No association between the alpha 1-antichymotrypsin A allele and Alzheimer's disease.

The alpha 1-antichymotrypsin (ACT) A allele was recently associated with Alzheimer's disease (AD), and the ACT AA genotype was reported to be more frequent in AD subjects with the apolipoprotein E (APOE) epsilon4 allele. We examined ACT and APOE genotypes in a sample of 160 subjects with probable AD and in 102 elderly control subjects. ACT A allele frequencies were similar in AD subjects (0.503) and elderly controls (0.519). In addition, we found no evidence that in AD the AA genotype is more frequent in subjects with the APOE epsilon4 allele than in those without it. Our results do not support an association between the ACT A allele and AD.

Alpha2 macroglobulin and the risk of Alzheimer's disease.

BACKGROUND: alpha2 Macroglobulin is a panproteinase inhibitor that is found immunohistochemically in neuritic plaques, a requisite neuropathologic feature of AD. Recently, a pentanucleotide deletion near the 5' end of the "bait region" of the alpha2 macroglobulin (A2M) gene was reported to be associated with AD in a large cohort of sibpairs, in which the mutation conferred a similar odds ratio with AD as the APOE-epsilon4 allele for carriers of at least one copy of the A2M gene (Mantel-Haenszel odds ratio, 3.56). METHODS: We studied three independent association samples of AD patients (n = 309) with an age range of 50 to 94 years and representative controls (n = 281) to characterize the allele frequency of the pentanucleotide deletion in this cohort. We detected the mutation near the 5' splice site of exon 18 using standard PCR and restriction fragment length polymorphism methods. The results were adjusted for age, gender, education, and APOE polymorphism. RESULTS: We found that the A2M gene polymorphism conferred an increased risk for AD, with an estimated Mantel-Haenszel ratio of 1.5 (95% CI 1.1 to 2.2; p = 0.025). There was no age- or gender-dependent increase in A2M gene allele frequencies in AD patients compared with controls. The combined sample showed the expected association between AD and APOE-epsilon 4. In one of our three samples there was an interaction between the A2M and APOE-epsilon4 genes, but the other two samples showed no interaction between the two risk factors. CONCLUSIONS: Our data support an association between the A2M gene and AD. This association is less pronounced, however, in our cohort than in the previously reported sample of sibpairs.

The relations among caregiver stress, "sundowning" symptoms, and cognitive decline in Alzheimer's disease.

OBJECTIVE: To investigate the relations among the initial perceived stress of Alzheimer patients' caregivers, the rate of change of perceived stress, patients' sundowning behaviors, and patients' rate of cognitive decline. DESIGN: A longitudinal cohort study in which Alzheimer patients and their caregivers were assessed at 6-month intervals. SETTING: Hospital out-patient clinic. Patients and caregivers lived at home. SUBJECTS: Subjects were 35 patients (50-79 years) with Alzheimer's disease and their primary caregivers (24 males and 11 females); all caregivers were spouses. METHODS: At time of entry into the study, caregivers indicated which of seven behaviors indicative of sundowning were exhibited by the patient. Patients were evaluated successively using the Mini-Mental State Examination, whereas caregivers completed the Perceived Stress Scale, provided an index of social support utilization, and completed the Beck Depression Inventory. MAIN OUTCOME MEASURES: Caregivers' initial perceived stress and the rate of change of perceived stress, patients' sundowning behavior, and rate of cognitive decline. RESULTS: The pattern of correlations indicated that both rate of cognitive decline and initial sundowning behavior were significantly correlated with initial perceived caregiver stress. The average rate of increase of caregivers' perceived stress was positively correlated with the initial incidence of sundowning behaviors, even when controlling for the effects of caregiver depression and social support utilization. CONCLUSION: Sundowning behavior of Alzheimer patients is associated with an increased rate of change of caregivers' perceived stress. This association may be specific to sundowning behavior because there was no relation between the rate of change of perceived stress and morning agitation. The findings suggest that future caregiver intervention programs could profitably focus on sundowning behavior rather than general agitation.

Issues and recommendations for the recruitment and retention of older ethnic minority adults into clinical research.

