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High levels of homocysteine are associated with cerebrovascular disease, monoamine neurotransmitters, and depression of mood. A plausible hypothesis for these associations is that high homocysteine levels cause cerebral vascular disease and neurotransmitter deficiency, which cause depression of mood. The homocysteine depression hypothesis, if true, would mandate inclusions of imaging studies for cerebrovascular disease and measures of homocysteine, folate, and B12 and B6 vitamins in the clinical evaluation of older depressed patients. Longitudinal studies and clinical trials should be designed to challenge the hypothesis.

A study on elderly patients with diabetes mellitus and the patterns of their executive and visuospatial dysfunctions is presented. Such cognitive deficits are likely to impair activities of daily living in these patients. The study is based on data from three homecare agencies in Massachusetts.

Postmenopausal hormone therapy and cognitive function in healthy older women have been studied based on data from the Nurses' Health Study, an ongoing prospective cohort study. Neither current nor long-term hormone users show better performance on an overall measure of cognition or on three test of verbal memory than never users. Current hormone users scored significantly better than never users on the test of verbal fluency, having a 30% decrease in risk of a low score on the verbal fluency test.

Objective: The purpose of this pilot study was to gain information about attitudes of individuals with bipolar disorder and their spouses toward some of the ethical and social issues arising from rapidly advancing genetic research on bipolar disorder. Method: Patients with bipolar disorder and their unaffected spouses were asked to answer questionnaires assessing their knowledge and attitudes about treatment response rates for bipolar disorder, probability of inheritance, genetic testing, disclosure of genetic information, abortion, marriage, and childbearing. Results: The overwhelming majority of the patients and spouses said that they would take advantage of genetic tests for bipolar disorder if such tests were to become available. Most patients and spouses agreed that the benefits of knowing whether one carries a gene for bipolar disorder would outweigh the risks. The decisive majority of respondents also felt that they would not abort a fetus that carried a gene for bipolar disorder. Furthermore, most patients and spouses agreed that the knowledge that one of them carried a gene for bipolar disorder would not have deterred them from marriage or childbearing. Conclusions: The results of this study suggest that most individuals believe that they would benefit from the use of genetic testing for bipolar disorder if it were to become available. Follow-up studies using a broader patient sample and nonclinical control groups would be useful in further evaluating the issues addressed in this pilot study.

Objective: Evidence suggests that the neuropathology of Huntington's disease, a neuropsychiatric disorder due to a mutation on chromosome 4, results from excessive activation of glutamate-gated ion channels, which kills neurons by oxidative stress. Therefore, the authors hypothesized that [Alpha]-tocopherol, which reduces oxyradical damage to cell membranes, might slow the course of Huntington's disease. Method: A prospective, double-blind; placebo-controlled study of high-dose d-[Alpha]-tocopherol treatment was carried out with a cohort of 73 patients with Huntington's disease who were randomly assigned to either d-[Alpha]-tocopherol or placebo. Patients were monitored for changes in neurologic and neuropsychologic symptoms. Results: Treatment with d-[Alpha]-tocopherol had no effect on neurologic and neuropsychiatric symptoms in the treatment group overall. However, post hoc analysis revealed a significant selective therapeutic effect on neurologic symptoms for patients early in the course of the disorder. Conclusions: Antioxidant therapy may slow the rate of motor decline early in the course of Huntington's disease.

Objective: The aims of this study were to estimate the prevalence and investigate the comorbidity and potential consequences of DSM-III personality disorders in the community. Method: A total of 810 adults were examined in the second stage of the Eastern Baltimore Mental Health Survey in 1981, part of the National Institute of Mental Health Epidemiologic Catchment Area program. The subjects were directly examined by psychiatrists using a semi-structured method that allowed diagnosis of all DSM-III personality disorders as well as other DSM-III psychiatric disorders. Results: The prevalence of personality disorders in these adults was 5.9% (9.3% when provisional cases were included). Men had higher rates than women, and subjects who were separated or divorced had the highest rates. There was little comorbidity among specific personality disorders. Subjects with personality disorders were significantly more likely to have a history of sexual dysfunctions, alcohol use disorders, and drug use disorders as well as suicidal thoughts and attempts. In addition, they reported significantly more life events in the past year. Among subjects with any axis I disorder, those with personality disorders were judged by the psychiatrists to be more in need of treatment; however, only 21% were receiving treatment. Conclusions: Personality disorders are relatively common in the community. They are associated with axis I disorders and life events. Only one-fifth of the individuals who qualify for diagnoses of personality disorders in the community are receiving treatment.

