Not long ago, I saw a science fiction film with the premise that genetic, medical, and computer technology had excelled to the point that within a matter of seconds, any ordinary citizen could submit a minute skin or hair sample for DNA analysis, which would yield his or her future lifetime medical history within rather certain probabilities. In this future society, I could learn that my new-born grandson would have an 83% probability of a severe myocardial infarction by age 62 and that if he survived it, he had a 91% chance that his Alzheimer's disease (AD) would progress to the moderate level by age 78.

Background: General relationships between dotage and infancy and childhood have been acknowledged for more than two millennia. Recent findings indicate precise relationships between functional, praxic, and feeding changes in the course of the degenerative dementia of Alzheimer's disease (AD) and inverse corresponding developmental sequences. Similar inverse relationships between AD and human development can be described for cognition and language skills; for physiologic measures of electroencephalographic activity, brain glucose metabolism, and developmental neurologic reflex changes; and for the neuropathologic and neuroanatomic progression of these processes. In AD, these processes may be termed “retrogenesis.” The relevance of the retrogenesis model for AD management is explored. Method: The functional stages of AD can be translated into developmental age equivalents that can be utilized to explicate observed changes in the disease. Results: The retrogenesis-based developmental age model can usefully inform an understanding of the general care needs, emotional and behavioral changes, and activity needs of the AD patient. This model must be amended by necessary caveats regarding physical differences, variations in age-associated pathology, differences in social and societal reactions, and differences in background between AD patients and their developmental age “peers.” Conclusions: Knowledge of retrogenesis and the developmental age of the AD patients can form a nidus for the development of a nascent science of disease management. Such a science must ultimately incorporate not only appropriate caveats but also relevant universal human needs, such as those for dignity, love, and movement.

A search for references relating to the treatment of anxiety disorders in the elderly was made using the BIDS computerized database back to 1981, the Medline computerized database back to 1983, and the PsycLIT computerized database back to 1974, together with a search of relevant citations. The profusion of clinical recommendations was found to contrast with the lack of adequate supporting controlled clinical trials. There was evidence of a trend away from the benzodiazepine class of anxiolytics and an upsurge in interest in agents active at the serotonin receptor, although with the possible exception of buspirone, there is so far little research evidence for advocating use of the new agents in the elderly. Psychological therapies may be useful for many types of anxiety in the elderly, but their efficacy is also as yet unproven. Rational prescribing recommendations for anxiety in this age group will require controlled clinical trials incorporating a multiaxial approach to anxiety assessment, quality-of-life measures, psychological and placebo controls, and adequate follow-up intervals.

Background: Sleep complaints are frequent in old age. These difficulties are often associated with health-related problems, drug consumption, and the presence of mental disorders. Nonetheless, only sparse information is available on the clinical characteristics of elderly persons with insomnia. Aims: (a) To evaluate the prevalence of sleep problems among the elderly assessed in a psychogeriatric outpatient clinic; (b) to evaluate the association between the use of sleep tablets and sleep difficulties in this sample of patients. Methods: One hundred eighteen consecutive subjects were recruited from a psychogeriatric outpatient service in São Paulo, Brazil. Their sleep pattern was systematically assessed with the “sleep inventory,” a questionnaire consisting of 31 items that evaluate a number of sleep-related features. Clinical diagnoses followed the ICD-10 clinical descriptions and diagnostic guidelines. The number of drugs consumed by patients was also recorded. Results: Sleep complaints were highly prevalent (59.3%), with early morning awakening and nightmares being more frequent among patients with a depressive disorder. The use of sleep tablets was reported by 37.3% of subjects, and was associated with subjective sleep difficulties (odds ratio [OR] = 7.13, p = .008), difficulties falling asleep (OR = 7.33, p = .021), and frequent awakenings during the night (OR = 7.10, p = .040) in a logistic regression analysis. Conclusion: Sleep dissatisfaction is frequent among psychogeriatric outpatients. Subjects taking hypnotic drugs have more sleep-related complaints than those who do not. The clinical use of hypnotics may not be very effective for the treatment of sleep-related problems in the elderly. There is an urgent need for systematic prospective controlled studies to assess the efficacy and safety of the various forms of treatment of insomnia in old age.

