This issue on the diagnosis of Alzheimer's disease (AD) is the product of a special meeting of the International Psychogeriatric Association with the cosponsorship of Alzheimer's Disease International, the European Federation of Neurological Societies, the World Health Organization, and the World Psychiatric Association. The meeting was held in Geneva, Switzerland, from November 10 to 12, 1996. Participants included many of the leading experts on the various aspects of AD diagnosis as well as clinical experts, general experts in the field of AD, organizational representatives, and outstanding clinician-scientists who served as facilitators and in other capacities.

Given the recent change in leadership at International Psychogeriatrics (IP), the editorial staff felt it was a good time to review where the journal has been in the last few years and how it is regarded both by International Psychogeriatric Association members and by the wider geriatrics community. The following special article was completed as part of an overall review of IP in 1997. Specifically, the article quantifies how the journal compares to others in the geriatrics field.

The term “Psychogeriatrics” is a misnomer. It also happens to be the name of this journal. How do we deal with this? As expected, with difficulty, because we're dealing with title recognition, which is marketing issue.

Our journal has been a quarterly for nearly 4 years. Prior to that, it came out twice a year. Now, a quarterly can come out by season or by named month. Season proved not to work for us because of objections from colleagues in the southern hemisphere. Specifying months has been better except that the journal has been coming out late. This has annoyed our readers. Why has this been happening?

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.

Few pieces of American legislation evoke as many raised eyebrows and quizzical looks in non-Americans as does the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). Incorporated into this legislation is the Nursing Home Reform Act, which contains guidelines for establishing a better environment and better care for nursing home residents. Certainly, some of the provisions focusing on nutrition, improved staff education, and the collection and evaluation of data have resulted in improved care, but the provision that regulates the prescription of psychotropic medications has received mixed reviews.

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.

In 1996, new editorial management took over International Psychogeriatrics (IP), only a year after the frequency of its publication increased from semiannual to quarterly. At the request of the editorial board, an assessment of the journal was conducted by comparing it to other journals in the field of geriatrics and, specifically, geriatric psychiatry. The evaluation included both a modified citation analysis and a review of journal content. The study was undertaken in order to identify the position the journal has within its discipline. Further, it was to identify the journal's strengths and weaknesses with the overall goal of recommending changes to IP's current content and format. IP ranked seventh of 15 journals in terms of impact factor. It is primarily oriented towards the publication of original research, and features fewer longer articles than others in the field. Adding a wider variety of content may increase the overall interest in the journal. However, these changes must be weighed against the goals of the journal and its reputation as a source of original research in the field of geriatrics.

Finding genetic linkage and identifying the genes responsible for disease can revolutionize our understanding of disorders with obscure or complex etiology and pathogenesis (Weatherall, 1991). When relevant genes have been cloned, the identification of specific mutations that cause disease (Goate et al., 1991) enables molecular pathogenesis of the condition to be addressed.

Visual hallucinations (VH) are a core feature of dementia with Lewy bodies (DLB), but little is known about their phenomenology. A total of 73 dementia patients (42 DLB, 30 Alzheimer's disease [AD], 1 undiagnosed) in contact with clinical services were assessed with a detailed standardized inventory. DLB was diagnosed according to the criteria of McKeith and colleagues, AD was diagnosed using the NINCDS-ADRDA criteria. Autopsy confirmation has been obtained when possible. VH were defined using the definition of Burns and colleagues. Detailed descriptions of hallucinatory experiences were recorded. Annual follow-up interviews were undertaken. The clinical diagnosis has been confirmed in 18 of the 19 cases that have come to autopsy. A total of 93% of DLB patients and 27% of AD patients experienced VH. DLB patients were significantly more likely to experience multiple VH that persisted over follow-up. They were significantly more likely to hear their VH speak but there were no significant differences in the other phenomenological characteristics including whether the hallucinations moved, the time of day that they were experienced, their size, the degree of insight, and whether they were complete. VH may be more likely to be multiple, to speak, and to be persistent in DLB patients. These characteristics could potentially aid accurate diagnosis.

The St. George Hospital Memory Disorders Clinic Occupational Therapy Assessment Scale (OTAS) is a performance-based assessment of activities of daily living (ADL) administered in the home environment to monitor function among patients with early cognitive decline. Of the 30 items investigated, 19 items that measured “higher” functional domains were found to be useful in discriminating between subjects. Psychometrically, these 19 items had high internal consistency (coefficientalpha = .89) and high interrater reliability (kappa coefficient range: 71–1.0), and correlated well with other measures of higher function (Lawton's instrumental activities of daily living scale: r = .75; Nottingham extended ADL scale: r = .67). However, unlike these latter measures, the OTAS also correlated well with the Mini-Mental State Examination (r = .73), indicating that OTAS is a valid instrument that should be sensitive to functional problems among patients in the early stages of cognitive impairment.

