Despite a growing list of potential new risk factors for Alzheimer's disease (AD), one of the oldest remains controversial. Is female gender a risk factor for AD? It is likely that the greatest influence on the gender differential in crude prevalence rates is the increasing incidence of dementia with age (Paykel et al., 1994) combined with the greater longevity women (Moritz & Ostfeld, 1990). This must be distinguished from the hypothesis that there may also be a gender difference in the age-specific prevalence rates some dementias such as AD. In turn, this could be due to either a higher incidence dementia in women, or to longer survival times in women following diagnosis. What is the evidence for these hypotheses?

Objective: Despite considerable data from a number of countries regarding psychotropic utilization in long-term-care facilities for the elderly, there has been a lack of similar data from Canada. The purpose of this study was to gather prescription data from a series of institutions in Ontario and to compare the results to those of other international studies. Method: Single-day surveys were carried out in six homes for the aged, four nursing homes, two retirement homes, and a veterans' center. The results were compared to those of recent studies from other countries. Results: The data revealed considerable differences in rates of prescription between different classes of institutions and between similarly classified institutions. The prescription rate of neuroleptics ranged from 11.8% (of patients) in retirement homes to 29.8% in nursing homes. Antidepressant use ranged from 12.2% in nursing homes to 24.6% in homes for the aged, and benzodiazepine use ranged from 22.5% in nursing homes to 36.4% in retirement homes. Conclusions: The overall rate of prescription for psychotropic medications was somewhat lower than in most international studies. The rate of prescription of neuroleptics in nursing homes fell in the midrange of studies, somewhat higher than in recent studies from the United States and an earlier Italian study, but lower than in recent reports from Sweden, Austria, and Australia. The rate of neuroleptic use in homes for the aged was comparable to the rate in the U.S. studies. The overall rate of prescription of antidepressants and benzodiazepines appears to be comparable to that in recent studies from other countries.

Background: Previous studies of dementia and family caregiving have focused on individuals seeking diagnosis and treatment, and have rarely been conducted in representative community samples. Identifying demented individuals participating in a community survey, we determined (a) the factors associated with demented elderly living alone; (b) the factors associated with the demented elderly having caregivers; (c) the factors associated with increased levels of burden among caregivers of persons with dementia. Population and Methods: During an epidemiological survey of a mostly rural U.S. community, the authors identified 116 noninstitutionalized elderly individuals with dementia. These individuals were classified into those living alone and those living with others; both groups were further classified into those with an without identifiable family caregivers. Characteristics of both caregivers and care recipients were examined. Results: Approximately a third of the subjects with dementia lived alone, and only half of them had caregivers. The average age of the caregivers was 67.4 years, and 73% of them were women. Almost half of the caregivers were spouses, whereas almost a third were offspring, of the demented individuals. Over two thirds of caregivers lived with the subjects. Female caregivers were significantly younger than male caregivers. Multivariate analyses revealed that subjects with dementia who were living alone were independently and significantly more likely to be women and to have dementias of shorter duration, lesser severity, and lesser functional impairment than those living with others. Demented subjects with caregivers were more likely to have greater dementia severity, functional impairment, and cognitive impairment and more current cognitive and behavioral symptoms than those without caregivers. Demented subjects whose caregivers reported higher levels of burden were more likely to be women and to have greater dementia severity, functional impairment, and cognitive impairment and more current symptoms than those whose caregivers had no/minimal burden. Conclusions: These results draw attention to the problems of persons with dementia living alone, particularly those without caregivers. Our data also provide epidemiological confirmation of previous clinical/volunteer studies of dementia caregiving, as well as a preliminary assessment of need in the community at large. Living arrangements and caregiver issues should be taken into account when planning services for the elderly.

Background: Demographic changes indicating a general aging of the population suggest that the key role of general practitioners (GPs) in the diagnosis and management of dementia becomes more salient. The encouragement of GPs to collaborate with specialists is one chance to support GPs in performing a variety of functions associated with the diagnosis and management of dementia. Method: We used a questionnaire to investigate the role of referrals in diagnosing dementia at the primary care level and variables potentially influencing the referral behavior of German GPs (n = 563). Results: Only 31% of the GPs stated that the diagnosis of dementia was made predominantly in the context of referral to a specialist. The chance that referrals were made was increased for those GPs who entertained extensive cooperative relationships with self-help groups, psychologists, or the “Alzheimer Society”/“Brain League” (odds ratio [OR] 1.74) and for those GPs who perceived a great preparedness on the part of the relatives of the patient to comply with a referral (OR 2.29) as well as who noticed a great readiness among specialists to accept patients for the diagnosis of dementia (OR 2.55). GPs whose therapeutic orientation was shaped by further training and scientific literature were more likely to refer (OR 3.54). Discussion: Enhancing the liaison between GPs and specialist physicians by improving the psychogeriatric competence of GPs as well as the connection to nonmedical services is discussed.

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.

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.

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.

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.

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.

In order to investigate to what extent various determinants in the decision-making process for the treatment of severely ill incompetent patients are influenced by cultural and sociopolitical factors, 540 physicians in Austria, Germany (East and West), and Sweden, countries representing different healthcare systems, were surveyed using a self-administered questionnaire. It provided three case vignettes with different levels of information about the patient's treatment wishes in case of incompetence in a life-threatening situation. We found a general trend to a lower level of treatment in line with the patient's wishes when the information provided was more detailed. Remarkably, a substantial number of doctors did not comply with the patient's wishes. Ethical concerns and patient's wishes appeared as the most important factors whereas religious beliefs of the physician and hospital costs scored lowest. Because of the variability of treatment decisions and the importance of various factors determining the decision-making, an advance directive may be a feasible way of reducing the number of conflicts in critical situations. We recommend that ethical issues of clinical practice should be emphasized in the medical curriculum and in the training of physicians.

The aim of the report was to study clinical differences between psychotic late-life depression and psychotic depression in younger patients, to determine if differences were age-related or specific for psychotic late-life depression. Three hundred seventy-six consecutive outpatients, presenting for treatment of unipolar or bipolar depression (with or without psychotic features), were assessed by means of the Structured Clinical Interview for DSM-IV, the Montgomery and Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. Results showed that psychotic late-life (50 years or more) depression, versus psychotic depression in younger patients, was associated with significantly higher age at study entry/onset, longer duration, and lower comorbidity. Psychotic depression versus nonpsychotic late-life depression, in late-life and in younger patients, was associated with significantly greater severity, lower comorbidity, more patients with bipolar I disorder, and fewer patients with unipolar disorder. Findings were related to psychosis or to age, and not to specific features of psychotic late-life depression. These results support a unitary view of psychotic depression.