A clinician should not rely entirely upon a caregiver's report regarding behavioral pathology when planning a treatment strategy. Direct observational evaluation instruments as well as caregiver-based assessments are necessary. A new scale for the empirical (observational) evaluation of behavioral symptoms in Alzheimer's disease (AD) and related dementias, the Empirical Behavioral Pathology in Alzheimer's Disease Rating Scale (E-BEHAVEAD) was developed. Interrater reliability of this new assessment instrument was examined. Additionally, the relationship between the observed occurrence of behavioral symptomatology on this new rating instrument was compared with the occurrence using a similarly designed, caregiver-based instrument. The interrater reliability study consisted of two raters who simultaneously evaluated 20 dementia patients. The comparative study employed a cross-sectional design (N = 49). Individuals were evaluated in an outpatient clinic setting. The study population consisted of cognitively normal individuals and dementia patients. Evaluations included the new, observationally based behavioral assessment (the E-BEHAVE-AD), a caregiver-based behavioral assessment (the Behavioral Pathology in Alzheimer's Disease Rating Scale; BEHAVE-AD), a clinical global measure (the Global Deterioration Scale), and a mental status assessment (the Mini-Mental State Examination). The interrater reliability study revealed an intraclass correlation coefficient of .97 (p < .01) for total scores on the new E-BEHAVE-AD rating scale. The correlation coefficient for the amount of agreement on the presence of symptoms in six symptomatic categories between caregiver-based information about the patient's behavioral pathology assessed on the BEHAVE-AD and the clinician's observations assessed with the new E-BEHAVE-AD rating instrument was .51 (p < .01). The New E-BEHAVE-AD rating instrument showed excellent interrater reliability. Furthermore, there was a statistically significant relationship between clinician observation of the occurrence of behavioral pathology assessed using the E-BEHAVE-AD and caregive-reported pathology assessed with the BEHAVE-AD. However the magnitude of the correlation between these measures indicated that the majority of variance was independent and nonoverlapping. Consequently, these data support theoretical models suggesting that the assessment of behavioral pathology in dementia might ideally encompass both direct observational and caregiver-report approaches, using measures such as the E-BEHAVE-AD as well as measures such as the BEHAVE-AD.

The predictive value of social and psychosocial factors for the occurrence of depression in elderly Finns is described using a longitudinal design. A population determined as not being depressed in an epidemiological study in 1984–1985 was clinically interviewed and examined in a follow-up study in 1989–1990 (N = 679). The potential predictive factors for depression were analyzed by contrasting the persons depressed in 1989–1990 with the ones not depressed. In men, depression was predicted by a poor relationship with one's wife and feelings about low appreciation of old persons or of the participant himself during the initial study and the loss of a mother while under 20 years of age. Certain changes and life events during the follow-up were related to the occurrence of depression in men, such as a change in the relationship with one's wife into a poorer direction, a decrease in the amount of hobbies, getting married, a grandchild's divorce, separation from someone important, moving into long-term institutional care, giving up hobbies or a position in a voluntary organization, and alcohol problems of a close person. In women, depression was predicted by living together with one's husband, living with other people, and a low activity in participating in religious events during the initial study and a loss of father while under 20 years of age. The risk of women living alone was lower compared to women not living alone. Also, certain changes and life events during the follow-up were associated with a high risk of depression in women, including a change in the relationship with one's neighbors into a poorer direction, an increase in the amount of time spent alone, a decline of the social activity level, getting married, occurrence of serious marital problems, separation from someone important, giving up hobbies or a position in a voluntary organization, alcohol problems of a close person, and a small number of social growth events. The results support the hypothesis about psychosocial factors playing a role in the etiology of depression in old age.

Three issues concerning behavioral problems of dementia emerge from research on family caregivers. The first issue concerns the reliability of caregivers' reports of behavioral disturbances. The second issue is the realization that caregivers can provide valuable information not available from other sources. The final issue concerns how caregivers' reports can clarify the determinants behavioral problems.