The Mental Alteration Test may be an effective method for evaluation of cognitive impairment in patients with HIV infection. Cognitive impairment is a common complication of HIV infection. Researchers compared the Mental Alteration Test to the Mini-Mental State Exam (MMSE) and the parts A and B of the Trailmaking Test in 62 patients with HIV infection. The patients' scores on The Mental Alteration Test were similar to those on the MMSE and part B of the Trailmaking Test. A score below 15 on the Mental Alteration Test was most effective for detection of abnormal cognitive function. Patient scores were reproducible and reliable with the Mental Alteration Test and it was easy to administer. Patients with an abnormal score on the Mental Alteration Test should have further evaluation for cognitive impairment.

Objective: The aim of this study was to assess the relationships between specific personality disorders and DSM-III axis I conditions in a community sample. Method: A total of 810 subjects were examined by psychiatrists in the second stage of the Eastern Baltimore Mental Health Survey, part of the Epidemiological Catchment Area Program of the National Institute of Mental Health. A semistructured examination, the Standardized Psychiatric Examination, was employed to assess axis I and axis II conditions. Scales for compulsive and antisocial personality disorders were derived from DSM-III criteria. The relationships between scores on these personality disorder scales and the presence of generalized anxiety disorder, alcohol use disorders (alcohol abuse and alcohol dependence), and simple phobia were evaluated by using logistic regression. Results: Higher compulsive personality scores were associated with a greater odds of generalized anxiety disorder and simple phobia but a smaller odds of alcohol use disorders. In contrast, higher antisocial personality scores were associated with a greater odds of alcohol use disorders but a smaller odds of generalized anxiety disorder. There was no relationship between antisocial personality scores and simple phobia. Conclusions: Personality disorders have specific relationships to axis I conditions, which suggests different vulnerabilities but also different protective influences.

Alzheimer's disease, a type of dementia, is characterized in part by delusions, hallucinations, and behavioral changes. Psychotic symptoms in Alzheimer's patients have been associated with poorer cognitive performance and more rapid cognitive decline. Aggressive outbursts, in the forms of physical violence, are reported by caregivers of Alzheimer's patients as well; sometimes aggressive patients are also abused by their caregivers. In the present study, data were collected on 181 patients with probable Alzheimer's disease who had been assessed every six months for up to 4.5 years. Summary notes were reviewed for each clinic visit, and the symptoms of delusions, hallucinations, misidentifications, and physical aggression were noted. In 43.5 percent of the cases, delusions were present, and in 29.6 percent, physical aggression was observed. The most common delusions were of persecution, and delusions frequently preceded episodes of violent behavior. While delusions were significantly associated with violence, it accounted for only 3.5 percent of the variance under statistical analysis. This suggests that there are other variables related to physical aggression as well. (Consumer Summary produced by Reliance Medical Information, Inc.)

A family history study was performed to investigate the relationship between Alzheimer's disease with depression and a family history of affective disorder. Depression often accompanies Alzheimer's disease, but it is not known if this is merely a response to the dementia or if it is a part of a major affective disorder. Affective disorders and dementia can coexist; depression may be the result of dementia, or cognitive disturbances may result from depression. Forty-one patients who were diagnosed with probable Alzheimer's disease and who experienced one episode of depression were assessed, along with 71 Alzheimer's patients who were not depressed. The 41 depressed patients met the criteria in the Diagnostic and Statistical Manual of Mental Disorders, third edition, (DSM-III) for major a depressive episode, and had no history of depression. For each of these patients, two first-degree relatives were interviewed and assessed for symptoms of depression, also using the DSM-III criteria. Data were analyzed and an association was found between the Alzheimer's patients with depression and a higher incidence of depression in first- and second-degree relatives. About half of the patients with depression had one or more relative with major depression, compared with only 11 percent of the Alzheimer's disease patients without depression. These results suggest that there is a genetic relationship between a family history of depression and the depression which may occur in Alzheimer's disease. Further investigation of this feature in Alzheimer's disease may provide a useful model for studying aspects of depression and its progression. (Consumer Summary produced by Reliance Medical Information, Inc.)

