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When the Titanic sped towards New York, the captain was less concerned about icebergs than about transatlantic records. Nevertheless when the ship crashed, the captain did his duty and went down with the ship. Captains lead lonely, but not necessarily isolated, lives. What about editors? I do not wish to drown, but do lament the lack of letters (or correspondence as it is called elsewhere in the English-speaking world). Despite the pleas, nobody answers the call for letters to the editor. Like the captain, I want to know what's going on and what people think.

This study compares the demographic and clinical characteristics of homebound (HB) elders referred for psychiatric services (N = 251) with those of inpatients (IP) admitted to a geriatric psychiatry unit (N = 594). Demographically, HB patients were older (78.8 vs. 74.7 years), were more likely to be women (83% vs. 68%), were widowed (54% vs. 44%), and had fewer years of education (10.3 vs. 11.1), but were similar in race, income, and proportion living alone. Clinically, HB patients had less functional disability, less severe depression, less cognitive impairment, and fewer medical problems. However, they were similar in the distribution of most psychiatric diagnoses except dementia (higher in the IP group) and dementia with depression (higher in the HB group). Outcome data for the HB group over 15 (range, 1 to 38) months revealed medical hospitalization in 20.7%, psychiatric hospitalization in 16.3%, nursing home placement in 9.2%, and mortality in 8.4%. These preliminary data show that the HB group had psychiatric problems that were comparable to those of the IP group but were not as severely impaired.

The strain of caregiving associated with the care of demented persons living at home often continues after relocation, and group-living-care units (GL), designed for a small number of subjects, have been developed. The aim was to prospectively describe caregiver burden in relationship to symptoms of patients with dementia after relocation to GL. Sixty-four caregivers and 64 demented patients were assessed before, 6 months after, and 12 months after relocation. Thirty-six caregivers were children, 7 were spouses, and 21 were others. Validated scales were used for caregiver burden and dementia symptoms. Total burden of caregivers decreased after 12 months, but the degree of isolation was unchanged and feeling of disappointment increased significantly. The burden was not related to changes of activities of daily life or disorientation. Patients' lack of vitality at relocation independently predicted caregiver's burden 1 year later. Hallucinations and changes of symptoms during the first year were associated with less caregiver burden, probably due to greater detachment of the relationship. The caregiver burden remains 1 year after relocation and any support to the caregiver should consider patients' symptoms, especially lack of vitality.

To examine early intellectual deficits in elderly patients with dementia of the Alzheimer type (DAT), 25 mildly impaired patients with DAT and 25 normal controls were compared using the Japanese version of the Wechsler Adult Intelligence Scale–Revised (WAIS-R). The two groups did not differ significantly in age, years of education, or sex ratio. Based on Horn's modified fluid and crystallized model, the WAIS-R subtests were classified into two categories (i.e., fluid intelligence and crystallized intelligence). The DAT group showed a significantly lower crystallized intelligence score, whereas the fluid intelligence scores did not differ significantly between the two groups. When the subtests were examined individually, the subtests for crystallized intelligence (i.e., information, comprehension, and similarities) were found to show the most significant deficits. These results suggest that elderly subjects with mild DAT have more impaired crystallized intelligence than those without dementia.

Frontotemporal dementia (FTD) is a dementing syndrome characterized by the occurrence of neuropsychiatric features early in the clinical course. Patients with Alzheimer's disease (AD) also have neuropsychiatric symptoms, but these symptoms typically emerge later in the course after the development of memory and other cognitive impairment. The BEHAVE-AD, an instrument developed to evaluate neuropsychiatric features in dementia, may help characterize the behavioral features of FTD and differentiate FTD from AD. This study evaluated BEHAVEAD results of 29 patients with the diagnosis of FTD compared to those of 29 patients with the diagnosis of probable AD of similar dementia severity. The FTD patients had significantly worse global BEHAVE-AD scores compared to the AD patients. Verbal outbursts and inappropriate activity characterized the FTD patients, and three BEHAVE-AD subscales correctly classified 69% of the patients. The assessment of neuropsychiatric symptoms with a standardized scale or inventory can help distinguish dementia patients with FTD and AD.

