Background: Ommoord District residents of Rotterdam, The Netherlands, age 55 and older, completed a two-stage interview to assess the risk factors for chronic disease and disability. Methods: In the in-home Stage I interview (N = 7,983), demographic data and medical history were collected by a trained lay interviewer. During Stage II, a physician interview and examination were conducted at the study center. Subjects (N = 7,129) were asked about their history of psychiatric disorders and 6,596 responded. Results: The lifetime prevalence of self-reported psychiatric disorders was 5.44% for unipolar and bipolar depressive disorders combined, 0.27% for psychotic disorders, 0.08% for alcoholism, 0.05% for drug addiction, and 3.71% for other diagnoses. Residents reporting a psychiatric diagnosis of depression were more likely to be currently taking an antidepressant medication (p < .001) and an antipsychotic medication (p < .0001), to be in current outpatient treatment (p < .001), to have been hospitalized for psychiatric illness (p < .001), to have undergone electroconvulsive treatments (p < .001), and to report a history of having made suicide attempts (p < .001). Conclusion: The self-reported lifetime prevalence of affective disorders was similar to the rates found in the Stirling County Study (Canada) and the Epidemiologic Catchment Area Survey (United States). The lower prevalence rates of the other psychiatric disorders may reflect underreporting or an age cohort effect, or may be due to the nonresponse bias.

In order to investigate to what extent various determinants in the decision-making process for the treatment of severely ill incompetent patients are influenced by cultural and sociopolitical factors, 540 physicians in Austria, Germany (East and West), and Sweden, countries representing different healthcare systems, were surveyed using a self-administered questionnaire. It provided three case vignettes with different levels of information about the patient's treatment wishes in case of incompetence in a life-threatening situation. We found a general trend to a lower level of treatment in line with the patient's wishes when the information provided was more detailed. Remarkably, a substantial number of doctors did not comply with the patient's wishes. Ethical concerns and patient's wishes appeared as the most important factors whereas religious beliefs of the physician and hospital costs scored lowest. Because of the variability of treatment decisions and the importance of various factors determining the decision-making, an advance directive may be a feasible way of reducing the number of conflicts in critical situations. We recommend that ethical issues of clinical practice should be emphasized in the medical curriculum and in the training of physicians.

The activities of daily living (ADL) functioning of 26 subjects with Alzheimer's disease was measured using the Assessment of Motor and Process Skills (AMPS) and family informants' Older Americans Resources and Services (OARS) Activities of Daily Living (ADL) reports. Concordance with a clinician's ratings of subjects' level of ADL functioning was achieved for 77% of the subjects based on their AMPS ADL process ability measures and for 54% for the subjects based on their family informants' OARS ADL ratings. In cases of discordance, subjects' AMPS ADL process ability measures were just as likely to overestimate (11.5%) as to underestimate (11.5%) subjects' ADL functioning. In contrast, 46% of the informants overestimated their family members' ADL functioning, and this was more likely to occur when subjects' cognitive impairment was mild.

This survey sought to determine (a) the prevalence of carer stress in patients with mild to moderate dementia, (b) whether caregiver burden was already associated with plans to institutionalize patients, and (c) which patient-related and caregiver-related variables best predicted caregiver burden. The principal caregivers of 93 Asian patients with mild to moderate dementia attending an outpatient cognitive assessment clinic were interviewed via a structured questionnaire that focused upon (a) patient-related variables such as their behavioral and functional abnormalities; and (b) caregiver-related variables such as whether they were having problems looking after the patients, the duration of their caregiving, their associated feelings of anger and/or depression, and their financial status as well as intentions to institutionalize patients. Forty-nine percent of caregivers reported problems in looking after the patients, and their perception of difficulties was significantly associated with institutionalization plans for the patients. Logistic regression analysis using a forward variable selection procedure showed two of the patients' behavioral abnormalities (repetition, agitation) and one of their functional impairments (urinary incontinence) as well as the carers' depressed feelings to be predictive of the carers' problematic status, explaining 40% of the variance. It is important that even in the early stages of dementia, the medical assessment also evaluate behavioral, functional, and social dimensions of the illness, so that appropriate interventions can be implemented to reduce caregiving burden and delay institutionalization.