Dementia is a term used to describe a broad impairment of intellectual (cognitive) functioning that is usually progressive and interferes with normal activities. Delusions are described as false beliefs that are brought about without appropriate external stimuli. Residents of nursing homes commonly have diagnoses of dementia with attendant behavioral problems. Studies have demonstrated delusions to be part of senile dementia, and when treated, behavior problems often subside. This study was done to assess the prevalence of delusions among newly admitted nursing home residents, how patients with delusions differ from nondelusional patients in behavior and functioning, whether the nursing staff can recognize delusions and knows how to treat them, and what illnesses delusions are associated with. Psychiatrists examined 125 nursing home residents within four weeks of their admission. The patient's behavior before nursing home placement was determined by an interview with a family member. Behavior and function in the nursing home was assessed by an interview with a nursing assistant. Almost 85 percent of the subjects had a psychiatric disorder, and dementia was seen in 67.2 percent. Twenty-six of these residents had delusions, and the family had recognized this in 64 percent of the cases. Even so, only six of the delusional patients had seen a psychiatrist in the year before admission. The nursing staff identified delusions in only five of these patients. The delusional patients did not differ from the nondelusional residents in their need for assistance with daily activities. They did, however, have more behavior problems before and after admission to the nursing home, and were also more cognitively impaired. Most of these patients were not receiving proper treatment for their symptoms, and in fact were often given medications which could make their conditions worse. The authors suggest that the behavior problems associated with delusions and dementia could be diagnosed and treated before or after placement, if these elderly patients receive skilled geriatric psychiatric evaluations, along with interviews with family members regarding symptoms that are manifest prior to this evaluation. Also, nursing home staff members need to be taught to recognize delusions and understand their clinical importance so referrals occur in a timely manner. (Consumer Summary produced by Reliance Medical Information, Inc.)

Chronic migraine headache sufferers have been described clinically to be ambitious, success oriented, conscientious, perfectionistic, obsessive, emotional, rigidly moralistic, tense, of above-average intelligence, and frequently angry, resentful and hostile. To verify these reports this study selected 162 migraine sufferers and 162 control subjects from the general population and assessed their personalities and psychological distress levels. The initial screening interview discerned the frequency of headaches, their characteristics and precipitants, and whether treatment had been sought. The Eysenck Personality Questionnaire was used to assess psychoticism (tough-mindedness), neuroticism (emotionality), extraversion and dissimulation (pretense). The General Health Questionnaire was used to detect psychological distress suggestive of emotional disorders. The migraine and control groups differed dramatically on the neuroticism scale, indicating that the migraine group members were more tense, anxious, and depressed than the controls. The migraine sufferers also scored significantly higher on the psychoticism scale indicating that they described themselves as less interpersonally sensitive, more hostile, and unique from their peers. Migraine sufferers also scored significantly lower on the lie scale suggesting that they are less defensive and more self-critical and willing to admit the truth about themselves than the controls, but this could also suggest hypervigilance and perfectionism out of which ordinary experiences are interpreted as abnormal. These results suggest a modal personality described as unguarded, anxiety prone, depressive, lacking in interpersonal warmth, and somewhat alienated from peers. The General Health Questionnaire results indicated that the migraine sufferers also experienced significant psychological distress. They scored higher than the control subjects on all the symptom scales, including anxiety, depression, and impaired social functioning. According to the criteria for emotional disorder, approximately 61 percent of the migraine group and 25 percent of the control group qualified for this description. This rate among the control group is consistent with levels found in other community samples. (Consumer Summary produced by Reliance Medical Information, Inc.)

Alzheimer's disease (AD) and Huntington's disease (HD) are chronic, degenerative brain diseases characterized by impaired mental functioning and motor disturbances. Patients afflicted with these diseases often become irritable and aggressive, and suffer from a loss of emotion (apathy). Recently, a new scale that measures irritability and apathy has been developed and tested in 31 patients with AD and 26 patients with HD. Aggression was also measured using an already existing test. Patients with AD and HD had similar rates of apathy and irritability. Fifty-nine percent of the patients with HD were aggressive and 39 percent of the AD patients were aggressive. A sample of patients with HD or AD who had a similar degree of mental impairment revealed that HD patients were more apathetic than patients with AD. This finding is consistent with the traditional view that HD patients suffer from a greater lack of emotion than patients with AD. Irritability in HD but not AD patients was related to whether the patient had a 'bad temper' prior to the onset of their disease. This new scale is reliable and obtains the information from an observer of the patient's behavior. In conclusion, a new reliable scale that measures apathy and irritability has been developed and should aid the clinician in the diagnosis of HD and AD. (Consumer Summary produced by Reliance Medical Information, Inc.)

The most common cause of dementia (mental impairment) among the 1.5 million patients in nursing homes in the United States is Alzheimer's disease. The dementia of Alzheimer's disease is considered untreatable, but these patients often have associated treatable conditions such as depression. This study was undertaken to evaluate the extent to which treatable conditions occurred before, and contributed to, institutionalization. Previous studies have been done to find factors that predict institutionalization, but none have assessed patients before they were admitted to nursing homes. If treatable conditions are predicting factors for institutionalization, then treating these conditions might prevent or delay unnecessary placements. Psychiatrists examined and interviewed 210 possible or probable Alzheimer's outpatients and their caregivers at six-month intervals between 1984 and 1987. When 25 (12 percent) of the patients had been admitted to nursing homes, the researchers matched them to 25 noninstitutionalized patients to compare data. The institutionalized group had not been ill longer than the control group, but they did score higher on the Hamilton depression scale, the Brief Psychiatric Rating Scale, and the behavior disorder, activities of daily living, and orientation subscales of the Psychogeriatric Dependency Rating Scales on their last examination before being placed. There were no significant differences on any measure of cognition (mental processing) between the two groups. These results show that potentially treatable psychiatric symptoms such as depression and agitation are among the predictors for nursing home placement, and suggest that psychiatric intervention and treatment may prevent or delay placement. The results of this study agree with earlier studies which have found behavioral, not cognitive, disorders to be the greatest risk factor for institutionalization among Alzheimer's patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Gait impairment is common in the elderly, especially those with stroke and white matter hyperintensities on conventional brain MRI. Diffusion tensor imaging (DTI) is more sensitive to white matter damage than conventional MRI. The relationship between DTI measures and gait has not been previously evaluated. Our purpose was to investigate the relationship between the integrity of white matter in the corpus callosum as determined by DTI and quantitative measures of gait in the elderly.