To understand the quality of life of persons with Alzheimer's disease (AD), it is necessary for investigators to examine the perspective of the victim of the disease. This requires more than assessment of memory and function; qualitative changes in quality of life as expressed by sucessful, adaptive, and problem behaviors need to be measured. The latter are often expressions of emotional distress that, if properly understood, may allow observers to appreciate the experience of AD from the patient's perspective. Such an approach provides a greater likelihood of preserving “the self” of the patient during intervention.

Disruptive behaviors have been reported in at least 50% of patients with Alzheimer's disease (AD) at some point during the course of their illness (Cummings et al., 1987). If patients with AD were carefully followed from the onset of illness through its terminal stages, the cumulative incidence of clinically significant disruptive behaviors would be even higher. Despite the paucity of data from well-designed studies evaluating the efficacy of management approaches to these disruptive behaviors, the prescription of antipsychotic medications (such as thioridazine and haloperidol) or antianxiety medications (such as benzodiazepines) to AD patients with disruptive behaviors is wide-spread, particularly in the long-term care setting (Harrington et al., 1992). The few interpretable placebo-controlled studies evaluating pharmacologic approaches to the management of disruptive behaviors have focused on anti-psychotic medications. Although these medications appear somewhat effective (approximately 20% greater than placebo response) (Barnes et al., 1982; Petrie et al., 1982; Schneider et al., 1990), their efficacy is much less than that observed in younger, nondemented patients with such major psychiatric diseases as schizophrenia. In addition, these medications often produce substantial motor and cognitive adverse effects that further minimize the variable and modest benefits of pharmacotherapy.

In a cross-sectional epidemiological study in Lieto, Finland, 61 men and 21 women with chronic obstructive pulmonary disease (COPD) were compared with age- and sex-matched controls from the same community to analyze the associations between COPD, cognitive performance, and occurrence of dementia. The cognitive assessment was based on the Mini-Mental State Examination (MMSE), previous clinical documents, and the assessment made by the research nurse after she had interviewed and tested each subject. These three measures revealed no differences between the COPD paients and the age-matched controls, and MMSE subtest scores did not differ significantly between the patients and controls. The findings suggest that the relative contribution of COPD to the occurrence of cognitive impairment and dementia in the elderly may be none or minimal at the community level.

Depression is the most prevalent mental health problem among the elderly, including Chinese-American elderly. A Chinese-language version of the popular Geriatric Depression Scale Long Form (GDS-LF) and Short Form (GDS-SF) was developed. Based on the responses of 50 elderly Chinese immigrants to the U.S. (25 women and 25 men), the GDS-LF evidenced high internal consistency but the GDS-SF did not. Factor analysis was then used to develop a new version of the GDS-SF, which was internally consistent. The revised GDS-SF is an important and easy-to-administer tool for community screening of depression among elderly Chinese immigrants.

The episodic and nonuniversal nature of behavioral disturbances of dementia challenges the notion that these symptoms result only from permanent changes in the brain. Few longitudinal data are available to correlate the occurrence of behavioral symptoms with the neurobiologic model of dementia, and most of these data are from clinical trials of institutionalized patients. Nevertheless, Dr. Cummings noted that even though behavioral symptoms are highly episodic, they tend to recur in the same subgroups of patients. The neurobiologic model, therefore, may help determine the vulnerability of a patient to behavioral disturbances but not the consistent expression of the behavioral symptom complex.

The aim of this study was to compare the performances on each item of the Mini-Mental State Examination (MMSE) of patients with Alzheimer's disease (AD) and multi-infarct dementia (MID). In order to identify the items that could better distinguish the two groups of patients, 70 AD and 31 MID patients matched for disease severity, age, and education were evaluated. The scores of the 101 patients on each of the MMSE items were entered into a principal component factor analysis using varimax rotation, and two main components were derived. Component 1 was probably representative of recently acquired information, whereas component 2 represented educational level. A score summing the items that loaded on component 1 and the recall item was calculated to generate a measure of episodic memory. Performing analysis of variance and covarying for age and education revealed that this score was statistically different in the two groups, with AD patients having lower values. The data suggest that the MMSE may demonstrate a pattern of impairment of memory that differs between AD and MID. Possible explanations of this finding should take into account the different neuroanatomical impairments and the different degrees of motivation, due to depression or attentional deficits, toward external stimuli.

