Diagnostic tests in the evaluation of dementia. A prospective study of 200 elderly outpatients.

We studied the components of the diagnostic evaluation in 200 patients older than 60 years of age with suspected dementia who received standardized diagnostic evaluation and follow-up. The most common dementia diagnoses were Alzheimer's-type dementia (74.5%) and dementia due to toxic effects of drugs (9.5%). Eleven patients with hypothyroidism, metabolic encephalopathies due to hyponatremia, hyperparathyroidism, and hypoglycemia required laboratory tests for diagnosis, whereas the other dementia diagnoses were made primarily on the basis of data available on the history and physical and neurologic examinations. The complete blood cell count, blood chemistry battery (especially sodium, calcium, and glucose concentrations), and thyroid function tests were of definite value for the diagnosis of unsuspected disease and were useful as routine tests in evaluating patients for dementia. A careful history and physical examination accompanied by complete blood cell count, chemistry battery, and a thyroid function test would have been effective in diagnosing treatable illnesses causing cognitive impairment. Other diagnostic tests could have been used selectively based on results of the examination and screening tests. Estimated diagnostic charges from a selective approach would be 25% to 34% of those for the "routine" evaluation.

A clinic for the impaired elderly and their families.

The need for improving psychiatric services to the elderly and for recognizing the importance of the family in caring for the impaired elderly led to the establishment of the Geriatric and Family Services, an outpatient clinic. This clinic provides psychiatric, medical, social, nursing, and architectural evaluations and recommendations for impaired older persons and also provides support and practical advice to the family. Most of the clinic's patients suffer from a dementing illness; of this group most have dementia of the Alzheimer's type. The authors studied the appointment-keeping behavior of the patients and also surveyed the patients' families as an indication of the clinic's success. Out of 50 patients the broken-appointment rate, as well as the drop-out rate, was 2%; 90% of the families who responded to the questionnaire indicated they would recommend the clinic's services to others.

Coexistence of cognitive impairment and depression in geriatric outpatients.

The authors diagnosed depression in 20 (23%) of 88 cognitively impaired geriatric outpatients. Three (20%) of these patients had depression only, and 17 (85%) had depression superimposed on an underlying dementia. The rate of coexisting depression decreased significantly with greater severity of the cognitive impairment: 9 (33%) of 27 mildly impaired patients were depressed, compared with 8 (23%) of 35 moderately impaired and 3 (12%) of 26 severely impaired patients. There was a nonsignificant trend for cognitively impaired women to be more likely to be depressed than for similarly impaired men. The authors conclude that although depression must be differentiated from dementia, it is equally important to consider the possibility that the diagnoses coexist.

Double-blind trial of imipramine in Alzheimer's disease patients with and without depression.

The authors divided 61 subjects with primary degenerative dementia of the Alzheimer's type into a group who also met DSM-III criteria for depression (N = 28) and a group who did not (N = 33). Both groups were randomly assigned to an 8-week double-blind trial of imipramine or placebo. Scores on the Hamilton Rating Scale for Depression, administered at baseline and weeks 2, 4, 6, and 8, indicated significant improvement in both groups. Two measures of cognitive function yielded differing results. The results suggest that moderate depression is a treatable condition in patients with Alzheimer's disease.

Five-year experience of a community outreach program for the elderly.

The authors report on more than 2,000 impaired elderly people who were referred to a geriatric outreach program during its first 5 years of operation. These patients were referred by a wide variety of professionals and private citizens, who were usually concerned about the person's ability to care for himself or herself or about psychiatric symptoms. The most common diagnosis was dementing illness (21% of the patients), followed by depression (13%). Intervention usually involved making appropriate plans based on an accurate diagnosis, often including coordinating the services of other agencies. A follow-up of 100 patients showed that most of the patients who were still living had maintained their independence.

A curriculum for education in geriatric psychiatry.

The authors present recommendations for educating medical students and psychiatric residents in geropsychiatry. They are primarily concerned with the objectives and methods rather than the content of training. Proposals are structured in terms of training objectives and educational settings in which such training takes place. The proposals are intended to be specific enough to be truly useful and at the same time sufficiently generalizable to adapt to geropsychiatric training in a variety of institutions. Priority is given to integrating knowledge of normal and abnormal aging with the clinical skills and empathy necessary to approach patients with competence and understanding.