Zusammenfassung:Der MikroMental Test ist ein in Anlehnung an die Mini-Mental-Status Untersuchung (MMSE) entwickeltes Kurzverfahren zum Screening bei Verdacht auf eine demenzielle Erkrankung. In der vorliegenden Arbeit wurde die Reliabilität und die diagnostische Validität einer deutschsprachigen Version (MikroMental Test) untersucht. 125 gerontopsychiatrische Patienten mit einer Demenzdiagnose (mittleres Alter 77.8 ± 8.0 Jahre) und 77 Probanden ohne Demenzdiagnose (mittleres Alter 71.1 ± 7.0 Jahre), darunter 43 gesunde ältere Kontrollpersonen (mittleres Alter 69.7 ± 6.8 Jahre) wurden mittels der MMSE und des MikroMental Tests untersucht. Als Außenkriterium diente die Diagnose nach ICD-10. Die Durchführung des MikroMental Tests dauerte im Mittel 8 Minuten, für die MMSE wurden durchschnittlich 15 Minuten benötigt. Testwiederholungsanalysen zeigten eine befriedigende Reliabilität. Analysen der Sensitivität und Spezifität ergaben für den MikroMental Test Parameter diagnostischer Güte, die mit der MMSE vergleichbar, hinsichtlich einzelner Werte sogar statistisch bedeutsam überlegen sind. Für den ambulanten Bereich stellt der MikroMental Test aufgrund seiner Kürze und seiner diagnostischen Güte ein geeignetes Instrument zum Demenzscreening dar.

This paper reviews the historical development of the American Psychiatric Association’s Diagnostic and Statistical Manual. It presents some of the issues that the clinician has found difficult in applying DSM-III and DSM-III-R criteria for delirium. In addition it introduces some options for DSM-IV criteria for delirium based on several empirical studies, These options should be studied and debated carefully over the next year because in part, they represent radical departures from existing diagnostic criteria for delirium.

The 1981 East Baltimore Mental Health Survey, part of the Epidemiological Catchment Area (ECA) program, provided data for the examination of the prevalence of delirium in the general adult population. From an original 3,841 households surveyed, 810 individuals were selected for psychiatric evaluation and, of these, 6 individuals were diagnosed as suffering from delirium. The estimated prevalence of delirium in the population was .4% and 1.1% among those 55 years of age and over. A comparison of these cases with cases of diagnosed demenita and individuals of the same age range who did not receive a psychiatric diagnosis found that those with a diagnosis of delirium suffer from a greater number of medical conditions, take more prescribed medications, and have a higher level of physical disability.

While all delirious patients have clouding of consciousness (alteration of attention) and cognitive dysfunction, the level of alertness of different patients may range from stuporous to hyperalert. We, therefore, developed an analog scale to rate the alertness of delirious patients, and a separate scale to rate the severity of their clouding of consciousness. Based on these scales, patients were categorized overall as relatively “activated” (relatively alert despite clouding of consciousness), or “somnolent” (relatively stuporous along with clouding of consciousness). Cognitive function was estimated using the Mini-Mental Status Exam. Separate ratings were made of hallucinations, delusions, illusions, and agitated behavior. Activated and somnolent patients had similar ages, overall severity of delirium, and Mini-Mental Status Exam scores. Activated patients, however, were more likely to have hallucinations, delusions, and illusions than somnolent patients, and were more likely to have agitated behavior. Patients with hepatic encephalopathy were more likely to have somnolent delirium, while patients with alcohol withdrawal appeared more likely to have activated delirium. These data indicate that phenomenologic subtypes of delirium can be defined on the basis of level of alertness. These subtypes are validated in part by their differing associations with symptoms unrelated to alertness. These subtypes may have different pathophysiology, and thus, potentially different treatments.

