the potential difficulties of studying elderly, cognitively impaired patients. Of particular concern is whether patients with Alzheimer's disease or vascular dementia should be included in the same study or whether basic differences between these two diseases warrant separate investigations.

Dr. Reifler commented in general about the difficulty of studying dementia and the behavioral disturbances associated with this disorder, particularly because these problems are not well defined. He speculated that Alzheimer's disease may ultimately be found to be more than one disease and that clinicians may be using different terminology to describe the same clinical phenomena. Dr. Reifler suggested that studying the assessment and treatment of the more easily definable behavioral syndromes might be a better approach than trying to tease out every possible behavioral disturbance.

Caring for a patient with Alzheimer's disease who has difficult behavior does not have to be depressing, frustrating, overwhelming, or sad. Caregivers can develop the skills to manage successfully and eventually prevent difficult behaviors from occurring while maximizing their patient's ability to function. This can make the caregiving experience more rewarding and improve the quality of life of both the patient and the caregiver.

Behavioral disturbances and psychiatric disorders are common in persons with Alzheimer's disease and other dementias. Personality changes are often the earliest sign of dementia; behavioral disturbances and psychiatric comorbidity generally occur in the middle and later stages of the disease. At some time during the course of their illness, most patients with dementia exhibit behavioral disturbances or signs of psychiatric comorbidity. The presence of a comorbid psychiatric condition increases the likelihood that the patient will have behavioral disturbances. Although the rate, severity, and effects of behavioral disturbances can be influenced by pharmacologic and behavioral management, the efficacy of these interventions often is modest.

Behavioral disturbance of dementia are described in the literature as related to brain damage and premorbid personality. This perspective, however, does not consider that a patient with dementia is a human being who feels, thinks, wishes, and behaves. It also does not consider that the dysfunctional behavior may be related to the patient's other behaviors or to the behaviors of the patient's caregivers. Although rating scales are commonly used to assess behavioral disturbances, an assessment that a patient shouts, for example, is meaningless unless the situation in which the patient shouts is considered. What provoked the patient to shout? How does the caregiver react when the patient shouts? Understanding the context in which the behavioral disturbance occurs is important for developing effective care plans. Effective treatment is necessary because behavioral disturbances can negatively affect the quality of care received by institutionalized patients with dementia.

In both the nursing home and community settings, behavioral disturbances of dementia have a considerable impact on caregivers. In long-term care facilities, behavioral problems impede the ability of nursing staff to perform their duties and affect their sense of job satisfaction. In the community, where persons with dementia typically are cared for by a spouse or adult child, behavioral problems affect the quality of life and sense of well-being of the caregiver. The overwhelming stress and feelings of burden engendered by behavioral disturbances often lead family caregivers to place patients in nursing homes.

In listening to the last several presentations, Dr. Schneider noted the tremendous heterogeneity among behavioral symptoms of dementia. Yet many of the speakers discussed behavioral disturbances of dementia as though they are a syndrome. Cognitive disturbances of dementia are not discussed in this manner. Clinicians refer to patients having dementia with marked transcortical sensory aphasia and apraxia or dementia with frontal lobe symptoms. Dr. Schneider expressed concern over the tendency to group many behavioral symptoms together as though they were a syndrome. Dr. Brodaty concurred with Dr. Schneider, noting that his group found meaningful relationships with caregiver distress only when behavioral disturbances were analyzed as separate components, not when they were examined together.

Argentina covers an area of 3 million square kilometers, with almost one third of the population living in the capital district of Buenos Aires and the greater Buenos Aires area (the neighborhoods surrounding the capital district). Like other Latin American countries, Argentina is populated by a mixture of different ethnic cultures; however, unlike other Latin American countries, most Argentinians are of central and west European descent. People older than age 50 are mainly European immigrants or first- or second-generation Europeans. The mestizos—a fusion of Europeans and native Argentinians—are the second largest ethnic group, followed by the natives, most of whom live in the central and north part of the country. Argentinian aborigines have been largely eradicated, consisting of a small community confined to special reserves. Volga German descendants are grouped in large colonies in the central and eastern regions of the country.

Indian physicians have long recognized that cognitive impairment is a potential illness of old age. As early as 800 B.C., Ayurvedic physicians described loss of memory in older persons and even developed treatments for it. However, given the limited descriptions of the conditions being treated, the specific diseases treated by these physicians remains conjectural. To clarify these issues, my colleagues and I currently are designing a clinical trial to evaluate the efficacy of these centuries-old medications in specific conditions.

Studying behavioral disturbances of dementia across cultures allows us to identify commonalities and differences that may be useful in determining the best approach to managing these problems. However, what we tend to find in cross-cultural studies is that the best approach may not be the same approach, given the different prevalence of and levels of tolerance for various behavioral problems. These differences are apparent in the authors' studies of four populations—Jamaicans in Kingston; Cree in Northern Manitoba, Canada; Yoruba in Ibadan, Nigeria; and African Americans in the United States. The Jamaicans in this study live in a poor suburb of Kingston, the Cree live in two fairly small, isolated communities in Northern Manitoba, and the Yoruba live in Ibadan, a city of more than 1 million people. The Yoruba community the authors are studying, although concentrated in the city center, functions much like a village. The African-American population resides in Indianapolis, Indiana, a moderately sized city of approximately 1 million people.

Alzheimer's disease and other dementing disorders have been reported in most ethnic groups living in the United States. Although the presence of these disorders in different U.S. ethnic groups is well documented, the characteristics of dementing disorders, such as the presence of behavioral disturbances, in these groups remains unexplored.

Although behavioral disturbances occur worldwide in patients with dementia, the magnitude of these symptoms appears to vary in different cultures. Dr. Reisberg commented on the low level of agitation and violence he observed among patients in psychiatric hospitals in India. He attributed this in part to the level of care the patients received, all of whom had family members with them in the hospital. Dr. Chandra agreed that the approach to patients with dementia in India involves a tremendous amount of human contact. Family members go out of their way to accommodate patients, as do the professional caregivers. Dr. Hendrie also remarked on the low level of behavioral disturbances seen among the nursing home patients in some countries in his study. Whether this results from caregivers' high level of tolerance for such behaviors or from an inherent difference in the type of dementia is not yet known.

The challenge facing researchers today is to develop a systematic approach to defining and studying behavioral disturbances of dementia. At present, behavioral symptoms of dementia are inconsistently and imprecisely defined. Further complicating the study of behavioral problems is the lack of standardized rating tools and the difficulty of obtaining accurate data, both from the patient and the caregiver. To provide a focus for researchers, the author outlines several areas that deserve consideration in future discussions of behavioral symptoms in patients with dementia.

The behavioral (e.g., repetitive questioning, hitting) and psychological (e.g., delusions, anxieties) signs and symptoms of dementia can result in suffering, premature institutionalization, increased costs of care, and significant loss in the quality of life for the patient and his or her family and caregivers.