The aim of the report was to study clinical differences between psychotic late-life depression and psychotic depression in younger patients, to determine if differences were age-related or specific for psychotic late-life depression. Three hundred seventy-six consecutive outpatients, presenting for treatment of unipolar or bipolar depression (with or without psychotic features), were assessed by means of the Structured Clinical Interview for DSM-IV, the Montgomery and Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. Results showed that psychotic late-life (50 years or more) depression, versus psychotic depression in younger patients, was associated with significantly higher age at study entry/onset, longer duration, and lower comorbidity. Psychotic depression versus nonpsychotic late-life depression, in late-life and in younger patients, was associated with significantly greater severity, lower comorbidity, more patients with bipolar I disorder, and fewer patients with unipolar disorder. Findings were related to psychosis or to age, and not to specific features of psychotic late-life depression. These results support a unitary view of psychotic depression.

We performed awake and resting electroencephalograms (EEGs) on 22 subjects with DSM-III-R schizophrenic disorder of late onset (at or after age 50 years), and compared them with the EEGs of 33 healthy community controls matched for age and gender. The EEGs were rated qualitatively and a 2-minute, artifact-free tracing from each subject was quantified manually by an experienced neurophysiologist unaware of the identity of the subject group. The only significant difference was the presence of more generalized slowing in the EEGs of schizophrenia patients, which was at least partially accounted for by the effect of neuroleptic drugs. The schizophrenic subjects did not have a greater prevalence of epileptiform disturbances or abnormal asymmetry of the EEG compared to the control group. Our study does not suggest the presence of underlying dementia in schizophrenia of late onset.

In this prospective cohort of 71 elderly patients undergoing cardiac surgery, each subject was interviewed before and after surgery to detect incident delirium using the Confusion Assessment Method (CAM), the Mini-Mental State Examination (MMSE), the Clock Test, and a health record review. The first 41 were assessed by a physician and the remaining 30 by two study nurses. Delirium was then diagnosed by a physician using DSM-III-R criteria. Delirium was present in 23 subjects (32.4%). The sensitivity of the CAM differed significantly when administered by physicians compared to nurses (1.00 vs. .13). When standard cutoffs were used, neither the MMSE nor the Clock Test were found to be sensitive markers for delirium (.30 and .09, respectively). Recognition of delirium by charting was superior in nurses compared to physicians (.83 vs. .30). We conclude that the sensitivity of markers for delirium, such as the CAM and health record documentation, is dependent on the training background of the operator.

Professor Morton Kramer, age 84, died on August 17, 1998, in Pikesville, Maryland, USA, near Baltimore. He is survived by three children and their families. He is remembered by hundreds of students, friends, and colleagues around the globe.

Background: Aggressive behavior among geriatric psychiatry inpatients spontaneously declines during serial measurements over time with rating scales. Method: Evidence for decline in aggressive behavior, over a 6-week period, on a continuing-care geriatric psychiatry ward was examined with the Staff Observation Aggression Scale (SOAS) and the Rating Scale for Aggressive Behavior in the Elderly (RAGE). Results: The RAGE and all its subitems did not spontaneously decline. The total number of aggressive incidents on the SOAS, the SOAS total score, and the subitem scores, except for the SOAS results subitem, spontaneously declined after Week 4 and became established by Week 5. Conclusion: A “run in” period of at least 4 weeks may be needed in intervention studies using the SOAS to reduce contamination by spontaneous decline.

Health-related quality of life (HRQL) was investigated in 211 inhabitants of five residential homes in The Netherlands and was assessed again 1 year later. It was examined (a) if HRQL was related to the presence of specific general medical illnesses, (b) if comorbidity resulted in poorer HRQL, independent of the type of illness, and (c) if HRQL remained stable over time (1 year). We found that the illnesses we investigated contributed only little power to the prediction of HRQL, although some coefficients were significant. Comorbidity was also found to be a significant predictor of several aspects of HRQL, but did not contribute much power either. Several aspects of HRQL (bodily pain, health perceptions, and social functioning) remained stable over time, whereas other aspects (role functioning, activities of daily living) deteriorated. There was a trend indicating that mental health improves over time. Improvement and deterioration on aspects of HRQL were relatively strongly related to the scores on these aspects 1 year earlier, but not to specific illnesses or comorbidity.