A burgeoning literature indicates that treatment of mental disorders offsets mortality, morbidity, and poor quality of life in senior citizens. Unfortunately, ethnic minority senior citizens, who are in most need of mental health services, have not been well represented in psychosocial research. This lack of attention is due, in large part, to difficulties that may arise in recruitment and retention of older ethnic minority adults in research studies. The purpose of this article is to discuss successful methods for recruiting older ethnic minority adults into psychosocial research and to offer specific suggestions for keeping this population involved in longitudinal studies. Also included is a discussion of past research and present data from treatment studies that used the methods discussed in this article.

Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers.

Clinically depressed family caregivers (N = 66) of frail, elderly relatives were randomly assigned to 20 sessions of either cognitive-behavioral (CB) or brief psychodynamic (PD) individual psychotherapy. At posttreatment, 71% of the caregivers were no longer clinically depressed according to research diagnostic criteria (RDC), with no differences found between the 2 outpatient treatments. The results suggested therapy specificity; there was an interaction between treatment modality and length of caregiving on symptom-oriented measures. Clients who had been caregivers for a shorter period showed improvement in the PD condition, whereas those who had been caregivers for at least 44 months improved with CB therapy. These findings suggest that patient-specific variables should be considered when choosing treatment for clinically depressed family caregivers.

Maintenance of gains versus relapse following brief psychotherapy for depression.

Cross-sectional and longitudinal data are presented from a 2-year follow-up study of 91 older adults, initially diagnosed as in an episode of major depressive disorder (MDD), who were treated with brief cognitive, behavioral, or psychodynamic psychotherapy. Using research diagnostic criteria (RDC), 52%, 58%, and 70% of the sample did not meet criteria for any RDC depressive disorder at posttherapy, and 12- and 24-month follow-ups, respectively. There were no significant differences in response rate by therapy modality. Using Longitudinal Interval Follow-up Evaluation (LIFE; Shapiro & Keller, 1979; Keller et al., 1987) methodology, we noted that patients not depressed at posttreatment remained depression-free for longer time periods than those who were minor or MDD. These rates compare favorably with published reports on younger depressed patients.

Endogenous depression in the elderly: prevalence and agreement among measures.

This article describes agreement among diagnoses made according to five definitions of endogenous depression in a sample of 99 depressed elders and discusses the relationship among these systems and selected demographic and clinical characteristics. Poor to fair agreement was generally demonstrated, except for Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) and Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (American Psychiatric Association, 1987), which demonstrated excellent agreement. Mostly, demographic and clinical variables (e.g., severity of depression) were unrelated to endogeneity diagnoses. The conclusion was reached that these criteria are not all measuring the same construct in older adults and that the relationship between depression severity and endogeneity should be discussed in terms of specific definitions rather than general terms.

Apolipoprotein E epsilon4 allele affects the relationship between stress and depression in caregivers of patients with Alzheimer's disease.

We examined the effect of the apolipoprotein E (apo E) epsilon4 allele on the relationship between self-reported stress and mood in caregivers of patients with Alzheimer's disease. Eighty-six female subjects between the ages of 28 and 82 years who were community-dwelling AD patient caregivers participated in the study. A cross-sectional analysis of stress and mood was performed using the Revised Memory and Behavior Problem Checklist and the Geriatric Depression Scale. All subjects were evaluated for normal cognitive function (Mini-Mental Status Examination) and apo E genotype. The results indicated that increased levels of stress were associated with increased levels of depressive symptoms in nondemented caregivers with the epsilon4 allele. This relationship was not observed in caregivers without the epsilon4 allele. These results suggest that carriers of the epsilon4 allele may respond differently to psychological stress than do individuals without the epsilon4 allele.

Patterns of coping preferences for male and female caregivers of frail older adults.

The similarities and differences in male and female caregivers' preferred strategies for coping and the perceived helpfulness of these strategies in managing caregiving stressors were examined in this study. Respondents were 170 caregivers (139 women and 31 men) who were primary caregivers for an elderly adult relative who was either cognitively impaired or physically frail. Results provide preliminary evidence that gender is related to frequency of use but not to the perceived helpfulness of specific coping strategies.

Dimensions of perceived social support in clinically depressed and nondepressed female caregivers.