Interrater reliability of Alzheimer's disease diagnosis.

To determine interrater reliability of dementia diagnosis, 4 physicians experienced in the evaluation of dementia patients applied 3 sets of diagnostic criteria to each of 62 patients, based on a standardized set of medical record information. All patients had undergone similar examinations and follow-up to establish the initial clinical diagnosis (76% had autopsy). Raters were blind to the diagnosis and to follow-up information after the initial evaluation period. This paper presents interrater agreement (kappa values) for a diagnosis of Alzheimer's disease using the American Psychiatric Association diagnostic criteria from the Diagnostic and Statistical Manual (DSM-III), the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) criteria for the clinical diagnosis of Alzheimer's disease, and the Eisdorfer and Cohen Research Diagnostic Criteria (ECRDC) for primary neuronal degeneration. The NINCDS showed somewhat higher average interrater reliability (kappa = 0.64) than the DSM-III (kappa = 0.55) and considerably higher interrater reliability than the ECRDC (kappa = 0.37). One rater displayed conspicuously lower levels of interrater reliability than the other 3, especially in DSM-III and ECRDC. This study indicates that interrater reliability of DSM-III and NINCDS criteria are comparable. Documentation of interrater reliability and, if necessary, training to improve reliability is an important consideration in research where different observers are diagnosing dementing illnesses.

The validity of 3 clinical diagnostic criteria for Alzheimer's disease.

To examine the validity of criteria-based (clinical) diagnosis of Alzheimer's disease (AD), 4 physicians experienced in the evaluation of dementia patients applied 3 sets of diagnostic criteria to each of 62 patients based on standardized medical record information. Diagnostic outcome was validated by neuropathologic examination (completed previously) for all (43) demented patients and 4 nondemented patients and by follow-up in the remainder (15) with no dementia. Raters were blind to the composition of the study group as well as to the clinical and pathologic diagnoses. We evaluated 3 diagnostic criteria sets for AD: the American Psychiatric Association diagnostic criteria from the Diagnostic and Statistical Manual (DSM-III), the NINCDS-ADRDA Work Group criteria for the diagnosis of Alzheimer's disease (NINCDS), and the Eisdorfer and Cohen research diagnostic criteria for primary neuronal degeneration (ECRDC). ECRDC had the highest specificity (0.88) but also the greatest odds of false-negative diagnosis (LRneg = 0.61, sensitivity = 0.46). NINCDS had the best sensitivity (0.92, specificity = 0.65), and DSM-III showed intermediate values (sensitivity = 0.76, specificity = 0.80). We conclude that the investigator or clinician who wishes to ensure that patients classified as AD are more likely to be AD should choose DSM-III, whereas the investigator who wishes to include the greatest number of AD cases, seldom assigning a diagnosis of no AD to a true case, should choose NINCDS.

Mixed cognitive-affective disturbances in the elderly: a new classification.

A new classification for mixed cognitive-affective disorders in the elderly is proposed. In Type 1, patients have depression as their only diagnosis, and the cognitive impairment resolves with treatment for the affective disorder. In Type 2, patients have two diagnoses--depression and dementia--and when the depression is treated, there is usually improvement in mood but not in cognitive ability. A review of the literature suggests that the number of Type 1 cases has been overestimated, and the number of Type 2 cases, underestimated.

Thiothixene plasma levels and clinical response in acute schizophrenia.

Plasma levels of cis and trans thiothixene were compared to clinical response in 8 acutely schizophrenic inpatients. While absolute plasma levels did not appear to correlate with clinical condition, the data did suggest that increases or decreases in cis plasma levels correlated with corresponding improvements or deteriorations in clinical condition in thiothixene responsive patients. While the results are very preliminary, the authors suggest that future studies differentiate the cis and trans isomers, and analyze relative as well as absolute changes in plasma levels as compared to clinical changes.

The association between aluminum-containing products and Alzheimer's disease.

