CLASSIFICATION, CLINICOPATHOLOGICAL CORRELATIONS, AND FUNCTIONAL-ORGANIC OVERLAP In this millennial issue, I shall recall some of the issues in the psychiatry of old age that were current in England half a century ago, based on my experiences at the Maudsley Hospital, Graylingwell, Stockholm, and Newcastle. In 1946, Aubrey Lewis, then Professor of Psychiatry at the Maudsley Hospital, lamented that while the numbers of old people being admitted to mental hospitals had steadily increased, the clinical psychiatry of old age was neglected (Lewis, 1946). Classification was in a state of confusion. Senile and vascular degenerations characterized the aging brain, and though affective and paranoid states occurred, they were widely regarded as depressive and paranoid forms of senile psychosis and not clearly distinguished from purely functional states. In the presence of degenerative changes in the brains of normal old people and the apparent lack of a clear quantitative relationship between clinical severity and neuropathology, the presence or absence of symptoms was determined by the premorbid personality and the ability to resist the effects of the cerebral changes (Rothschild, 1937).

Caregiver support is an important factor in recovery from depression among older patients. We examined whether caregivers' perceptions regarding patients' ability to control depressive symptoms were related to depression recovery. Depression treatment, demographics, number of depressive symptoms, and health were controlled. The sample comprised 51 geriatric psychiatry inpatients who met DSM-IV criteria for major depression and who had a primary caregiver. Depression was assessed at both admission and discharge. Caregivers were asked to indicate whether they believed their patient-relatives could control their depressive symptoms. At discharge, 33 patients (64.7%) were “remitted” and 18 (35.3%) were “nonremitted.” Multivariate analyses indicated that receiving electroconvulsive treatment, having fewer depressive symptoms caregivers perceived to be within patient control, and being female predicted depression remission at discharge. This study highlights the important relationship between family dynamics and course of depression.

Suicide rates for the elderly continue to be the highest for any age group. Although these rates are known to be significant, little study has been given to the ethnic variability associated with this phenomenon. This retrospective study was undertaken to explore this issue and involved a review of the coroner's reports for completed elder suicides (65 years of age or older) for Honolulu County from 1987 through 1992 inclusive. The results showed a mean age of 75 years, with the highest incidence of completion in the 80+ age group. The predominant method of suicide completion in this study group was found to be hanging, followed by jumping, firearms, and poisoning. There were significant gender and ethnic differences in the method of suicide completion. Almost half of the sample saw a healthcare provider within the 6 months before their death. Comparisons with other elder suicide studies are presented.

This study examined the prevalence and nature of personality change in 99 patients with dementia of the Alzheimer type and multi-infarct dementia. Personality was assessed using an informant-rated inventory of the patient's personality before and after the onset of dementia, with the difference equating to a change in personality. Personality characteristics were related to the patients' age and sex, duration of illness, degree of cognitive impairment, the presence of a grasp reflex, and extrapyramidal signs. Personality change was found to be almost universal and negative in nature and was particularly associated with severity of cognitive impairment, longer duration of illness, and neurological signs. The findings reflect those from other studies and emphasize the biological basis of personality changes in dementia.

The reliability and validity of the Subjective Burden Scale (SBS) were investigated in 255 Japanese family caregivers of elderly relatives with dementia. Values of the Cronbach's alpha reliability, split-half reliability (r), and test-retest reliability (r) were .87, .80, and .72, respectively. The SBS score was significantly positively correlated with the degree of mental health, which was assessed with the Japanese version of the 60-item General Health Questionnaire (r = .41). The family caregivers who gave up the caregiving of their relatives showed significantly higher SBS scores than those who did not. The SBS scores for caregivers indicated satisfactory predictive validity both in the degree of their mental health and in the prospects of family caregiving about 6 months later. These findings suggest that the SBS is adequately reliable and valid and can be used to assess the subjective burden of Japanese caregivers.