Suicide rates for the elderly continue to be the highest for any age group. Although these rates are known to be significant, little study has been given to the ethnic variability associated with this phenomenon. This retrospective study was undertaken to explore this issue and involved a review of the coroner's reports for completed elder suicides (65 years of age or older) for Honolulu County from 1987 through 1992 inclusive. The results showed a mean age of 75 years, with the highest incidence of completion in the 80+ age group. The predominant method of suicide completion in this study group was found to be hanging, followed by jumping, firearms, and poisoning. There were significant gender and ethnic differences in the method of suicide completion. Almost half of the sample saw a healthcare provider within the 6 months before their death. Comparisons with other elder suicide studies are presented.

Older widowers have high rates of completed suicide but have rarely been the subject of systematic inquiry. We investigated the prevalence of depressive symptoms and major depressive episodes (MDEs) in recently widowed older men over the first 13 months after bereavement. We employed a matched-pairs longitudinal design and recruited subjects from a suburban community population. Fifty-seven recently widowed older men were identified from official death records and 57 matched married men were identified from the electoral roll. Subjects were assessed for the presence of current DSM-III-R MDEs using the Composite International Diagnostic Interview (CIDI), a fully structured psychiatric interview. Widowers were assessed at 6 weeks after bereavement (T1) and 13 months after bereavement (T2). Married men were assessed at similar intervals. At T1, seven widowers (12.3%) and no married men were found to have CIDI cases of current MDE. At T2, one widower (1.9%) and no married men were found to have CIDI cases of current MDE. Current MDE was not predicted by a past history of dysphoria. At T1, 14.0% (8/57) of widowers reported specific suicidal thoughts or actions. At T2, 15.4% (8/52) of widowers reported suicidal thoughts or actions. We conclude that health workers should monitor closely the clinical course of MDEs in recently widowed older men. Routine inquiry about suicidal ideation should be an essential component of the clinical assessment of recently widowed older men.

Objectives: To improve performance with mnemonic techniques for remembering words and proper names. Design: For word recall, a 2 × 2 factorial in which type of pretraining and length of training were between-subjects manipulations. For proper name recall, a two-group design in which type of pretraining was manipulated between subjects. Setting: Community. Participants: 268 community-dwelling adults over the age of 55 years who wished to improve their memory. Measurements: Recall of words and proper names both before and after training in mnemonics. Intervention: Participants received a 2-week training course on two mnemonic techniques, the method of loci for words and a name association technique for proper names. Results: There was no effect of the pretraining manipulation on proper name recall. For word recall, however, a multiple regression that included age indicated that the older-old participants benefited more from a combination of comprehensive pretraining and extended mnemonic training than did the younger-old. Conclusions: Increased training time coupled with a comprehensive pretraining regimen can improve the performance of the older-old in using mnemonics; this improved performance cannot be attributed solely to enhanced knowledge of the mnemonic.

Background. Few randomized, double-blind studies that examine antidepressant treatment in patients 70 years and older are available. To provide additional data on the safety and efficacy of antidepressants in this rapidly growing population segment, a subgroup analysis of a larger sertraline vs. nortriptyline elderly depression treatment study was performed. Methods. Outpatients (N = 76) who met DSM-III-R criteria for major depression with a minimum Hamilton Depression Rating Scale (HAM-D) severity score of 18 were randomized to 12 weeks of flexible dose treatment with sertraline (50–150 mg) or nortriptyline (25–100 mg). Results. Both treatments significantly improved depression as measured by the HAM-D and Clinical Global Impression scales. At Weeks 10, 12, and endpoint, sertraline demonstrated a significantly greater reduction in depression severity compared to nortriptyline as measured by improvement on the 24-item HAM-D (mean adjusted change score of 14.8 vs. 7.6, respectively, at Week 12; p = .001). Sixty-five percent of sertraline-treated patients were responders by Week 12 (50% or greater reduction from baseline in 24-item HAM-D score) compared to 26% of nortriptyline-treated patients (p < .05). Sertraline treatment had a significantly more positive effect, when compared to nortriptyline, across almost all associated measures of cognitive function, energy, anxiety, and quality of life and was better tolerated than nortriptyline, with a lower attrition rate/side effect burden. Conclusion. The efficacy advantage of sertraline appeared to be even greater in this subgroup of older patients drawn from a larger treatment study of depression that included elderly individuals over the age of 60.

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.