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

• OBJECTIVE. —To determine the contribution of genetic factors to cognitive functioning in older men. DESIGN. —Cognitive testing by telephone interview in an epidemiologically defined population. PARTICIPANTS. —2077 monozygotic and 2225 dizygotic male twin pairs, all between the ages of 62 and 73 years, recruited from the National Academy of Sciences twin registry. MAIN OUTCOME MEASURES. —The Telephone Interview for Cognitive Status—Modified total score and factor scores were analyzed. The Falconer heritability statistic and maximum likelihood estimates of genetic and environmental components were computed. RESULTS. —Heritability of the total Telephone Interview for Cognitive Status—Modified score was estimated to be 30%. Shared environmental effects accounted for an additional 18% of the variance; most of this was related to years of education. Of the four cognitive factors derived, the language/attention factor had the highest heritability estimate. CONCLUSIONS. —Genetic factors and educational achievement together account for almost half of the variance in the cognitive functioning of older men. Studies of the genetics of dementing illnesses need to consider the degree to which cognitive capacities are themselves under genetic control.

• We studied DSM-III diagnoses made by the lay Diagnostic Interview Schedule (DIS) method in relation to a standardized DSM-III diagnosis by psychiatrists in the two-stage Baltimore Epidemiologic Catchment Area mental morbidity survey. Generally, prevalence estimates based on the DIS one-month diagnoses were significantly different from those based on the psychiatric diagnoses. Subjects identified as cases by each method were often different subjects. Measured in terms of K, the chance-corrected degree of agreement between the DIS and psychiatrists' one-month diagnoses was moderate for DSM-III alcohol-use disorder (abuse and dependence combined), and lower for other mental disorder categories. The unreliability of either the DIS or psychiatric diagnoses is one potential explanation for the observed disagreements. Others include the following: (1) insufficient or inadequate information (on which to base a diagnosis); (2) recency of disorder; (3) incomplete criterion coverage; (4) overinclusive DIS questions; and (5) degree of reliance on subject symptom reports. Further study of the nature and sources of these discrepancies is underway. This work should produce a more complete understanding of obstacles to mental disorder case ascertainment by lay interview and clinical examination methods in the context of a field survey.

Twenty-one families with familial Alzheimer disease were ascertained in a dementia clinic and assessed by multiple family interviews. Eight autopsies were reviewed. The age of onset varied from 25 to 85. Seven pedigrees showed evidence of 3 generation transmission. Paternal age of the founders of 4 lines which could be assessed was higher than controls.

Two Huntington disease (HD) pedigrees are presented which differ according to mean and distribution of the age at onset, the effect of paternal transmission on the age at onset, presence of manic-depressive symptoms, and type of presenting symptoms. Together with previous reports, the data suggest clinical heterogeneity between HD kindreds which may imply some kind of genetic heterogeneity, most likely subsequent mutation at a single HD locus. The possibility of genetic heterogeneity has important consequences, both in research, and in the counseling and care of families and patients with differing manifestations of the disease.

We investigated all patients in Maryland reported to have Huntington's disease (HD), and found considerable diagnostic inaccuracy. Fifteen percent of cases reported as HD actually had some other diagnosable condition; 11 of cases that met diagnostic criteria for HD had been given some other diagnosis. Diagnostic errors could be reduced by documentation of the family history by systematic interviewing of relatives and by demonstration of the characteristic disorder of voluntary movement in addition to chorea.

The relationship of duration of illness and severity of neurological impairment to psychometric performance and activities of daily living was examined in 57 patients with Huntington's Disease (HD). As earlier studies suggested, a distinct cognitive profile characterized patients early in the disease. Duration of symptoms, however, proved to be a weaker correlate of cognitive decline than was motor impairment at the time of testing. For predicting adaptive functioning, both duration of symptoms and neurological status were important variables. This study underscores the limitations of length of illness as a classificatory variable in studies of dementia in HD. We further suggest that future studies consider the contribution of defects in precise timing and sequential operations to the cognitive and adaptive deficits of these patients.

