Suicide rates for older people are increasing worldwide, thereby creating a major public health concern. There has been an absence of public policy and research interest in this area, although the needs are pressing and promise to be even more so.

What a time it is for psychogeriatric research! This supplementary issue, drawing upon papers submitted for the 1991 IPA Research Awards in Psychogeriatrics, attests to the growth, vigor, and international reach of such studies. Also apparent are the depth and breadth of this field, as reflected in the papers published here— ranging in focus from dementia to depression, from biology to behavior, from cognition to culture. Especially exciting is the growing number of young investigators entering the field and contributing in an important way to the advancement of psychogeriatric knowledge.

We express our sincere gratitude to Barry Reisberg, M.D., and Gerald Oppenheim, M.B., B.S., F.R.A.N.Z.C.P., for their guest editorship in compiling a group of important papers on the clinical course of Alzheimer's disease, as well as the methodological implications of clinical changes in Alzheimer's disease for pharmacologic trials. The papers were presented initially at a special symposium of the IPA Fifth International Congress in Rome, Italy, August 18–23, 1991. This issue of International Psychogeriatrics is our second supplement within a year, derived from important presentations at IPA meetings and deemed worthy of dissemination to the wide IPA audience.

Few brief self-report memory questionnaires are available, and none has been well validated. We designed a brief questionnaire, the MAC-Q, to assess age-related memory decline. Validity and reliability of the MAC-Q were assessed in 232 subjects meeting diagnostic criteria for age-associated memory impairment (AAMI). Concurrent validity of the MAC-Q was supported by a significant correlation (r = .41, p < .001) with a lengthy, well-validated memory questionnaire. Multiple regression analysis indicated that memory test scores were significant predictors of MAC-Q scores. MAC-Q scores were not predicted by Hamilton Depression Scale scores, suggesting that memory complaint in AAMI is not related to affective status. Internal consistency and test-retest reliability of the MAC-Q were satisfactory. Our data support the validity and reliability of the MAC-Q, a new brief memory questionnaire. The MAC-Q is of particular relevance to the assessment of AAMI, but should also prove useful in any clinical or research setting requiring a brief index of memory complaint.

Increasing numbers of people in absolute terms, and even more so in relative terms, are reaching an age in which psychogeriatric illness, as well as geriatric illness, frequently is manifested. This unprecedented increase in average individual lifespan is due largely to advancement in life standards of the population as a whole, the enormous improvement in hygiene, and the progress made by preventive and curative medicine in controlling acute and fatal disease, in addition to advancements in available treatments of chronic disease in old people.

Alzheimer's disease (AD) is now recognized as a major cause of morbidity and mortality in elderly populations throughout the world. Tragically, no clearly effective treatment for this major illness entity has emerged. In part, the lack of an effective treatment is the result of an absence of fundamental knowledge regarding the etiology and pathogenesis of the illness. However, treatment implies the amelioration of symptoms, not cure. In other neuropsychiatric illnesses such as schizophrenia, major depression, and idiopathic Parkinson's disease, there is a similar absence of knowledge regarding etiology and, to a greater or lesser extent, regarding pathogenesis. Nevertheless, symptomatic treatment for these other neuropsychiatric illnesses is available. The same potential for symptomatic treatment exists in AD. The absence of consensus or systematic information regarding treatment in AD is in large part due to the failure to apply appropriate methodologies to symptomatic assessment and pharmacologic treatment.

The IPA Research Awards in Psychogeriatrics were conceived through the vision of Manfred Bergener. I have had the pleasure of coordinating the award process since its inception.

Research on the nature of clinical symptomatology in AD indicates that two fundamentally different types of symptoms are identifiable. Symptoms within each of these two domains have common characteristics. The first symptomatic domain has been termed the “cognitive domain” and the second the “noncognitive behavioral domain.” Symptoms and losses in the cognitive domain occur invariably and progressively with the advance of AD over time. Symptoms in the behavioral domain do not invariably occur in AD and do not progress monotonically with the advance in AD over time. However, characteristic behavioral domain symptoms can be described over the course of AD.

The two symptomatic domains are likely to differ not only in nature and progression in AD, but also in underlying pathophysiology and in terms of possible treatment modalities. They also pose fundamentally different issues of assessment in AD. These distinct factors necessitate the separate assessment of the two Symptomatic domains in AD treatment trials. Judgments of efficacy and utility in remediating either symptomatic domain in AD should take into consideration the effects of treatment on both cognitive domain and behavioral domain symptoms separately and interactively. Appropriate assessment procedures are discussed.

