In this issue, you will see that we are introducing the first of a series of guest editorials. Eventually, we want two or three per issue. Topics will vary greatly, but every effort will be made to include the factual, funny, controversial, political, and so on. As a quarterly, we cannot be immediate, but we will try to stay current. We would like readers to contact us with ideas, but all editorials must be contracted with the Editor-in-Chief. Moreover, we would like spirited letters in response to the editorials and the articles and, wherever possible, these will be published.

Alzheimer's Disease International (ADI) aims to promote and support the work of national Alzheimer associations. Their main purpose is to support carers of people with Alzheimer's disease and related dementias, and to raise awareness of the impact of the disease on the individual and the carer.

During the past 2 years there have been several consensus conferences on diagnostic testing for Alzheimer's disease (AD), specifically related to the use of new genetic tests (Farrer et al., 1995; Relkin et al., 1996). Unfortunately there is an appearance of controversy between some of the published opinions and the empirical data (Saunders et al., 1996; Slooter et al., 1996). The clinical paradigm for AD has changed from “ruling out” a small list of reversible and treatment causes of dementia to “ruling in” the diagnosis of AD using adjunctive genetic tests with a high positive predictive value for some patients (Roses & Saunders, in press).

The prevalence of dementia increased in women (from 31% to 46%) but not in men (from 27% to 25%) in a representative birth cohort followed from age 85 to 88. The increase was mostly attributed to a higher rate of new cases among women than among men. The proportion of moderate to severe dementia increased, and mild dementia decreased, mainly because of progression of mild dementias to severer forms and because most new cases were of moderate to severe degree. The proportion of vascular dementia was 47% at age 85 and 54% at 88 despite a higher mortality in vascular than in other dementias. Diagnosis changed to vascular dementia in 9 out of 31 cases of Alzheimer's disease because of new cerebrovascular events. This study illustrates that prevalence is influenced by several factors, such as number of new cases, refusal rate, diagnostic change, and mortality. These factors act in different directions and may differ between populations.

Despite their limitations, mental status tests and self/proxy reports of instrumental activities of daily living (IADL) are often used to predict functional competence. In contrast, the Assessment of Motor and Process Skills (AMPS) is a direct observational assessment of IADL competence. Sixty-four community-dwelling elderly (20 Alzheimer's disease [AD] patients and 44 nondemented) were assessed with the AMPS, the Mini-Mental State Examination (MMSE), and the Older Americans Resources and Services (OARS)-IADL. Performance on all three assessments was significantly lower for the AD sample. The MMSE did not correlate significantly with the AMPS motor ability measures but it correlated modestly with the AMPS process ability measures. The OARS-IADL correlated significantly with the AMPS motor ability measure for the nondemented sample alone. Although mental status and self/proxy assessments provide some insight into individuals' IADL competence, direct observation of IADL task performance provides additional information regarding the subtle process and motor skills changes that occur in progressive dementing conditions.

Blessed-Roth Dementia Scale has been one of the most widely used rating scales in dementia. Previous studies indicated that this behavioral assessment scale is a useful tool for differentiating elderly subjects with no or minimal intellectual decline from those with cognitive deterioration. In the present study, the authors examined the validity of the Chinese version of the Blessed-Roth Dementia Scale (CDS) in Hong Kong. A total of 106 Chinese subjects were recruited from a social center, an old-age home,and psychogeriatric outpatient clinics. At a cutoff score of 3 of 4, the CDS achieved a sensitivity of 90.5% and specificity of 98.1% in differentiating demented from healthy control subjects. In the Chinese population studied, the scale was readily acceptable and considered to be an useful adjunct in screening of dementia.

To determine predictors of cognitive deterioration, the authors performed baseline and 1- to 5-year follow-up (mean ± SD = 2.5 ± 1.2 years) neuropsychological assessments on 36 persons (mean age ± SD = 62.1 ± 8.0; range = 50 to 81 years) with age-associated memory impairment. Subjects were recruited from a larger group of volunteers, had minimal medical comorbidity, and 25 of them had a family history of Alzheimer's disease. Baseline age and a subjective memory measure indicating reported frequency of mnemonics usage were significant decline predictors. Subjects reporting more frequent mnemonics use at baseline were more likely to show objective cognitive decline at follow-up. Baseline full-scale IQ, educational level, and family history of Alzheimer's disease failed to predict decline. These findings suggest that although age is the strongest decline predictor in some people with age-associated memory impairment, self-perception of memory function may also predict subsequent cognitive loss.

