The International Classification of Impairments, Disabilities, and Handicaps (the ICIDH) was developed in the 1970s as an extension of the World Health Organization's International Classification of Diseases (ICD). It was developed principally to meet the criticisms of ICD users who thought that the ICD (a) did not sufficiently cover the impact of a given disease on an individual and the society in which he or she lived, and (b) was unable to describe the heterogeneity of the clinical expression of a disorder and the disorder's variable evolution in different individuals and societies. The ICIDH was first published by the World Health Organization (WHO) in 1980 and is currently undergoing its first major revision. In this revision process, psychiatry is being given an important place in response to complaints of users that the ICIDH presently has limited application in the mental health field. In a brief discussion here, I would like to describe the role of the ICIDH in relation to mental health—and to psychogeriatrics in particular—drawing on a number of debates in which I have been involved over the past few years.

The aim of this study was to evaluate the ability of a trained primary health care (PHC) nurse to discriminate dementia, by systematic assessments, from other psychogeriatric diseases. The reported study emanates from a dementia prevalence survey in an elderly (65+) population (n = 851). Forty-two frail elderly people (mean age 77.8 years) referred to a psychogeriatric hospital for further clinical investigation were tested. Dementia rating scales were used by the trained nurse, who noted her clinical observations systematically as well. The instrument results of the testing procedures, evaluated in combination with the clinical picture of the patients, were correlated to the DSM-III-R criteria of dementia. Thereafter, the nurse's judgments were compared with the clinical diagnoses based on thorough geropsychiatric investigations. The nurse's diagnoses of moderate and severe dementia had a sensitivity of 80% and a specificity of 82%. The predictive value of a positive test for moderate and severe dementia was 87%. When the mildly demented patients were included, sensitivity was 93%, specificity was 75%, positive predictive value was 90%, and kappa value was. 70.

The Clinical Dementia Rating (CDR) scale is a qualitative staging instrument that has traditionally been used for assessing the severity of dementia. We used it for screening dementia in a population study of 75-,80-, and 85-year-old people. The modified CDR scale was easy to establish and it proved to be useful in screening dementia. A more thorough examination is needed in the second phase to identify the false positives. The sensitivity of the CDR scale was 95% and the specificity 94%.

The goal of this research was to examine the relationship of family social support and social conflict to stressors and depression. Fifty-seven caregiving women were interviewed regarding caregiving stressors, social support, and social conflict. Three dimensions of social support and social conflict were assessed: instrumental, informational, and affective. The findings supported the importance of distinguishing between social support and social conflict, and among the three dimensions of support and conflict. Respondents reported higher levels of support than of conflict, but consistent with earlier research, social support was not related as strongly to outcomes as social conflict was. Although instrumental support was related significantly to depression, informational and emotional support was not. Social conflict, however, was significantly related to depression. Both emotional conflict and informational conflict were significant predictors of depression. Implications for future research and interventions are discussed.

Observed cognitive decline in the elderly has been widely reported in the literature. The relation of experimental cognitive ability measures to real-world cognitive competence has been questioned. This research examines the validity of English-language versions of two measures of everyday competency: the Memory in Reality test involving object placement recall and the Coin Test, a money-sorting task. The measures were developed as part of a Swedish epidemiologic study. Validity was evaluated by comparison of these tasks with standard cognitive tests and with a measure of metamemory. It was expected that the ecological measures would have a stronger association with metamemory than the standard tests. Subjects were 93 community-dwelling women, aged 75 and older. The ecological tasks correlated positively with the standard tests, but there were inconsistent relations of both standard and ecological measures with metamemory. The results partly support use of these measures for evaluating everyday functioning.

Although one would expect a relationship on the basis of anecdotal evidence, there is little objective evidence for a hypothesized relationship between the social environment provided in institutional settings and the psychological well-being of the residents. In an attempt to operationalize this hypothesis, the present study examined the effect of nursing staff turnover, frequency of visitors, and the presence or absence of close friends on depressive symptoms among nursing home residents. Once physical dependency and past history of depression were taken into account, there was no demonstrable relationship between staff turnover and depressive symptoms among the residents of this sample of nursing homes. There was, however, a significant relationship between absence of close friends among other residents and depressive symptoms, although only 13% of the total variance was explained.

Age of onset of depressive episodes may serve as a useful marker of pathogenetic heterogeneity in late-life depression. Medical illness may play an important role in the pathogenesis of depression in the elderly, but its relationship to age of onset has not been carefully examined. We prospectively studied 110 older inpatients with DSM-III-R major depression. Using multiple regression techniques, we found that medical illness was not independently associated with age of onset. Independent predictors of older age of onset were age, male sex, absence of substance abuse history, and absence of melancholia. Our discussion reconsiders the usefulness of age of onset as a primary research variable for elucidating heterogeneity of late-life depression.