One hundred and seven newly diagnosed, untreated patients with Parkinson's disease (PD) were divided into two groups according to their age at reported onset of symptoms. Of these, 79 patients were under age 70 (early-onset) and 28 patients were age 70 and over (late-onset). The group of 50 control subjects comprised spouses, friends of the PD patients, and community volunteers. The patients were participants in a multicenter drug study of Parkinson's disease. Each had received a detailed neurological and neuropsychological assessment in the baseline placebo phases of the study. Thirty-4 patients with early-onset and 12 patients with late-onset were reassessed 3 years after treatment with low-dose levodopa, with bromocriptine, or with a combination of the two drugs. The results of the baseline phase of the study revealed that 8% of the early-onset group and 32% of the late-onset group were classified as demented. The 3-year follow-up revealed that the prevalence of dementia had increased to 17% in the early-onset group and to 83% in the late-onset group. This study confirms that at least two distinct subtypes of Parkinson's disease exist. The subtypes differ both clinically and neuropsychologically. The age at onset of symptoms is a critical determinant of the rate and type of cognitive decline in Parkinson's disease.

Computer-analyzed EEG data and mental functions of the healthy aged (28 survivors and 20 nonsurvivors) were followed for nine years in a study of their relationship with age and longevity. The study revealed that decrease in fast waves occurred from early senescence. The slowing of EEG, the increase in theta waves, and the decrease in alpha frequency became obvious in late senescence, after the late 70s or beyond 80 years. The amount of alpha waves was maintained until the early 80s. The decline of mental functions occurred with the slowing of EEG in late senescence. The slowing of EEG and the lowered scores of psychometrics were closely related to the longevity of life, comparing the survivors and nonsurvivors in retrospect.

Personality traits in euthymic elderly subjects with and without past histories of major depressive episodes were assessed using the Structured Clinical Interview for DSM-III-R and the Social Adjustment Scale-SR. Recovered depressed subjects were characterized by significantly more personality traits from DSM-III-R Clusters B and C than controls, and they exhibited differences in social adjustment, as well. Subjects who have recovered from depressive episodes may show significant diferences in personality and social adjustment that might represent residua of past depression, a trait characteristic, or a risk factor for recurrence.

The Behavioral Syndromes Scale for Dementia (BSSD) is a new instrument that showed strong internal consistency and interrater reliability in an outpatient sample of 106 patients with probable Alzheimer's disease. Factor analysis provided support for a priori symptom groupings, particularly the syndromes of disinhibition and apathy-indifference. Dependency (87%), denial of illness (63%), and motor agitation (55%) were common, while sexual disinhibition (2.9%) and self-destructive behaviors (2.9%) were rare. Virtually all symptoms were predominantly minimal to mild in severity. Patients with longer illness duration were more apathetic. Disinhibited behaviors and apathy-indifference increased with greater severity of dementia. Catastrophic reactions, aggression, and agitation were associated with greater functional impairment. There was great heterogeneity in symptom presentation. In Alzheimer's disease, several behavioral changes might be direct manifestations of underlying brain pathology, rather than being solely secondary to cognitive impairment.

The authors reanalyzed previously published data from a prospectively randomized, placebo-controlled, double-blind phase-III study of 130 inpatients with dementia syndrome. The patients in the study had been diagnosed as having suffered from organic brain syndrome (ICD 290), which is the core syndrome of dementia (so-called dementia syndrome) for at least two years. They were treated with piracetam for three months at a dose level of 4,800 mg/d.

These data were reexamined in order both to survey the extent of drugrelated improvement and response rates when assessed at different levels and to investigate the comparability of efficacy in subgroups suffering from either senile dementia of the Alzheimer type or multi-infarct dementia. Three scales were used for the assessment of efficacy. They were the CGI, or Clinical Global Impression, completed by the physicians; the SCAG, or Sandoz Clinical Assessment Geriatric, used by clinical psychologists; and the BGP, or Beurteilungsskala f$uUr Geriatrische Patienten (Evaluation Scale for Geriatric Patients), employed by the nursing staff. The Syndrom-Kurztest (SKT) and Benton tests served to measure performance.

The items and subscores of the SCAG and the SKT were highly intercorrelated at baseline, forming a common factor fairly independent of the information gained by BGP. This suggests that merely using different kinds of information-gathering methods, i.e., clinical scales and performance tests, completed by different groups of observers, does not automatically result in nonredundant comprehensive information.

The short- and long-term treatment tolerance of low-dose clozapine was retrospectively investigated in 18 psychogeriatric patients. Discontinued use of the drug because of side effects or inefficiency was required for only four patients. In the long-term treatment group leukopenia was not observed, and disturbances of liver function appeared to be very infrequent. A second group of seven severely demented psychogeriatric inpatients who were currently being treated with low-dose clozapine underwent a withdrawal study in order to evaluate the therapeutic efficacy of the drug, measured by the NOSIE and the SCAG scales. The results indicate that for patients such as these, with paranoid or socially disturbing behavior who also tend to develop severe neurological side effects with classical neuroleptics, a low-dose administration of clozapine is an acceptable alternative treatment.

