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.

In psychogeriatrics, clinicians are often confronted with the problem of whether a patient's clinical disorder is associated with an organic brain syndrome. Such pathological cerebral changes and the associated impairments are often very difficult to distinguish from “normal,” nonpathological changes. Everyone has to cope with some limitations in old age. Having to cope with changes in social position and social environment and with the loss of certain abilities is part of the aging process, but in psychogeriatrics, attention must go beyond the assessment of how a person deals with loss. A so-called normal aging person can overcome such losses, compensating for deficits in a particular area by drawing on skills acquired through a lifetime of experience.

During an epidemiological survey conducted in Tokyo in 1988 by the Department of Psychiatry, Tokyo Metropolitan Institute of Gerontology, I met two demented elderly women in the course of interviewing city residents.

A generation ago, geriatric depression was regarded as either a natural reaction to the privations and multiple losses that accompany old age, or an irreversible consequence of cerebral degeneration heralding a dementia. Even if physicians overcame their expectation of the inevitability of depression in old age, an unhealthy nihilism concerning the effects of antidepressant treatment in this group held sway (Ford & Sbordone, 1980). Because Freud had taught that patients over the age of 45 years were resistant to change in psychoanalysis, even talking therapies were closed to this group. There is an inescapable irony in that Freud was himself in his 40s when he took this position—now regarded as not only ageist but essentially untrue (Jarvik & Small, 1989).

Two of the most commonly cited risk factors for suicide are older age and male gender. Among the industrialized countries that provide statistics on suicide, all report that men commit suicide more frequently than women (see Mościcki, this issue). In a majority of those countries, suicide rates rise progressively with age; in all but one, the highest suicide rates occur for men age 75 and older (Table 1; based on countries reporting statistics to the World Health Organization from 1988 to 1991 [WHO, 1990, 1991]). Despite the dramatic effects of gender and age on suicide risk, relatively little attention has been paid to the risk factors for and clinical profiles of late-life suicide. Given the progressive aging of populations around the industrialized world, and assuming that the relationship between older age and suicide will persist, the absolute number of elderly suicides is likely to increase dramatically in coming decades.

This study examined the relationship between subjective memory complaints and performance on tests of memory by relatives of patients with probable Alzheimer's disease (AD) and by older adults without a family history of dementia. Relatives of AD patients did not differ significantly from controls either in level of complaint or in performance on neuropsychological tests. However, among relatives of patients with early-onset AD, significant correlations were found between performance on memory tests and self-rated changes in everyday memory. These findings raise the possibility that relatives who have entered the age range in which their parents or siblings developed dementia symptoms are monitoring their memory performance more diligently than relatives of patients whose illness began at much later ages or persons who have no close relatives with AD.

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.

A longitudinal study based on consecutive admissions to all residential homes for the elderly was conducted in the industrial city of Mannheim (Germany) and in the London borough of Camden (England). Inclusion criteria were that the elderly persons (65 years old and older) came directly from their own home or, if transferred from a hospital, had been there for less than 3 months. At each site, 60 home residents were interviewed at admission and 3 months and 8 months later. Depression and dementia were assessed with the aid of the Brief Assessment Scale. The prevalence of depression (Mannheim: 34.6%; Camden: 47.9%) was already high at admission and did not change significantly over time. Residents in Camden were more demented and more impaired in their activities of daily living at the time of admission, and the percentage of those who died or were transferred to a hospital or nursing home within 8 months thereafter was higher in Camden (30%) than in Mannheim (5%). Multiple regression analysis revealed that, in both study areas, depression at baseline was the best predictor for depression 3 months and 8 months later. This relationship was particularly strong in Camden, where a high percentage of the depressed at admission showed a chronic course of illness. Sex, age, home visits, social isolation, activities of daily living, cognitive impairment, and somatic symptoms at the time of admission were not significantly associated with depression 3 months later. Eight months after admission, a similar pattern was found in Mannheim. In Camden, however, in addition to depression, a lack of home visits by relatives and friends, and somatic symptoms at baseline, were significant predictors of depression 8 months after admission.

The antidepressant literature for depression in late life tends to be interpreted as saying that certain antidepressant medications—e.g., nortriptyline, doxepin, fluoxetine—have fewer and milder side effects than others, whereas overall efficacy is equivalent (Plotkin et al., 1987; Rush, 1993; Salzman et al., 1995; Schneider, 1994). Further examination of this literature, however, suggests that both efficacy and side effect rates for any particular medication vary among trials, and often depend on the medications being compared, the use of placebe, the dose, and the design of the trial.