Fourteen patients suffering from dementia of the Alzheimer type were treated with tacrine (tetrahydrominoacridine, THA) for 1 year in an open trial. Clinical results were evaluated every third month with neuropsychological tests and rating scales. During the dose-finding, two patients were temporarily withdrawn from medication and one patient was excluded because of elevated levels of liver enzymes. With individualized doses the treatment caused few side effects. Plasma levels of THA varied substantially among patients and correlated with elevation of liver enzymes but not with clinical response. Two patients showed a gradual increase in plasma levels of THA despite unchanged doses. Although results of the neuropsychological tests and clinical ratings were mostly negative, the study indicates that THA can be administered safely for prolonged periods of time. Clinical observations and dose-titration strategy in relation to side effects are discussed.

We set out to investigate the possible beneficial effects on cognitive function of demented patients with cobalamin deficiency after cobalamin replacement. A total of 181 consecutive, demented (DSM-III or DSM-III-R criteria and score below 24 on the Mini-Mental State Examination [MMSE] outpatients (mean age 77.5 years) were prospectively evaluated and had their vitamin B12 level measured by radioimmunoassay. The frequency of vitamin B12 deficiency (less than 200 pg/mL) was 25% (46 patients). Treatment outcome was obtained in 19 patients (19 of 46). Despite cobalamin replacement, 16 of 19 patients persisted in showing progressive decline during follow-up visits (3 to 24 months). The nonresponse to vitamin B12 replacement in most cases seems to reflect the presence of associated irreversible dementia or a follow-up of shorter duration in a few patients. All of the patients who showed some improvement (MMSE returned to normal values) had mild dementia with a history of less than 2 years. Thus, screening for B12 deficiency should be considered in patients with recent onset of mild mental status changes.

Depression in the geriatric population is a frequents, serious, and potentially reversible disorder, yet relatively few blinded, controlled, antidepressant trial have been reported. A number of age-related issues complicate safe and effective pharmacotherapy. In a 6-week, double-blind trial in moderately to severely depressed (nonpsychotic) outpatients over age 60, fluoxetine (N = 335) was statistically significantly more efficacious than placebo (N = 336) in overall response (43.9% vs. 31.6%, p = .002) and remission (31.6% vs. 18.6%, p < .001) rates. Analyses of early discontinuations because of an adverse drug event revealed no statistically significantly greater rate with fluoxetine (n = 39; 11.6%) than was seen with placebo (n = 29; 8.6%). These results corroborate that major depression in an older population is responsive to antidepressant pharmacotherapy. Specifically, fluoxetine, at a conventional 20-mg dose, was both safe and effective relative to placebo in this special population.

This study examined some aspects of psychogeriatric care in Münster, Germany. The diagnostic and therapeutic attitudes of 94 general practitioners/internists and neurologists/psychiatrists toward demented patients were investigated by questionnaire. This figure represents a return rate of approximately 55% on the questionnaires. As is typical in Germany, no physicians were specializing in geriatric patients, and fewer general practitioners/internists than neurologists/psychiatrists had undergone supplementary psychogeriatric training. A higher percentage of the latter group estimated more than 10% of their elderly patients were demented. Both estimated Alzheimer's disease as less frequent than multi-infarct dementia. Physicians with training in psychogeriatrics claimed to treat more elderly patients than physicians with out it. With regard to therapeutic procedure, physicians with psychogeriatric training prescribed nootropics more guardedly. The data from this pilot study suggest that there are no eminent discrepancies between the different medical groups with regard to psychogeriatric care, but there is a great need for supplementary training.

To assess the economic burden of Alzheimer's disease (AD), we carried out a cross-sectional prevalence cost-of-illness study in France. Fifty-one probable AD patients (NINCDS-ADRDA) actually treated in ambulatory care were recruited in two university outpatient centers. Demographic, clinical (including actual Mini-Mental State Examination scores), and economic data were collected by clinical investigators and trained interviewers. Total costs included actual expenditures such as direct medical costs and direct nonmedical costs, as well as indirect costs (loss of earnings due to loss of productivity). Cost valuation was based on the societal perspective using an opportunity costing approach. We found that indirect costs represented a significant portion of total costs (36%-40%). In terms of expenditures, patients and caregivers were found to bear the major part of AD total costs. We found a positive and significant correlation between disease severity and costs. Our findings support the hypothesis of a relationship between disease evolution and healthcare costs.

Sixteen patients with dementia were studied 4 years after admission to group-living (GL) units, an intermediate level of dementia care. Of eight patients who were still alive, four lived in the GL units and four had been institutionalized. The eight patients who had died had spent 89% of their survival time in GL. Aggression was the most frequent cause of institutionalization.