Older widowers have high rates of completed suicide but have rarely been the subject of systematic inquiry. We investigated the prevalence of depressive symptoms and major depressive episodes (MDEs) in recently widowed older men over the first 13 months after bereavement. We employed a matched-pairs longitudinal design and recruited subjects from a suburban community population. Fifty-seven recently widowed older men were identified from official death records and 57 matched married men were identified from the electoral roll. Subjects were assessed for the presence of current DSM-III-R MDEs using the Composite International Diagnostic Interview (CIDI), a fully structured psychiatric interview. Widowers were assessed at 6 weeks after bereavement (T1) and 13 months after bereavement (T2). Married men were assessed at similar intervals. At T1, seven widowers (12.3%) and no married men were found to have CIDI cases of current MDE. At T2, one widower (1.9%) and no married men were found to have CIDI cases of current MDE. Current MDE was not predicted by a past history of dysphoria. At T1, 14.0% (8/57) of widowers reported specific suicidal thoughts or actions. At T2, 15.4% (8/52) of widowers reported suicidal thoughts or actions. We conclude that health workers should monitor closely the clinical course of MDEs in recently widowed older men. Routine inquiry about suicidal ideation should be an essential component of the clinical assessment of recently widowed older men.

Introduction: The measurement of quality of life is an increasingly important issue, particularly in regard to treatment of severe and chronic diseases. The aim of this pilot study was to assess potentially divergent profiles of quality of life in persons with two different pathologies: moderate dementia and cancer. Method: This pilot study was carried out in the neurology and cancer services of the medical school in Montpellier, France (Hôpital Gui de Chaulliac and CRLC Val d'Aurelle). The cumulative self-reporting test WHOQOL 100 (World Health Organization Quality of Life with 100 questions) was administered in 57 patients with either moderate senile dementia (27 cases with a Mini-Mental State Examination score > 15; mean age of 73) or cancer (30 cases, mainly women with breast cancer; mean age of 53). The stability of responses was tested in a 2-week period. Results: Results of the study showed clear and significant differences between the two groups in the domains of mobility and psychology. Further, eight questions and six facets with a significant difference in responses were found. Responses seemed more stable in the domains of autonomy, social relationship, and religion for the cancer group, and in autonomy and psychology for the dementia group. The age difference may be an important factor in the different quality of life measured but did not significantly influence responses to the test questions. Conclusion: The WHOQOL 100 seems a powerful instrument to assess quality of life in diseases such as cancer and moderate dementia. In this study, interesting differences in responses to the test questions between the two pathologic conditions were identified. Items that were unreliable on retesting are singled out. These results will be applied and reevaluated in the development of future, illness-specific and shorter versions of the WHOQOL 100.

I have chosen the 30 years, 1969–1999, for this article, because this represents my psychiatric career from entry into the training scheme at the Maudsley Hospital to being current head of the old-age group at the Institute of Psychiatry. What becomes apparent, on looking back, is that the developments at this campus, which contains a psychiatric teaching hospital and a postgraduate research institute, reflect those in the UK over that time. In many areas, the lead has come from here. These activities will be reviewed and some challenges for the next decade proposed. The latter will be personal, from a researcher with an epidemiological/public health perspective.

Objectives: To improve performance with mnemonic techniques for remembering words and proper names. Design: For word recall, a 2 × 2 factorial in which type of pretraining and length of training were between-subjects manipulations. For proper name recall, a two-group design in which type of pretraining was manipulated between subjects. Setting: Community. Participants: 268 community-dwelling adults over the age of 55 years who wished to improve their memory. Measurements: Recall of words and proper names both before and after training in mnemonics. Intervention: Participants received a 2-week training course on two mnemonic techniques, the method of loci for words and a name association technique for proper names. Results: There was no effect of the pretraining manipulation on proper name recall. For word recall, however, a multiple regression that included age indicated that the older-old participants benefited more from a combination of comprehensive pretraining and extended mnemonic training than did the younger-old. Conclusions: Increased training time coupled with a comprehensive pretraining regimen can improve the performance of the older-old in using mnemonics; this improved performance cannot be attributed solely to enhanced knowledge of the mnemonic.

Objective: The goal of this study was to compare the effectiveness of a memory improvement course to a course in general psychology. Methods: Thirty-four healthy elderly persons enrolled in a college memory improvement course for senior citizens, and 33 who enrolled in a parallel course, Introduction to Psychology, were tested on verbal and visual memory prior to and after completing the course. Before they took the course, they were also assesed on subjective memory (self-assessment scale of memory efficacy) and psychological distress (General Health Questionnaire). Changes within and between groups were examined using multivariate analysis of covariance to control for baseline scores. Results: Both groups had similar improvements on all cognitive measures. The memory improvement course group showed very significant correlations between objective and subjective memory. Conclusions: It appears that participation in academic courses is associated with improvement in certain aspects of cognitive functioning. Awareness of objective memory functioning may be a natural selection factor or a significant motivating factor for healthy elderly to enroll in memory enhancement courses.

