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.

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.

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.

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.

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.

Situated at the crossroads of three continents, characterized by a unique composition of aging people, featured by a wide range of special problems—psychological, social, cultural, linguistic, and many others—Israel represents a natural laboratory for innovative approaches toward epidemiology, assessment, treatment, organization of services, policy, teaching, training, and research in the field of interdisciplinary psychogeriatrics.