A screening instrument based on the DSM-III-R was developed in order to differentiate aged persons with or without a DSM-III-R mental disorder. The usefulness of this instrument was investigated in six geriatric institutions with 171 residents aged 65 to 93 years in Finland. The nursing staff independently rated the mental status of residents; researchers (a psychiatrist and general practitioner) made a diagnosis based on DSM-III-R criteria. The majority of the residents (mean 69%, varying from 33% to 84% in different institutions) had a DSM-III-R mental disorder. This screening instrument functioned well in differentiating residents without a mental disorder from those with DSM-III-R mental disorder: The nursing staff's agreement was 90%, kappa .71, sensitivity .90, and specificity .88. However, only half the cases of depression were diagnosed correctly: Sensitivity was .50 and specificity .95. With a more specific 9-class diagnostic instrument based mainly on DSM-III-R categories, agreement was only moderate (68%) and kappa .59. The instrument developed in this study seemed to be a useful screening method when applied by the staff, but accurate diagnostics require psychiatric knowledge, especially of depression.

This article reviews the history of Clinical Global Impressions of Change (CGIC) instruments, their use and limitations in clinical trials of Alzheimer's disease, and the development of the National Institute on Aging's Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change Scale (ADCS-CGIC). Originally, CGICs were simple and unstructured instruments that asked a clinician to rate change over the duration of a clinical trial. The method, however, failed to consistently detect treatment effects, leading to the development of more structured and subsequently validated approaches, such as the Clinician Interview-Based Impression Scale (CIBI) and the ADCS-CGIC. Both are currently used in clinical trials. The implications and importance of choosing an appropriate global rating are discussed.

Behavioral disturbances are a frequent feature of Alzheimer's disease (AD) and other dementing disorders. Although this observation has been noted since the beginning of this century, subsequent investigations into dementia have focused primarily on memory and cognitive impairments, with little attention to disturbances in behavior.

Sixty-five consecutive patients with dementia, treated at a psychogeriatric day hospital, were studied regarding prevalence of psychiatric symptoms. The clinical diagnoses were dementia of the Alzheimer type (n = 19), vascular dementia (n = 27), mixed Alzheimer's disease and vascular dementia (n = 13), vascular dementia of frontal type (n = 2), and other diseases (n = 4). Mean age at referral was 75.6 ± 6.6 years and the average treatment time was 21 ± 14 months. About 90% of the patients showed one or several significant psychiatric symptoms during the course of dementia. Most common were delirious episodes, anxiety, sleep distrubances, and depressed mood. The relationship between clinical features and the type and duration of dementia was analyzed. Sleep disturbances and depressed mood often appeared early, whereas misidentification and delusions became more prevalent later in the course of dementia. The results indicate that the psychogeriatric day hospital may offer effective and flexible care and support to demented persons living at home.

In the present open study, the long-term safety, tolerability, and efficacy of citalopram in the treatment of elderly people with emotional disturbances were studied. One hundred twenty-three elderly patients with symptoms of depression-anxiety were included. Most of the patients (76%) were demented. Fifty-two patients completed a 12-month treatment. Irritability, depressed mood, anxiety, restlessness, and fear-panic were significantly reduced. The severity of illness from baseline to Month 9 was rated as significantly improved. The side effects were infrequent and mostly mild.

The purpose of this study was to examine the utility of the clock drawing task (CDT) in differentiating between patients with mild and very mild Alzheimer's disease (AD) and normal controls. Thirty normal elderly individuals and 30 patients with probable AD were entered into the study and asked, in a standard fashion, to draw a clock from memory. All the clocks were scored according to two previously described standardized scoring systems, and the accuracy of classification into normal or AD groups was determined. Both CDT scales could discriminate between moderate AD and normal aging but lacked sensitivity in the very mild AD cases; mild cases showed intermediate sensitivity. In conclusion, the CDT as a test for AD is insensitive in the early-stage cases, but sensitivity improves with increasing severity of dementia. The CDT is unlikely to be useful in distinguishing between AD in its early stages and normal aging.