The association between exposure to aluminum through the lifetime use of antiperspirants and antacids and Alzheimer's disease (AD) was explored in a case-control study of 130 matched pairs. Cases were clinically diagnosed between January 1980 and June 1985 at two geriatric psychiatric clinics in Seattle, Wash. Controls were friends or non-blood relatives of the case. Subjects were matched by age, sex, and the relationship between the case and his or her surrogate. For all antiperspirant/deodorant use, regardless of aluminum content, there was no association with AD (adjusted odds ratio (OR) = 1.2, 95% CI = 0.6-2.4). For aluminum-containing antiperspirants, the overall adjusted OR was 1.6 (95% CI = 1.04-2.4) with a trend toward a higher risk with increasing frequency of use (p for trend = 0.03), the adjusted OR in the highest tertile being 3.2. For antacids regardless of aluminum content, the overall adjusted OR was 3.1 (95% CI = 1.2-7.9). Here, a steep dose-response gradient was found (p for trend = 0.009), with an adjusted OR for the highest tertile of 11.7. However, when only aluminum-containing antacids were analyzed, the overall adjusted OR was only 0.7 (95% CI = 0.3-2.0) and there was no significant dose-response trend. These results are provocative but inconclusive due to methodologic problems relating to the necessary use of surrogate respondents and the long time period of potential exposure for this dementing disease.

Arguments for abandoning the term pseudodementia.

The term pseudodementia should be avoided in clinical practice. Its importance lies in the fact that it has alerted clinicians to the existence of potentially reversible, or at least treatable, cases of intellectual dysfunction. However, two major problems are associated with its use. First, it implies that the patient has either an organic or a functional illness, whereas many patients have elements of both, especially when depression is superimposed on a true dementia. Second, the term is often mistakenly used diagnostically, whereas it is only descriptive. The term cognitive impairment is preferable to pseudodementia.

Behavioral disturbance in dementia of the Alzheimer's type.

Behavioral problems are thought to be pervasive and devastating to patients with dementia of the Alzheimer's type and their families. Despite this, little empirical data are available concerning the nature of such impairments, their rate of occurrence or their relationship to the disease process. This study investigated 127 patients with a primary diagnosis of dementia of the Alzheimer's type. Two methods of behavioral assessment were employed: a standardized dementia rating scale and a checklist of behavioral problems. Results indicated a) the overall number of problems significantly increased with increased cognitive impairment, b) the types of problems reported varied with cognitive severity, and c) behavioral problems were not significantly associated with patient's age, gender, duration, or age at onset of dementia. These findings are discussed as they relate to the phenomenology of dementia of the Alzheimer's type and to suggestions for interventions at different stages of the disease process. Problems found associated with level of impairment such as wandering, agitation, incontinence, and poor personal hygiene are thought to be characteristic of the disease and therefore predictable. Problems found not associated with level of impairment such as hallucinations, irrational suspicions, falls, and restlessness are likely to be idiosyncratic. The former should probably be incorporated into education and intervention programs; the latter addressed as needed on an individual basis.

Dementia of the Alzheimer's type and depression.

This retrospective review of medical records was designed to address three questions: 1) Can the depression seen in some patients with Dementia of the Alzheimer's Type (DAT) be successfully treated? 2) Does this treatment lead to any long-term improvement in the patient's cognitive status? and 3) Do patients with coexisting DAT and depression have a different long-term clinical course than nondepressed DAT patients? In the authors' sample of 131 DAT subjects, 41 (31%) also met DMS-III criteria for a major affective disorder. Of those DAT plus depression patients whose records reflected treatment (usually with a tricyclic antidepressant), 85% (17 of 20) showed clear evidence of improvement in mood, vegetative signs, or activities of daily living (ADLs) based on review of the medical record. An analysis of change in cognitive function (measured by the Folstein Mini-Mental State) and five global measures failed to reveal any differences between the depressed and nondepressed groups after a mean interval of 17 months. The depression that occurs in approximately one-quarter to one-third of DAT patients appears to respond to appropriate therapy. These patients often show improvement in their mood and ADLs but remain demented.

Functional status and cognitive impairment in Alzheimer's patients with and without depression.

Cognitive impairment and depression each compromise functional status in the elderly, but it is not known whether their coexistence is associated with additive functional impairment. The effect of the presence or absence of a diagnosis of major depression on functional status was examined in a group of 50 community-residing patients with dementia of the Alzheimer's type (DAT). Patients were diagnosed as depressed (N = 20) or not (N = 30) according to DSM-III criteria. Cognitive status was assessed with the Mini-Mental State Exam (MMSE), and functional status was assessed by family report of Instrumental Activities of Daily Living (IADLs). Consistent with previous reports, patients with a depression diagnosis were less cognitively impaired than their nondepressed counterparts. When cognitive status was controlled for, depression diagnosis was found to have a main effect on functional impairment. Although the direction of effects between depression and functional limitations was not determined here, these results suggest that alleviating depression may decrease functional limitations in DAT patients.