OBJECTIVES: To detect cases of Alzheimer's disease (AD) in a large population of twins living throughout the United States and to examine concordance for AD in twins as a function of age and genotype for apolipoprotein E (APOE). SETTING: Nationwide survey. DESIGN: Multistage screening and field evaluation beginning with two telephone interviews and culminating with laboratory tests, longitudinal neuropsychological measures, physician examination, and diagnostic consensus among experts. PARTICIPANTS: Membership in 1990-1991 of intact pairs in the National Academy of Sciences—National Research Council Registry of veteran twins, then aged 62 to 73 years. MAIN OUTCOME MEASURES: Completeness of case detection was examined in collateral studies. Zygosity and APOE genotypes were determined by restriction mapping. Concordance was calculated by the proband method. RESULTS: Ninety subjects who screened positively for AD were studied in person, and 60 whose differential diagnoses included AD were followed up, as were their cotwins. Sensitivity of screening was estimated at greater than 99%, but 24% of subjects refused participation after initial screening. Seven of 38 diagnoses of AD have been confirmed at autopsy, and 31 other subjects eventually met criteria for probable or possible AD (prevalence estimate, 0.42%; 95% confidence interval, 0.29% to 0.56%), with good interrater reliability (intraclass r=.86). Excluding one discordant pair with unknown zygosity, concordance rates were 21.1% (4/19) for monozygotic and 11.1% (2/18) for dizygotic probands. Concordance was 50% for twins sharing the ε4/ε4 genotype at APOE, but there were no affected co-twins of 15 probands with onset before age 70 years, no ε4 allele, and no family history of AD. The mean (SD) period of discordance in the latter pairs was 11.3 (3.3) years. CONCLUSIONS: The multistage case-detection approach achieved reliable and valid diagnoses of AD with high apparent sensitivity but substantial attrition after initial screening. Genetic influences in AD at this age are limited, except among homozygotes for allele ε4 at APOE. Subjects with early-onset AD who lack the ε4 allele are not rare, and their condition appears to have little genetic influence. They should be ideal for studies on environmental causes of AD.

OBJECTIVES: To develop an informant-based semistructured interview to determine the onset and duration of symptoms of Alzheimer's disease, and to use this instrument with informants to characterize a cohort of mildly impaired patients with Alzheimer's disease. DESIGN: In study 1, interrater and interinformant reliability was examined for the date of onset and the order of appearance for specific symptoms that were elicited by the semistructured onset interview. In study 2, the instrument was used to characterize disease onset in a cohort of patients with Alzheimer's disease who were participating in a large multicenter study. SUBJECTS: Informants of patients with Alzheimer's disease. RESULTS: In study 1, interrater reliability for duration of illness was excellent (intraclass correlation coefficient=.99, P<.001), and interinformant reliability was good (intraclass correlation coefficient=.86, P<.001). Agreement for the presence of a given symptom was highest for those that were most commonly reported (eg, memory and performance difficulty). In study 2, 89% of the cohort had memory problems, and 63.9% had performance difficulties as the first or second symptom. Depression and language problems were less commonly reported. Psychosis and behavioral disturbances were rarely reported as the first problem. CONCLUSION: This instrument provides a reliable procedure for standardizing the estimation of duration of illness based on retrospective report.

OBJECTIVE: To determine whether patients with Alzheimer's disease (AD) who do not have historical or clinical evidence of stroke but who do have computed tomographic or magnetic resonance imaging evidence of noncortical lesions smaller than 2 cm or periventricular "caps" differ from other patients with AD. METHODS: The computed tomographic or magnetic resonance imaging scans of 158 patients meeting criteria of the National Institute of Neurological Disorders and Stroke—Alzheimer's Disease and Related Disorders Association for probable AD were reviewed by one neuroradiologist. Two measures of disease severity—the Modified Mini-Mental State examination and the Blessed Dementia Rating Scale (Part I)—were subjected to two-way analysis of variance with scan type (computed tomography or magnetic resonance imaging) and lesion number as between-group factors and age and disease duration as covariates. RESULTS: No relationship was seen between lesion number or periventricular caps and disease severity. CONCLUSION: In this cross-sectional analysis using these clinical measures, patients with AD who have well-defined radiographic abnormalities cannot be differentiated from patients with AD who do not have them.

Hospitalized patients with anorexia nervosa N 17 or bulimia N 11 were given a standard liquid meal containing 400 calories. Using analogue scales, bulimic patients were found to have greater anxiety, lower mood, lower sexual arousal, and more fear of fatness than either control or anorectic patients. This finding of increased general “dysphoria” in bulimic patients persisted after the meal without any significant premeal to postmeal changes. Anorectic patients also differed from controls, but less than the bulimic patients. Some measures of anxiety correlated significantly with body mass index before the meal in bulimic patients, whereas in anorectic patients the correlation was significant only after the meal.

A hand-held tachistoscope for use at the bedside was constructed and used to examine 40 normal controls and 170 psychiatric and neurological patients. This instrument quickly provided an index (perception time) which distinguished between idiopathic psychiatric illness and delirium, and between cortical and subcortical neuropathology. Slow perception time was seen in patients with delirium or cortical neuropathology.

Fifty-four patients with Alzheimer's disease performed on the Dementia Assessment Battery that comprised of finger tapping, forward digit span, naming, verbal memory, visual memory, Token Test, digit cancellation, word-list generation, symbol-digit substitution, and copying geometric designs. Four forms of the battery were administered at weekly intervals. The equivalence of the forms, the relative difficulty of the tests, retest reliability, and factorial composition of the battery are presented. Performance improved with repetition. Impairments in visuo-spatial and verbal abilities were independent of each other. The fragility of the patients' working memory was identified as a main cause for their poor recall. The importance of "component analysis" in individual assessment is illustrated.