Most of the tests, questionnaires, and neuropsychological batteries for the assessment of dementia have been translated and adapted for use in the Hispanic population without having normative data, which results in a high number of false positives when age and educational level are not considered. The Short Cognitive Performance Test (SKT) is a psychometric instrument evaluating memory and attention deficits that has been developed and standardized in Germany (Erzigkeit, 1989a, 1989b). The objective of this study was to adapt the SKT, to establish normative criteria that take into consideration age and educational level, and to establish its concurrent validity in comparison to other neuropsychological tests: Brief Neuropsychological Evaluation for Spanish-Speaking Subjects (Ostrosky-Solís et al., 1994), the Mini-Mental State Examination (Folstein et al., 1975), and the Blessed Functional Scale (Blessed et al., 1968) in 238 neurologically intact subjects and 97 subjects with mild to moderate dementia. The SKT showed adequate sensitivity (80.5%) and specificity (80.3%) in subjects with medium and high educational level; however, the sensitivity and specificity diminished (75% and 56.7%) in subjects with no education or low educational level. The adapted and validated version of the SKT in the Mexican population has been shown to be a psychometric instrument that in subjects with medium educational level can detect cognitive alterations and is able to determine the severity of deterioration; however, in subjects with low educational level and severe dementia, the SKT cannot be usefully administered.

During the late 19th and early 20th centuries, elderly individuals with severe mental illness living in the United States were cared for in state-run facilities that went by various names (asylums, psychopathic hospitals, state hospitals, state mental hospitals, and medical centers). Since the beginning of the 20th century, approximately 20% of patients in state hospital facilities had brain diseases such as dementia, usually complicated by behavioral disorder.

Objectives: To identify profiles of subjects who respond to mnemonic training for serial word and proper name recall. Design: Analysis of J. O. Brooks et al.'s (1999) mnemonic training data using Quality Receiver Operating Characteristic (QROC) and longitudinal regression analyses (LRA). Setting: Community. Participants: 224 community-dwelling adults 55 years of age and older who wished to improve their memory. Measurements: Performance on serial word and proper name tests; performance on cognitive ability tests. Results: Although the QROC and LRA identified several common predictors (baseline performance, mental rotation ability, and paired associate learning), the QROC identified additional predictors and cognitive ability profiles associated with successful response. Conclusions: Similar degrees of response to mnemonic training are associated with heterogeneous cognitive profiles. This finding highlights the fact that participants rely on a variety of abilities to derive benefit from mnemonic training and thus suggests different avenues from which to approach this training.

Prior studies have identified that quality of social functioning is strongly associated with both physical and cognitive recovery from stroke as well as with the existence of depression. This study was undertaken to identify the specific elements of social functioning that are related to depression and impaired recovery and to determine whether these elements are different between acute and chronic periods following stroke. There were 50 patients with acute stroke who were assessed in the hospital and at short-term (3- or 6-month) and long-term (12- or 24-month) follow-up. An impaired relationship with the patient's “closest other” prior to the stroke and limited social activities were both associated with depression immediately after the stroke as well as with depression at long-term follow-up. An impaired relationship with the closest other prior to the stroke was also associated with impaired recovery in activities of daily living and cognitive recovery at long-term follow-up. Fears of economic stability and limited social activity were associated with depression at short-term follow-up whereas loss of job or job satisfaction was associated with depression at long-term follow-up. These findings suggest that during the first few weeks following stroke, social supports and contact are essential needs for patients, whereas during the chronic period, other factors such as financial security, adequacy of living arrangements, and loss of job satisfaction also become important. Future research should examine the effect of enhanced social support on poststroke depression and physical and cognitive recovery.