Depression is common among acutely ill elderly medical inpatients. Identification of such depression by the geriatric medicine staff would allow early treatment. The impact of a depression screening procedure on documentation of depressive signs and symptoms in the medical and nursing case-notes was examined. Thirty-five sets of medical and nursing case-notes of medically ill elderly inpatients, for whom data from the Brief Assessment Schedule and the short Geriatric Depression Scale (GDS) were also available, were examined for documentation of signs and symptoms of depression, prescription of antidepressants, and referred to the psychogeriatric service. Depressive signs and symptoms were documented in only a few medical (29%) and nursing (11%) case-notes. Only a small number of depressed patients were prescribed antidepressants (20%) or were referred to the psychogeriatric service (13%). The frequency of documentation of depressive signs and symptoms after the screening procedure with the short GDS was associated with subsequent prescription of antidepressants and referral to the psychogeriatric service. The screening procedure itself may increase the general awareness of depressive signs and symptoms and affect its management. These results require replication.

Anxiety is commonly reported in patients with dementia, resulting in a further decline in functioning. An overview of the clinical application of cognitive-behavioral techniques in treating anxiety in elderly patients with brain damage is presented. Two cases are described with a focus on clinical anxiety management techniques that have been modified to suit cognitively impaired elderly patients. These modifications include simplifying material, using more structured techniques, and recognizing the critical role of the patient's caregiver in therapy. It is concluded that cognitive-behavior therapy can help in reducing anxiety in the demented population; the potential benefits of this therapy are an increase in patients' self-esteem and independence and the prevention of hospitalization.

Ethnic differences in rates of dementia nationally, within multiethnic communities, and internationally have important repercussions. The question “Do ethnic differences exist in rates of dementia?” is a crucial one that has implications for service delivery and also offers opportunities for future research on possible etiological factors. Epidemiological surveys suggest that ethnic and geographical differences do occur in rates of dementia, but cross-cultural surveys are fraught with problems. The need for further methodologically sound, cross-cultural comparative studies is paramount to confirm or disclaim the ethnic differences observed to date.

Objectives: To assess the longitudinal effects of acetyl-L-carnitine (ALC) on patients diagnosed with Alzheimer's disease. Design: Longitudinal, double-blind, parallel-group, placebocontrolled. Setting: Twenty-four outpatient sites across the United States. Participants: A total of 334 subjects diagnosed with probable Alzheimer's disease by NINCDS-ADRDA criteria. These data were originally reported by Thal and colleagues (1996). Measurements: Cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS) given every 3 months for 1 year. Results: The average rate of change was estimated using the trilinear approach, which allows for periods of both change and stability. Both the ALC group and the placebo group exhibited the same mean rate of change on the ADAS (0.68 points/month). However, a multiple regression analysis revealed a statistically significant Age × Drug interaction characterized by younger subjects benefiting more from ALC treatment than older subjects. Further analyses suggested that the optimal, though not statistically significant, cutpoint for ALC benefit was 61 years of age. Conclusions: ALC slows the progression of Alzheimer's disease in younger subjects, and the use of the trilinear approach to estimate the average rate of change may prove valuable in pharmacological trials.

Suicide rates in Alaska Native elders are studied to further explore cultural factors in elderly suicide. Data for the 1960s and 1970s are reviewed, and new data on Alaska Native suicide rates are presented for the 10-year period of 1985 through 1994. In many areas throughout the world, suicide rates are highest for the elderly. During the Alaska “oil boom,” suicide rates more than tripled for the general population but decreased to zero for Alaska Native elders. Cultural teachings from the society's elders were more important during this time of cultural upheaval. During the study period, the cultural changes dissipated, and suicide rates for Alaska Native elders, although lower than those of White Alaskans, increased. This provides further evidence that suicide rates for elders can by influenced by social factors—both to raise and to lower rates.

The cognitive and functional decline of demented residents in a specialized Alzheimer's facility was compared to that of demented residents living in a traditional nursing home. All residents met DSM-III-R criteria for dementia. The evaluation consisted of a clinical interview with patients and collateral assessments of cognition, general health, problem behaviors, depression, and a broad range of activities of daily living (ADLs) including mobility. Residents were evaluated at baseline and 6-month intervals over 18 months. Similar rates of decline were found in cognition and overall ADLs in both groups. However, the most striking finding was preserved mobility in residents of the Alzheimer's facility. This finding suggests that specialized facilities do not halt or slow the overall progression of cognitive and functional decline seen in Alzheimer's disease; however, residents of such facilities may show slower decline in mobility.