Psychiatrists, using a standardized clinical method, examined a probability sample of 810 subjects in eastern Baltimore and made diagnoses of mental disorders among those subjects according to DSM-III criteria. The authors estimated that there were 4.6 active cases of schizophrenia per 1000 adult noninstitutionalized population, and 6.4 cases per 1000 population, including both active and remitted cases. Among the 17 active and remitted schizophrenics identified in the survey, one half were not receiving any form of mental health services at the time of the survey; these data yield a prevalence rate of untreated cases of 3.1 per 1000 population. All of the untreated schizophrenics were deemed by the examining psychiatrist to be in need of services.

The prevalence and significance of clinical heart disease and hypertension were compared in three groups of elderly patients. One group was diagnosed as dementia of an Alzheimer's type (AD), another as multiinfarct dementia (MID), and the third as major depression. Clinical heart disease and hypertension were uncommon in the AD group with the prevalence being lower than that reported in most epidemiologic studies. Four percent of the AD patients had a history of myocardial infarction, 5% angina, 1% arrhythmias, and 3% heart failure. Electrocardiographic changes of an old myocardial infarction were present in 9%, atrial fibrillation in 1%, and left ventricular hypertrophy in 3%. A history of hypertension was present in 24% of the AD patients. In comparison, a history of myocardial infarction, angina, and heart failure was five times greater, and electrocardiographic abnormalities were twice as prevalent in the MID group. A history of hypertension was three times more common and actual blood pressure readings were higher. In the depression group heart disease was not uncommon and the prevalence, in general, was comparable with the MID group. However, a history of increased blood pressure and actual increased blood pressure readings were statistically less than in the MID group. (J Am Geriatr Soc 33:530, 1985)

Investigators have reported poor recognition of dementia by primary physicians. For this reason, mental status examinations were performed on 72 demented and 144 nondemented medical inpatients to assess the sensitivity, specificity, and predictive value of components of this examination in the diagnosis of dementia. Sensitivity of individual level‐of‐orientation items was low (15.3 to 56.9%), though specificity was high (91.7 to 100%). Sensitivity of several nonorientation items was high (80.6 to 100%), though specificity was low. A multivariate discriminant equation using both orientation and nonorientation items achieved high sensitivity (89.6% test cases, 87.5% validation cases) and specificity (78.1% test cases, 87.5% validation cases). Adding the easily obtained patient characteristic of age to the equation further increased sensitivity (95.8%, 91.3%), while maintaining specificity (82.3%, 85.4%). From these results, it is concluded that the level‐of‐orientation screening examination used by clinicians to detect dementia is unacceptably insensitive. In contrast, a composite decision rule including nonorientation items achieves high sensitivity with relatively high specificity.

In order to determine the meaning of cognitive impairment in community dwelling elderly, 3,481 adults were interviewed in their homes using the Mini‐Mental State Examination. Ninety‐six per cent of the population aged 18–64 scored 23 or higher, whereas 80 per cent of the population 65 and over scored 23 or higher. Individuals with low scores were suffering from a variety of psychiatric disorders including dementia. Thirty‐three per cent of the elderly population scoring in the range of 0–23 had no diagnosable DSM‐III condition. Prevalence of dementia from all causes was 6.1 per cent of the population over age 65. Two per cent of the population over age 65 were diagnosed as having Alzheimer's disease

Six hundred fifty‐one psychiatric consultations performed during a one‐year period were reviewed retrospectively. Cognitive impairment was present in 54 per cent and depression in 27 per cent of the elderly patients in the population studied. A second study of the point prevalence of cognitive and emotional disorders in the hospital was carried out using the Mini‐Mental State Exam and the General Health Questionnaire. Emotional disorders had similar prevalences in all age groups but cognitive disorders were more common in the elderly. Twenty‐one per cent of consultations were done on patients over the age of 60, although elderly patients occupied 28.5 per cent of hospital beds. Thus, elderly patients were less often referred for psychiatric consultation than younger patients, although the incidence of psychiatric disorders increases with age.