Background. Few randomized, double-blind studies that examine antidepressant treatment in patients 70 years and older are available. To provide additional data on the safety and efficacy of antidepressants in this rapidly growing population segment, a subgroup analysis of a larger sertraline vs. nortriptyline elderly depression treatment study was performed. Methods. Outpatients (N = 76) who met DSM-III-R criteria for major depression with a minimum Hamilton Depression Rating Scale (HAM-D) severity score of 18 were randomized to 12 weeks of flexible dose treatment with sertraline (50–150 mg) or nortriptyline (25–100 mg). Results. Both treatments significantly improved depression as measured by the HAM-D and Clinical Global Impression scales. At Weeks 10, 12, and endpoint, sertraline demonstrated a significantly greater reduction in depression severity compared to nortriptyline as measured by improvement on the 24-item HAM-D (mean adjusted change score of 14.8 vs. 7.6, respectively, at Week 12; p = .001). Sixty-five percent of sertraline-treated patients were responders by Week 12 (50% or greater reduction from baseline in 24-item HAM-D score) compared to 26% of nortriptyline-treated patients (p < .05). Sertraline treatment had a significantly more positive effect, when compared to nortriptyline, across almost all associated measures of cognitive function, energy, anxiety, and quality of life and was better tolerated than nortriptyline, with a lower attrition rate/side effect burden. Conclusion. The efficacy advantage of sertraline appeared to be even greater in this subgroup of older patients drawn from a larger treatment study of depression that included elderly individuals over the age of 60.

The Revised Memory and Behavior Problems Checklist (RMBPC) is a 24-item caregiver report that measures observable behavioral and memory problems in dementia patients and their caregivers' reaction to these problems. The purpose of the present study was to evaluate the applicability of the RMBPC for use in Taiwanese patients with Alzheimer's disease (AD). The subjects included 76 AD patients (39 men and 37 women, mean age 72.3) and their caregivers (34 men and 42 women, mean age 53.5) who participated in a comprehensive assessment at the Veterans General Hospital-Taipei. The Chinese version of the Cognitive Abilities Screening Instrument was administered to the patients. Their caregivers rated the RMBPC and the short version of the Geriatric Depression Score (GDS). To assess the test-retest reliability, 30 caregivers rated a second RMBPC 3 days after the first evaluation. The mean score for the frequency rating on the RMBPC was 32.63 (SD = 12.44, range = 5–61) and the mean reaction score was 10.96 (SD = 11.53). The reaction score was significantly correlated with the GDS score (r = .363, p = .001). The Cronbach's alpha coefficients for frequency and reaction scores were .816 and .895 respectively. The test-retest reliabilities of total frequency and reaction scores were significantly correlated; overall correlations were .89 for frequency (p < .001) and .74 for reaction (p < .001). These findings suggest that the RMBPC be recommended as a reliable tool to assess behavioral and memory disturbance in Taiwanese AD patients.

The focus of this report is the treatment of persons with dementia who are of a non-English-speaking background (NESB). Noisemaking is one behavioral manifestation associated with severe dementia. It can have devastating effects on persons with dementia by limiting their access to activity programs and social interaction, and is also very distressing for professionals and family carers. It can be especially difficult for carers when they do not speak the first (non-English) language of the person with the noisemaking problem, when the person has lost his or her ability to speak English as the dementia progresses. Behavioral interventions have been found to be successful in decreasing the occurrence of noisemaking in some people with severe dementia. This article reports on a study of an elderly Italian woman with dementia. The study used a randomized, alternating-treatments design in order to determine whether an Italian-language intervention would be more effective in reducing her noisemaking than the same intervention given in English. The main result of the study was that the Italian intervention was found to be significantly more effective in reducing noisemaking than the English intervention. Therefore, this exploratory study provides empirical evidence for the increased effectiveness of an intervention program in the patient's original language. The study also demonstrates the need for individualized intervention programs, particularly for NESB patients living in predominantly English-speaking institutions.

Although estimates as to the incidence of personality disorder in the elderly remain controversial, it is well known that such a disorder is prevalently ego-syntonic and capable of interfering with the onset and treatment of other somatic and psychic pathologies, especially in later life, when individuals tend to be particularly vulnerable. Misdiagnosis or failure to treat these disorders may greatly diminish the quality of life of older adults and their families. The aim of this work is to define the chief psychopharmacological and psychotherapeutic guidelines for treating personality disorders in the elderly. Pharmacologically, patients require treatment with molecules designed to rebalance neurotransmitter system alterations, which underlie the symptomatological picture. As regards psychotherapeutic treatment, although there are only a few validation studies, we believe that dialectical behavior therapy and interpersonal psychotherapy may constitute valid therapeutic approaches that meet both the needs and the individual characteristics of patients affected by personality disorder and those of elderly patients.