With reconsideration of the role of vascular risk factors for Alzheimer's disease (AD; Gorelick et al., 1996), and with a recent Consortium to Establish a Registry for Alzheimer's Disease (CERAD) report that pure vascular dementia may be more difficult to find than has been widely assumed (Hulette et al., 1997), it is appropriate to reevaluate our understanding of so-called mixed dementia, or the dementia syndrome that arises from the combination of AD and ischemic vascular injuries. Such a reevaluation leads to potentially important lessons, an outline of which is presented here.

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).

Current knowledge with respect to the diagnosis of Alzheimer's disease (AD) is reviewed. There is agreement that AD is a characteristic clinicopathologic entity that is amenable to diagnosis. The diagnosis of AD should no longer be considered one of exclusion. Rather, the diagnostic process is one of recognition of the characteristic features of AD and of conditions that can have an impact on presentation or mimic aspects of the clinicopathologic picture. The present availability of improved prognosis, management, and treatment strategies makes the proper, and state-of-the-art, diagnosis of AD a clinical imperative in all medical settings. Concurrently, information regarding the relevance and applicability of current diagnostic procedures in diverse cultural settings must continue to accrue.

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.

It is a great honor and a privilege for me to introduce the fifth biennial IPA Research Awards in Psychogeriatrics sponsored by Bayer AG. As noted, these awards are sponsored and supported by Bayer AG, and on behalf of the IPA and the psychogeriatric community, I'd like to thank Bayer for their very generous support.

Recent studies indicate that neuroimaging techniques such as magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography can accurately differentiate patients with Alzheimer's disease (AD) from elderly controls. This report reviews the results of neuroimaging studies of two at-risk populations: subjects with the ε4 allele of the apolipoprotein E and those with mild cognitive impairment. The results of the work published to date indicate that the presence of the ε4 allele is a risk factor for AD and that its predictive validity can be enhanced by neuropsychological and/or neuroimaging evaluation. The results also show that patients with mild cognitive impairment display a number of structural and functional imaging abnormalities that are more pronounced in the temporal and parietal lobes. We suggest that the use of neuroimaging techniques can improve the detection of subjects early in the course of AD, although the sensitivity and the specificity of this approach still await a more detailed prospective evaluation.

Psychometric characteristics of the Alzheimer's Disease Assessment Scale (ADAS) were examined on the basis of data from 440 patients with dementia of the Alzheimer type that were collected before treatment in a multicenter clinical drug trial. Coefficients of internal consistency of above .80 for the cognitive (ADAS-Cog) and the noncognitive section (ADAS-Noncog) indicated a high degree of homogeneity of item contents within the two assessment domains. Test-retest reliability was estimated to be .93, .98, and .96 for ADAS-Cog, ADAS-Noncog, and the total score (ADAS-Total), respectively. Reliably detectable individual changes, which were derived from the reliability estimates, were 7,3, and 8 points for ADAS-Cog, ADAS-Noncog, and ADAS-Total, in that order. Factor analysis and correlations with MMSE, SKT, and NOSGER scores support the validity of the ADAS-Cog and ADAS-Noncog scores with regard to the cognitive and the noncognitive assessment domains. The ADAS summary scores, almost all of the cognitive items, and some of the noncognitive items discriminated significantly between stages of severity of dementia, as classified independently by MMSE and SKT scores.

Alzheimer's disease (AD) is an example of cortical dementia, where most of the pathological changes lie in cortical association areas and the predominant clinical features are symptomatic of cortical dysfunction. The differential diagnosis of AD is complex and is usually made in two stages: diagnosis of the dementia syndrome and diagnosis of the underlying etiology. Each of these stages is complicated by the existence of conditions that mimic dementia in presentation and by the risk of inappropriately diagnosing AD where other conditions are responsible for the dementia state. Despite the fact that the concept of dementia, in terms of a decline in cognitive function and behavioral change, has existed for many years, there is still a general lack of agreement about the components of the syndrome. This article reviews the issues surrounding the differential diagnosis of the dementia syndrome and explores the points of differentiation between AD and some similar etiologies encountered when making a differential diagnosis.