OBJECTIVES: Assessment of the relationship between visual function and functional status/quality of life in clinical research involving patients with eye disease by investigating whether the scores of four existing functional status/quality of life patient questionnaires are sensitive to differences in visual acuity and studying whether selected subscales of the questionnaires provide similar information concerning the relationship between functional status/quality of life and visual acuity as do the respective full-length questionnaires. DESIGN, SETTING, PARTICIPANTS: Case patients consisted of 86 consecutive patients seen at The Wilmer Ophthalmological Institute Retinal Vascular Center, Baltimore, Md. Controls consisted of 51 individuals with normal visual acuity and no known ocular disease and were frequency-matched to the case patients by age (±5 years), sex, and race. Subjects were interviewed in person using each of the following questionnaires: the Sickness Impact Profile, the vision-specific Sickness Impact Profile, the Community Disability Scale, and the General Health Questionnaire. RESULTS: Scores of all four questionnaires and their subscales were significantly associated with visual acuity. The vision-specific Sickness Impact Profile and the Community Disability Scale were independently significant predictors of visual acuity. Regression analysis revealed that in our study, selected subscales of the respective full-length questionnaires were able to demonstrate the association between vision and functional status/quality of life. CONCLUSIONS: Ophthalmic patients are at high risk for decreased functional status/quality of life. Subscales of existing questionnaires potentially may be substituted for the full-length questionnaires, thereby increasing the efficiency of functional status/quality of life measurement in such patients.

A number of new methods for the assessment of cognitive impairment, depression, anxiety, delusions, and hallucinations, as well as a variety of abnormal behavior, are now available for use in elderly populations. The findings, using a variety of rating scales, are beginning to converge confirming the validity of this methodological approach.

This study examined the prevalence of memory complaint and poor memory performance on brief screening measures within a community sample of 810 adults. All individuals received an extensive household interview and a clinical psychiatric evaluation. Overall, 22% indicated that they currently had trouble with their memory. This percentage increased with age, rising to 43% for those 65 to 74 years old, 51% for those 75 to 84 years old, and 88% for those 85 years of age and older; the percentage indicating memory problems decreased with educational attainment. The prevalence of poor memory performance was 11%, also increasing with less education and increased age, rising to 26% for those 65 to 74 years old and to 40% for those older then 75. Those who complained of memory trouble were twice as likely to show poor memory performance (29%) compared with those who did not complain (15%). Multivariate analysis found age, emotional distress, and physical illness to be independent predictors of memory complaint; age, functional disability, education, and physical illnesses proved to be independently associated with poor memory performance. A higher prevalence of complaints of memory trouble was found not only for those with affective disorders, as might be expected, but also among those with schizophrenic, cognitive, anxiety, and adjustment disorders. However, only individuals with cognitive disorders showed a higher prevalence of poor memory performance.

Progressive cognitive impairment is a defining feature of the dementia of Alzheimer's disease (AD), yet disagreement exists over which abilities decline most precipitously and which cognitive tests are most sensitive. In this study, 51 AD patients in the early to middle stages of illness and 22 age-matched normal controls were administered a battery of neu ropsychological tests at 6-month intervals over a 2-year period. While the performance of the normal controls remained stable over the 2 years, the AD patients displayed progressive decline on all tests. The greatest declines occurred on tests requiring lexical/semantic processing (Boston Naming Test) and comprehension of syntactic relationships (Token Test). Performance on visuospatial tests (Wechsler Adult Intelligence Scale-Revised Block Design, Benton Visual Retention Test, Spatial Delayed Recognition Span Test) declined less rapidly. The findings support previous reports that language impairment may be central to the dementia of AD, and that confrontation naming is particularly sensitive to decline in this illness.

Because there are both treatable and untreatable causes of dementia, the physician's ability to conduct (or refer a patient for) a differential diagnosis could have a profound effect on health outcomes for patients and on health care costs. This study was undertaken to assess physician practices with regard to the diagnosis of dementing disorders. Data from 53 physicians (a response rate of 48%) in several specialties were obtained from a self‐administered mail questionnaire. Results indicate that the majority of physicians provided history taking, physical examination, and neurological examination. Physicians were more likely to refer patients for psychiatric and neuropsychological examinations than to provide these services themselves. The results also point to deficiencies in two key areas: the use of formal, published diagnostic criteria, and the use of mental status and cognitive function tests. Over 75% of physicians surveyed did not use either DSM‐III or NINCDS‐ADRDA diagnostic criteria, and 42% of physicians did not provide any mental status tests themselves. The need for continuing education to close knowledge gaps is emphasized.

• To determine how accurately dementia was diagnosed among medical inpatients, we compared the judgments of medical interns with diagnoses based on standard criteria. Fifty-seven interns rendered opinions regarding the presence of dementia in 380 medical inpatients who were simultaneously examined by physician-investigators applying criteria derived from DSM III. The sensitivity and specificity of diagnosis by interns were 79% and 80%, respectively. Patients who were misdiagnosed as demented were less likely to be high school graduates than their correctly classified nondemented counterparts, and those with unrecognized dementia were more likely to be younger than 65 years than patients whose dementia was recognized by house staff. It is concluded that misdiagnosis is related to age and educational status and that attention to these factors may improve diagnostic accuracy.(Arch Intern Med 1984;144:73-75)