In this report we review selected clinical trials, and summarize and discuss a previously published meta-analysis. Treatment recommendations from the 1991 NIH Consensus Development Conference on the Diagnosis and Treatment of Depression in Late Life and from the Agency for Health Care Policy Research are discussed. Directions for fume research are suggested.

Both antidepressant medications and brief structured psychotherapies have efficacy in the acute treatment of elderly depressed outpatients with major unipolar, nondelusional depression. Effective treatment for depression involves consideration of the type and severity of illness, adequate prescribing, patient education, and regular patient monitoring for compliance, symptom change, side effects, and intercurrent medical disorders, which may complicate antidepressant therapy.

This article presents the epidemiology of suicide with a special focus on suicides among the elderly, and discusses the known risk factors for suicide within a framework designed to encourage a systematic approach to theory testing and prevention. Throughout the world, suicide rates are highest among the elderly. The risk factors for suicide can be classified as distal or proximal, and, within these broad categories, as sociodemographic, psychiatric, biological, familial, and situational. Mental and addictive disorders are the major risk factors for suicide in all age groups. Other risk factors include male gender, disrupted marital status, prior suicide attempt, reduced brain stem serotonergic activity, family history of psychiatric disorder or suicide, a firearm in the home, and a recent, severely stressful life event. Since risk factors for suicide rarely occur in isolation, prevention efforts are more likely to succeed if multiple risk factors are targeted.

The effects of training on two memory and two attention tasks were investigated in 24 healthy elderly and 23 young subjects. Two training periods, each consisting of four sessions, were performed, and the effects of training were assessed during two test sessions 1 week thereafter. Significant age-related effects at the pretraining test session were found for reaction times to a simple visual stimulus, retrieval time of information from long-term storage, and the speed of focusing attention. In both age groups, performance of the first two tasks was significantly improved by training; however, the age-related effect remained significant after training. In the focused attention task, the age difference at baseline disappeared after training due to an opposite learning trend in young and elderly subjects. Thus, the cognitive performance of elderly subjects could be trained to a large extent. Significant age differences, however, could be decreased only if the test performance of young subjects did not improve.

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%.

There is a paucity of data regarding Alzheimer's disease (AD) patients' longitudinal deterioration in the ability to conduct numerous activities required for daily living. In this study, 52 patients with AD were assessed at baseline and at a 1-year follow-up using the Direct Assessment of Functional Status (DAFS) scale, an objective, well-validated measure of a broad spectrum of functional capacities that is administered within the clinical setting. An important finding was that the level of initial performance on each of the 11 functional tasks measured did not related to the degree of functional decline in that particular area. Communication skills, such as using the telephone (deterioration among 35.4% of the patients) and preparing a letter for mailing (deterioration among 32.7%), showed the most frequent deterioration among patients upon follow-up. More than half of the AD patients studied demonstrated impairment on one or both of these measures. The pattern of findings indicates that many subtests of the DAFS were sensitive to functional decline after a 1-year period and that the scale has utility in objectively establishing longitudinal patterns of deterioration.

Major depression in the elderly is often a relapsing, chronic illness with high risk for chronic invalidism, poor treatment compliance, and suicide. In most cases, maintenance treatment to prevent recurrence and to enhance the quality of life is thought to be indicated. We review recent data from our onging studies that support both the efficacy and the safety of pharmacotherapeutic and psychotherapeutic maintenance treatments. However, the challenges of conducting maintenance therapy research (particularly with a placebo control) with the elderly are many, involving such areas as recruitment, retention, compliance, choice of outcome measures, and informed consent. We discuss each of these challenges and our responses to them. Finally, we suggest that maintenance therapy trials should be extended in several directions: (a) long-term treatment of bipolar and delusional subtypes in the elderly, as well as depression associated with progressive neurodegenerative disorders such as Alzheimer's dementia; (b) assessment of the benefits and risks of long-term therapy with other than tricyclic and monoamine oxidase inhibitor antidepressant agents, such as selective serotonin reuptake inhibitors; and (c) development of models of long-term course, including the interaction of treatments with medical and psychosocial variables that can have a profound impact on illness onset and offset. These issues are illustrated with a discussion of a new protocol designed to test the acute and maintenance efficacy of antidepressant therapy for depressed patients with Alzheimer's disease.