Psychiatric symptoms and behavioral disturbances are of importance in dementia of the Alzheimer type (DAT) but have been relatively neglected by researchers. The main psychiatric symptoms are disorders of thought content (delusions and paranoid ideation), disorders of perception (hallucinations and misidentifications) and disorders of affect (depressed and elevated mood). They occur commonly in DAT, and there is evidence that they may indicate subtypes of the disorder in view of their demographic, structural, and prognostic correlates. Personality changes are very common, and these may be the earliest manifestation of dementia. Behavioral disturbances tend to be associated with advanced dementia and are particularly disruptive to caregivers. Structural correlates suggest that some behaviors are a direct result of brain damage. Psychiatric and behavioral features in DAT are important, as they may serve as a model for symptomatology in functional psychiatric disorders.

Benzodiazepine hypnotic medications are widely prescribed for elderly patients, but there is a paucity of information available concerning the resudual cognitive and psychomotor (the morning-after) effects of these drugs. We compared two commonly used hypnotics—temazepam and triazolam—in a double-blind, placebo-controlled, single-dose study with community-dwelling healthy elderly with a DSM-III-R diagnosis of primary insomnia. Fortyfive subjects over the age of 65 (mean age 72.23, SD = 4.44) qualified for the study. Subjects were randomly assigned to one of five treatment groups (placebo, triazolam 0.125 mg., triazolam 0.25 mg., temazepam 15 mg., and temazepam 30 mg.). Neuropsychological testing was completed at baseline and 12–14 hours after the dosing.

Patients were evaluated with a variety of tests that measured attention, concentration, motor speed, immediate memory, and learning of new information. Separate repeated measured analyses of variance were performed to assess the significant changes among the five treatment groups. We found improved performance or no change in all the measures for all medication groups except for impairment of performance on a serial learning task for both high-dose medication groups. The significance of these results and the need for further research in elderly insomniacs is discussed.

Twenty-four highly agitated, cognitively impaired nursing home residents were studied in depth to determine whether they manifested temporal patterns of agitation. Results demonstrated that agitated behaviors were significantly associated with temporal factors. For instance, residents made more requests for attention during lunch than other time periods, and residents screamed most often during the night. Some agitated behaviors (e.g., aggression) were manifested more frequently in the evening than in the day, consistent with the notion of sundowning in the nursing home. Implications of temporal patterns of agitation for caregivers of severely cognitively impaired and agitated nursing home residents are discussed.

Evaluation of changes in functional performance and activities of daily living skills is an essential aspect of the assessment of elderly individuals with chronic illness. Although functional decrement is a central aspect of Alzheimer's disease (AD), many measures currently utilized to assess these changes have limitations. Empirical and systematic examination of the functional changes occurring in patients with AD has resulted in the development of an assessment measure termed Functional Assessment Staging (FAST) that allows for the specific evaluation of these changes throughout the entire course of AD. In this paper the results of three separate investigations regarding the reliability, validity, and progressive ordinality of FAST are described. The results indicate that FAST is a reliable and valid assessment technique for evaluating functional deterioration in AD patients throughout the entire course of the illness. Moreover, the results suggest that the FAST elucidates a characteristic pattern of progressive, ordinal, and functional decline in AD. Because the elements of functional capacity incorporated in FAST are relatively universal and readily ascertainable, as well as characteristic of the course of AD, FAST can serve as a strong diagnostic and differential diagnostic aid for clinicians. The sensitivity of FAST to the entire course of AD, even in its most severe stages, may be indicative of the potential value of this instrument for further investigation of the temporal longitudinal course of AD, and of the relationships between clinical pathology and neuropathology throughout the entire longitudinal course of AD.

The purpose of this study is twofold: to estimate the prevalence of depressive symptoms among older adults in four culturally diverse groups (white Americans, black Americans, Japanese, Taiwanese), and to assess whether there are cross-cultural variations in the way depressive symptoms are manifest. Data from three recent nationwide surveys in the United States, Japan, and Taiwan reveal that the lowest overall levels of depressive symptoms are found among Japanese elderly, followed by Taiwanese, white Americans, and black Americans respectively. Based on previous cross-cultural research, it was hypothesized that the Japanese tend to express depressive symptoms as interpersonal complaints, whereas Taiwanese are more likely to manifest somatic symptoms. In contrast, Americans were expected to express depressive symptoms in the form of depressed cognitions. The findings failed to support these hypotheses. Instead, older Americans tended to have higher scores than Orientals on all three depressive symptom clusters.