The relationship between social support and depression was studied in 165 women caring for frail family members. The Arizona Social Support Interview Schedule (Barrera, Sandler, & Ramsay, 1981), which includes 4 dimensions of availability and use of resources and satisfaction with and need for support, was used to examine 7 categories of supportive activity. Depression was assessed according to Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) with the Schedule of Affective Disorders and Schizophrenia (Endicott & Spitzer, 1978). There were no differences in overall satisfaction with received support in comparisons of depressed and nondepressed caregivers. However, depressed caregivers (n = 87) reported a higher incidence of negative interactions with others. Both groups appeared to have equal access to social support, with nondepressed caregivers (n = 78) reporting significantly greater use of those resources.

The effects of late-life spousal bereavement over a 30-month interval.

Self-report measures of grief, depression, and general psychopathology were studied in widows and widowers over a 2.5-year period following death of their partner. A comparison sample of men and women was also followed for the same period. Differences in severity of depression and psychopathology previously reported at 2 months postloss (Gallagher, Breckenridge, Thompson, & Peterson, 1983) diminished to nonsignificant levels at 12 and 30 months. However, significant differences between bereaved and comparison subjects on measures of grief were still apparent 30 months after spousal loss. A main effect of gender for depression and psychopathology (but not for grief) was found at 2 and 12 months: Women reported more distress than men regardless of bereavement status. Results indicate that the experience of grief persists for at least 30 months in both older men and women who have lost their spouse.

The psychological impact of genetic testing for Alzheimer disease.

Information regarding one's genetic risk for a particular disease might effectively inform medical, financial, and reproductive decisions and perhaps promote established risk reduction behaviors. However, genetic testing may also lead to significant levels of anxiety, depression, or other forms of distress, especially when psychological coping strategies and social reserves are not adequate to manage positive or inconclusive results. This paper focuses on the psychological impact of predisposition genetic for Alzheimer disease (AD). We present stress and coping models that capture the essence of this impact and discuss the potential role of counseling and follow-up interventions. The discussion draws primarily from the experiences of professionals working with other diseases, and seeks to expand that experience into the AD arena. In addition, we emphasize two issues we believe need additional attention in the psychological literature regarding genetic testing and counseling: (i) the psychosocial vulnerability of individuals being tested and, (ii) the sociocultural context of the AD patient and their family members.

Cognitive-behavioral interventions for treatment of depression in Alzheimer's patients.

This paper presents two strategies for treating depression in Alzheimer's patients. Cognitive therapy, used with mildly demented adults, challenges the patient's negative cognitions in order to reduce distortions and enable the patient to generate more adaptive ways of viewing specific situations and events. Behavioral intervention, used with more moderately or severely demented adults, attempts to modify person-environment interactions by increasing the level of positive activities and decreasing negative ones (Lewinsohn et al., 1984). Both theories have been used successfully in clinical settings.

"Coping with frustration" classes: development and preliminary outcomes with women who care for relatives with dementia.

We describe a novel intervention program in which wives or daughters who are caregivers are taught several specific skills to enable them to manage their frustrations more effectively. These skills include learning to relax in very stressful situations and learning to be appropriately assertive with their frail elder and with other family members. Class content and structure are presented, along with preliminary data on class efficacy that is based on an N of 48 caregivers who have currently completed this particular class series. We close by noting that this psychoeducational intervention has been very well received by colleagues in other agencies serving family caregivers. In fact, this class series is now being offered to a broad range of caregivers in the San Francisco Bay area.

Hopelessness and suicidal ideation in older adults.

This study examined the role that hopelessness plays in geriatric suicidal ideation. Sixty institutionalized elderly males were recruited. Multiple regression analyses revealed that while hopelessness was strongly related to suicidal ideation, the relationship between hopelessness and suicidal ideation was dependent on level of depression. Participants who reported moderate or higher levels of depressive symptoms were more likely to have suicidal ideation with increasing hopelessness, whereas hopelessness had little effect on level of ideation at mild or lower depressive symptom levels. Unlike previous studies in younger adults, hopelessness did not predict suicidal ideation better than depressive symptoms, although the relationship between depression and suicidal ideation was stronger within higher levels of hopelessness. These findings highlight the importance of considering depression and hopelessness simultaneously when assessing and treating geriatric suicidal ideation.