Treatment results at a multi-specialty clinic for the impaired elderly and their families.

Geriatric and Family Services at the University of Washington provides a comprehensive evaluation and treatment program for the impaired elderly, and also offers support, counseling and practical advice for their families. Although most of the 76 patients in this first-year study had cognitive impairment, about one-fourth of them showed unequivocal motor, cognitive and/or affective improvement with treatment for previously undetected illnesses. The rating of "unequivocal improvement" required objective data, as well as corroboration by the patient and family. These therapeutic gains and the increased public interest led to expansion of the program.

Cognitive performance and functional competence in coexisting dementia and depression.

Assessment was made of the impact of depression on the intelligence, memory, and functional competence of elderly community residents (aged 57-88 years) with senile dementia of the Alzheimer's type. Outpatients with either dementia (n = 21) or dementia coexisting with depression (n = 14) were given the Wechsler Adult Intelligence Scale (WAIS), Wechsler Memory Scale (WMS), and Dementia Rating Scale (DRS). No significant group differences were found for verbal IQ, performance IQ, or WMS memory quotient. Patients with coexisting dementia and depression earned significantly lower full scale IQ scores than patients with only dementia. Analysis of WAIS and WMS subtest scores and profiles revealed no difference between the two groups. Significant associations were found among the various cognitive measures and functional competence in both groups, but the patterns of these relationships differed. Intellectual measures accounted for the greatest proportion of functional competence variance in the patients with dementia, whereas memory measures accounted for the greatest proportion of variance in the patients with coexisting dementia and depression.

Financial performance among adult day centers: results of a national demonstration program.

OBJECTIVES: This paper describes the financial performance (defined as percent of total expenses covered by net operating revenue) of 16 adult day centers participating in a national demonstration program on day services for people with dementia, including examination of possible predictors of financial performance. METHODS: Participating sites submitted quarterly financial and utilization reports to the National Program Office. Descriptive statistics summarize the factors believed to influence financial performance. RESULTS: Sites averaged meeting 35% of expenses from self-pay and 29% from government (mainly Medicaid) revenue, totaling 64% of all (cash plus in-kind) expenses met by operating revenue. Examination of center characteristics suggests that factors related to meeting consumer needs, such as being open a full day (i.e., 7:30 am to 6:00 pm) rather than shorter hours, and providing transportation, may be related to improved utilization and, thus, improved financial performance. Higher fees were not related to lower enrollment, census, or revenue. CONCLUSIONS: Adult day centers are able to achieve financial viability through a combination of operating (i.e., fee-for-service) and non-operating revenue. Operating revenue is enhanced by placing emphasis on consumer responsiveness, such as being open a full day. Because higher fees were not related to lower utilization, centers should set fees to reflect actual costs. The figure of 64% of expenses met by operating revenue is conservative inasmuch as sites included in-kind revenue as expenses in their budgeting calculations, and percent of cash expenses met by operating revenue would be higher (approximately 75% for this group of centers).

Depression coexisting with dementia. Evaluation and treatment.

Depression and dementia are the most common syndromes of geriatric psychiatry. Although emphasis is often placed on distinguishing the two, patients frequently have both disorders. Treating the complications of irreversible dementia, while unaltering the underlying disease process, can result in significant functional improvement in affected patients.

Depression, dementia, and reversible dementia.

This article reviews the syndromic concepts of depression and dementia and the concurrence of these common entities. In DAT, depression appears to be a reversible source of excess disability, amenable to pharmacologic as well as environmental interventions. In the vascular dementias, depression appears to be a specific complicating feature, in which localization of the lesion plays a significant role. The abulic state should not be mistaken for a depressive syndrome, although its presence should alert the clinician to evaluate for dementia and depression. Depression is especially prevalent in the subcortical dementias. Future studies using dynamic neuroimaging will help define the limits of this important concept. Reversible forms of dementia are much less common than previously suspected. The clinician's task is to identify causes of excess disability due to superimposed illnesses while avoiding diagnostic or therapeutic nihilism. The appropriate use of medication and the ongoing surveillance for adverse drug reactions are the foremost tasks of today's clinician treating the elderly patient.