Rates of suicide differ markedly as a function of age and gender. In a great majority of countries that report suicide statistics, rates are higher in the elderly than in younger age groups. Few data are available to determine whether this age-related pattern of rates is reflected in a differential prevalence of other factors known to be associated with increased suicide risk. Using the psychological autopsy method, researchers have established the distribution of psychiatric diagnoses in samples of adolescents, young adults, and elders who have committed suicide, and in victims across the life course in community-based populations. Review of those studies reveals that affective disorders, substance use disorders, and their comorbidity are common in completed suicides of all ages. Although methodologic issues and cohort and period effects limit the conclusions that can be drawn, comparison by age within and between studies further suggests that depressive illness is more common and substance abuse less prevalent in later-life victims. That the aging process itself (biological, psychological, and social) may account for the observed pattern has important implications for further research and the design of intervention strategies. There is a need for more coordinated and comprehensive study of psychopathological correlates of suicide across the life course in a broad range of cultures.

The purpose of the literature review discussed in this article was to determine the effect of formal respite care on patients with dementia and their caregivers. Three computerized databases were searched for relevant English-language articles published from 1975 to 1994, and the bibliographies of retrieved articles were systematically reviewed for additional references. Five studies met the following inclusion criteria: original research; controlled trial of a defined respite intervention; sample including a dementia population; and at least one outcome measure relating to at least one of eight specified caregiver and patient variables. Four studies met validity criteria and were included for the review. There was little evidence that formal respite care has a significant effect on caregivers' burden, psychiatric status, or physical health; or on patients' cognition, function, physical health, or rate of institutionalization. However, given the small number of controlled studies found and their methodological and conceptual limitations, these data should be interpreted with caution.

Background: We attempted to determine baseline characteristics predicting response in a 6-week, double-blind, geriatric depression trial, which showed a significantly higher remission rate for fluoxetine (20 mg daily) than for placebo (31.6% vs. 18.6%, p < .001). Methods: Outpatients (N = 671) were 60 years or older (mean ± SD = 67.7 ± 5.7), met Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., American Psychiatric Association, 1987) criteria for unipolar major depression, had baseline scores on the 17-item Hamilton Depression Rating Scale (HAMD17) of 16 or more, and were randomized after a 1-week placebo lead-in. Potential baseline predictors of percentage change in last-visit-carried-forward HAMD21 total scores were entered into a stepwise regression model. The sample was randomly divided into two groups (development and validation data sets) so that potential predictors could be confirmed in a second analysis. Results: Of the 266 variables considered for their prognostic ability, 13 were found to be significant predictors using the development data set, including (a) presence of somatic complaints, absence of agitation, and presence of previous accidental injury for fluoxetine response: and (b) reported feelings of emptiness, absence of somatic complaints, and absence of early insomnia for placebo response. The second analysis using the validation data set failed to confirm statistical significance of predictors identified in the development data set. Conclusions: Although potentially useful baseline characteristics were initially identified as response predictors, conservative statistical methods failed to confirm any significant predictors of differential responses between fluoxetine and placebo in this double-blind, placebo-controlled trial.

There is an accumulating body of research suggesting that suicidal behavior may be associated with abnormalities of the central serotonin system. Other monoaminergic, peptidergic, and neuroendocrine systems have been implicated as well. A review of studies that examine neurobiological variables in postmortem tissue of suicide victims and controls reveals that investigators in most instances have viewed age as a confound to be controlled rather than considering it as a variable of interest. However, the close associations between aging and increased suicide rates, and the knowledge that the functional integrity of many of these same systems changes with normal and abnormal aging processes, raise the possibility that biological aging contributes to suicide risk, and that the underlying neurobiology of suicide in the elderly differs from that of younger people. The few available studies that did examine the association of age with neurobiological measures indicate directions for future research into the role that aging may play in determining the biological bases of suicide risk.

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.

Memory can be assessed with either explicit or implicit tasks. Implicit memory tasks, in contrast with explicit tasks, do not refer to conscious recollection of a previous learning experience. Implicit memory is revealed by a change in task performance that can be attributed to previous learning. Amnesic patients perform poorly on explicit memory tasks, but exhibit normal performance on implicit tasks. Recently, researchers have studied the implicit memory performance of patients with Alzheimer's disease. This article aims to give an overview of the performance of Alzheimer patients on four tasks of implicit memory. Compared with normal elderly controls, patients with Alzheimer's disease seem to demonstrate impaired performance on conceptual, but not on perceptual, implicit memory tasks. This dissociation could yield important information about the neurologic systems subserving implicit memory processes. Some suggestions for future research into the implicit memory of Alzheimer patients are given.