Eighty-seven out of a clinical cohort of 124 patients with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) dementia were followed up at monthly intervals for 1 year. Psychotic symptoms were assessed using the Burns's Symptom Checklist, and cognitive functioning was evaluated with the CAMCOG. The annual incidence rate of psychotic symptoms was 47%, although many of the incident symptoms lasted less than 3 months. Fifty-three percent of patients with psychosis experienced resolution of their symptoms. Patients either experienced brief or persistent psychotic disorders, with few having an intermediary course. Persistent psychosis was significantly associated with a 3-month duration of symptoms at baseline. Neuroleptics did not significantly influence the course of psychotic symptoms.

Many nursing home residents are candidates for antipsychotic pharmacotherapy for dementia-related behavioral disturbances that include physical agitation and aggression, verbal outbursts, anxiety, and depression. These patients are often resistant to or intolerant of standard neuroleptics and are usually receiving multiple medications for concurrent psychiatric or medical conditions. New medications must be carefully considered because they may interact with concurrent medications or aggravate concurrent medical problems. Low doeses of risperidone may be better tolerated in the elderly because the drug poses little risk of extrapyramidal side effects or blood disorders. One hundred and nine patients with dementia-related behavioral disturbances were studied in 9 nursing homes; most initially received 0.25 to 0.5 mg of risperidone twice daily. Their behavior was recorded for up to 6 months on questionnaires completed by a nursing staff member at each home. Risperidone was well tolerated overall and nursing staff viewed it as helpful in 38 of 100 patients, moderately helpful in 26, slightly helpful in 17, and not helpful in 19.

The recent literature on informal carers of dementia patients is reviewed. Families bear the major responsibility for such care. The production of “burden” in carers is a complex process, involving developmental and cultural factors, in addition to the stressors of dementia itself. Also influential are the carer's gender, coping style, social network, and the carer's level of inimacy with the elder. The interpretation of actual morbidity is complicated by methodologic problems. However, carers appear to suffer from at least moderate levels of psychological symptomatology. Carers tend to judge their own health to be poorer than that of controls. Some studies have also found aspects of caregiving to be associated with elder abuse, but this is controversial. Caregiving in dementia appears to be at least as stressful as that in chronic physical illness and depression. Finally, the implications for service provision and future research are considered.

There is a paucity of research that examines the role of family members and friends in the lives of older schizophrenia patients. This study compared 66 middle-aged and elderly outpatients with 31 normal comparison subjects. Five dimensions of social network were assessed: (a) family composition, geographic proximity, and frequency of contact; (b) instrumental support; (c) emotional support and interpersonal difficulties; (d) role of friends; and (e) use of formal service providers as sources of support and assistance. As compared with normal subjects, the schizophrenia patients were less likely to be married, less likely to have children, more likely to live alone, and had fewer friendships. The patients were, however, similar to comparison subjects on the following family-relationship variables: frequency of contact, instrumental support received, presence of a family confidant, and extent of interpersonal difficulties. These findings do not support the stereotype of older schizophrenia patients as being estranged from family members. The need for developing interventions that use key family members to interface with service providers and to monitor treatment compliance and continuity of care is discussed.

Alcohol abuse and dependence are an increasing health problem among the elderly, but there is only scanty information about their prevalence and associated risk factors in developing countries. The authors set out to evaluate the prevalence and associated clinical/demographic features of alcoholism in a sample of male elderly subjects attending a Geriatric Primary Health Outpatient Clinic in a State University Hospital in the City of São Paulo-Brazil. Three hundred four patients were assessed with the Brazilian version of the Michigan Alcoholism Screening Test and a semistructured questionnaire designed to investigate associated features. Lifetime alcoholism was present in 15.1% of the sample, although only 4.3% were active drinkers. Patients classified as “cases” were younger than their nonalcoholic counterparts (70.61 vs. 73.31), and there was a mild, though not significant, excess of Blacks and Mulattos among the former (32.6% vs. 15.9%). Cases were also more likely to rely on their family for financial support (59.0% vs. 43.5%) and to acknowledge a positive family history of alcoholism (51.4% vs. 31.2%). Alcohol abuse or dependence was further associated with heavy smoking (58.7% vs. 44.0%). The authors concluded that alcoholism in this Brazilian elderly sample was likely to be associated with an earlier age at onset of medical problems, financial dependence, Black/Mulatto race smoking, and positive family history of alcohol abuse/dependence. The authors suggest that the use of standardized methods of assessment of alcoholism in general medical settings may increase the detection of case and contribute to improved health measures for the management of these patients.