This article addresses three areas of consideration in designing behavioral studies that will assist in slowing the progression of the symptoms of Alzheimer's disease (AD). The areas are (a) the type and design of intervention studies needed, (b) the development and use of outcome measures, and (c) the issue of efficacy versus effectiveness.

Establishing a medical diagnosis serves two utilitarian purposes: providing information necessary to initiate treatment and communicating information regarding prognosis. A nosology or diagnostic nomenclature (i.e., a classification of diagnoses) provides further utility by establishing a foundation for clinical research. In his book, Wulff outlined four types of diagnoses: (1) symptomatic or pseudoanatomic diagnoses (e.g., chronic headache, persistent diarrhea, or irritable bowel); (2) syndromes; (3) anatomic diagnoses; and (4) causal diagnoses. By definition, syndromes have no means of being validated by measures external to the constructs themselves. Often, specific syndromes reflect diverse origins, and conversely, specific etiologies may cause multiple syndromes (e.g., syphilis, human immunodeficiency virus, and diabetes).

Alzheimer's disease (AD) is asociated with an increased mortality in comparison with aged control populations. The relationship between the clinical and the temporal course of AD has not been well studied over significant intervals. Community residing patients with probable AD (N = 103, 42 men, mean age = 70.2 ± 8.0 years) were studied at baseline on demographic and clinical variables, including measures of global deterioration (Global Deterioration Scale; GDS), mental status and cognition (e.g., Mini-Mental State Examination; MMSE), and functional impairment (Functional Assessment Staging; FAST). Baseline characteristics included a GDS range of Stage 4, 5, or 6 (38.8%, 39.8%, and 21.4% respectively) and a mean MMSE score of 15.4 ± 5.6. The mean follow-up interval was 4.6 ± 1.4 year. Follow-ups were done blind to baseline measures and when necessary were conducted in residential and nursing home settings. Of locatable subjects (n = 95, 92%), 30 (31.6%) were deceased. Survivors (n = 65) had a mean GDS stage of 6.2 ± 0.9 and a mean MMSE score of 5.1 ± 6.9; 51% had MMSE scores of 0. Increased age and male gender, but not baseline clinical dementia variables, increased the risk of death (ps < .01). Change in clinical variables correlated significantly with time elapsed (r = .32, p < .05, for MMSE change, to r = .48, p < .001, for GDS change). Significant variance in temporal change (i.e., time elapsed) was accounted for by change in two of the five clinical measures studied (i.e., GDS and FAST; multiple r = .53). The results support previous estimates of mean duration of the GDS and FAST stages. For subjects with probable AD followed over approximately 5 years, clinical variables changed significantly over time in survivors. However, the majority of temporal variance in the course of AD remains unexplained.

Mental status changes were assessed and compared in 172 general surgical and orthopedic patients and 190 nonsurgical patients, all aged 55 and over, during a 10-month period. Assessments included a structured psychosocial questionnaire and standardized tests of cognition, affect, and function. The relationship of surgery, type of surgery, age, gender, and postoperative delirium to long-term postoperative decline was evaluated. Analyses of variance directly tested main effects pertaining to each of the five hypotheses and interactions of surgery with background variables. Hierarchical multiple regression analyses assessed the unique contributions of demographic and surgical variables to cognitive, affective, and functional change. None of the independent variables tested made a significant contribution to changes from baseline to long-term follow-up. The findings may be due to the physical and psychological health of this sample, and replication of this work in more impaired populations may be productive.

Rachel Billington: My assignment here is to give the caregiver's view, and I feel that's an awesome responsibility. Because I'm with Alzheimer's Disease International (ADI), I must take a global view of this disease. We recently surveyed our members—all national Alzheimer's societies-and according to 21 early respondents, they have an estimated 15 million people with Alzheimer's disease (AD) in their countries. Total population in those countries is 1.7 billion, and the total world population is 5.7 billion.