Strategies for increasing participation of ethnic minorities in Alzheimer's Disease Diagnostic Centers: a multifaceted approach in California.

A unified, state-wide effort to increase outreach activities targeted to ethnic minority families with a demented relative is described. A variety of strategies are reported, along with data supporting the effectiveness of these outreach efforts. At present, it appears that the three major ethnic minority groups in the State of California (i.e., Hispanic, African American, and Asian) are utilizing the network of state diagnostic centers at a rate proportional to their representation in the population.

Judging outcomes in psychosocial interventions for dementia caregivers: the problem of treatment implementation.

PURPOSE: In published dementia caregiver intervention research, there is widespread failure to measure the level at which treatment was implemented as intended, thereby introducing threats to internal and external validity. The purpose of this article is to discuss the importance of inducing and assessing treatment implementation (TI) strategies in caregiving trials and to propose Lichstein's TI model as a potential guide. DESIGN AND METHODS: The efforts of a large cooperative research study of caregiving interventions, Resources for Enhancing Alzheimer's Caregiver Health (REACH), illustrates induction and assessment of the three components of TI: delivery, receipt, and enactment. RESULTS: The approaches taken in REACH vary with the intervention protocols and include using treatment manuals, training and certification of interventionists, and continuous monitoring of actual implementation. IMPLICATIONS: Investigation and description of treatment process variables allows researchers to understand which aspects of the intervention are responsible for therapeutic change, potentially resulting in development of more efficacious and efficient interventions.

Standards for psychological services in long-term care facilities.

Psychologists in Long-Term Care (PLTC), a national network established in 1983, has developed, with input from colleagues and consumers, standards for psychological practice in long-term care facilities. These standards address provider characteristics, methods of referral, assessment practices, treatment, and ethical issues. This article describes the document's development and offers suggestions for its use.

A comparison of marital interaction patterns between couples in which the husband does or does not have Alzheimer's disease.

UNLABELLED: Objectives. Our main purpose was to examine similarities and differences in patterns of interpersonal interaction between Alzheimer's disease (AD) caregiving and noncaregiving couples (n = 54). Methods. Twenty-seven wives caring for moderately impaired husbands with probable AD and 27 noncaregiving wives from comparable sociodemographic backgrounds were videotaped in their homes during both mealtime and a future event planning task. In addition, they completed self-report questionnaires to assess depression, stress, relationship mutuality, and perceived hope. Results. Compared with their counterparts, caregiving wives reported higher levels of depression and stress, but similar shared values and closeness. For the three factors developed from the Marital Interaction Coding System (MICS, version IV; Supportive Facilitative, and Rapport Building), a complex pattern of results was found in which disease status, type of task, and gender interacted significantly. Noncaregiving couples were more interactive overall and expressed more support to each other. Caregiving wives were found to be most facilitative during the planning task, whereas AD husbands were highest on interactions that built rapport (e.g., smiling) during that same task. Caregiving wives actually increased their facilitative behavior from the mealtime to planning task, probably reflecting the increased demand characteristics of the latter. DISCUSSION: This study is one of a small body of literature to describe the negative impact of AD on spousal communication as observed and coded in two videotaped interaction situations in the home. Suggestions are made for future research, including the inclusion of longitudinal designs and non-Caucasian couples.

The role of social supports in the bereavement process of surviving spouses of suicide and natural deaths.

This report examines the changing role of social supports in the bereavement of spouses of elderly suicide and natural deaths, focusing on differences and similarities in relation to gender, time, and mode of death. Measurements were obtained 4 times after death (within 2 months, at 6 months, at 12 months, and at 2 to 2 1/2 years) on 79% of the 108 survivors of elderly suicide, 89% of the 199 natural death survivors, and 79% of the nonbereaved controls. The results indicated that the suicide survivors received significantly less emotional support for their feelings of depression and grief than the natural death survivors, and that they did not confide in the persons in their network any more than the nonbereaved controls did. Women report receiving more support overall than men. A low spot in social supports occurred at the 6-month point after loss for both bereaved groups, but primarily in practical help received by natural death survivors. By the end of the second year, both practical and emotional supports had increased to at least the same level as immediately after death.