Samuel Johnson, at age 76, wrote about “this world where much is to be done and little to be known.” Two hundred years later, in the world of psychogeriatrics, too little is known about what is done. This becomes quite apparent at scientific meetings—especially international ones—where information is exchanged about new research and evolving ideas. Unfortunately, while research findings are more likely to find their way to dissemination via publication in a professional journal, innovative service and service delivery developments are less likely to be readily or adequately disseminated via the written word.

Mental disorders and illnesses in old age are not an inescapable fate, particularly if physicians can look beyond the medical aspects of an illness to the potential interpersonal, familial, and social influences. Indeed, the different factors involved in the genesis of mental disorder intertwine to form an intricate network, from which it is very difficult to isolate single components. Moreover, the importance of the components that trigger an acute mental disorder and shape the course and diversity of the symptomatology can continue to change. The interweaving of different pathogenic factors contributes further to the diversity and ambiguity of the clinical symptomatology.

Alzheimer's disease affects an estimated 2 million elderly in the U.S. and challenges primary care physicians to assist caregivers in dealing with the daily management of these patients. To support the clinical observation of weight loss in Alzheimer patients despite adequate food intake, we reviewed the existing literature. To date, eight international studies have focused on nutrition in Alzheimer's disease and all have found weight loss. It is not clear whether this weight loss is a component of or a consequence of the disease.

These findings suggest systemic, metabolic alterations in Alzheimer's disease. They require further investigation as to their nature and as to their appropriate recognition and management to retard the deteriorating effects of chronic weight loss and malnutrition. Finally, some reports lead to speculation that nutritional strategies may improve cognitive function.

Neuropsychopharmacological research in our time is a most exciting and challenging task and comparable in significance to the early period of research on antibiotics. Since the beginning of the psychopharmacological era in 1952, when chlorpromazine was first prescribed for psychiatric patients, a revolutionary development in psychiatric treatment has been set in motion. Subsequently, the extremely important discovery of psychoactive drugs with distinctly different pharmacodynamic properties substantiated that structurally different substances can affect different mental functions.

There is increasing evidence that mildly impaired patients with Alzheimer's disease (AD) may be distinguished from mildly impaired patients with multi-infarct cognitive disorder (MICD) by their degree of semantic memory impairment. However, despite these observed group differences, it is unknown whether AD and MICD patients differ in their ability to perform a broad array of functional activities required for daily living and the degree to which severity of cognitive impairment is associated with functional deficits. Using a measure assessing numerous functional domains within the clinical setting, we were able to directly compare the functional capacity of mildly impaired AD and MICD patients, as well as a more cognitively impaired AD group.

Although mildly impaired AD patients scored significantly lower on tests of semantic memory relative to their mildly impaired MICD counterparts, deficits in functional capacity were relatively equivalent. The AD group with more severe cognitive impairment scored lower on both memory and functional measures. A relatively high proportion of mildly impaired AD and MICD subjects evidenced impairment across a number of functional domains, suggesting that functional impairment may occur with relatively high frequency in these patient groups.

The IPA Research Awards were established in order to call attention to some of the most meritorious research being conducted in our field. Research is not only a rigorous enterprise, it can also appear at times to be a somewhat isolated enterprise. Clearly, it is necessary that investigators receive feedback and recognition for their efforts, particularly when these efforts are a benefit and/or a stimulus for the broader medical and scientific communities. The Research Awards are one mechanism by which investigators can receive richly deserved recognition for their contributions.

A double-blind randomized trial was performed involoving 162 patients with age-associated memory impairment (AAMI) selected and followed by their general practitioners. Two intervention methods—a drug and a cognitive therapy—were assessed in combination. Three randomized parallel groups of 54 patients each, aged 55 years and, over, were followed and treated for 3 months. After a placebo wash-out period of 10 days, one group received 2.4 g of piracetam, another group, 4.8g, and the third, a placebo. A total of 135 patients, 45 in each group, completed the study. Combined therapy was most effective in patients whose baseline performance on memory tests was lowest. The best results were observed with 4.8 g of piracetam, especially when training sessions began after 6 weeks of drug treatment. This result was confirmed by the global impression of the principal investigator.

Ubiquitin (Ub) was determined by a competitive enzyme-linked immunosorbent assay (ELISA) in serum (S) and cerebrospinal fluid (CSF) samples from 29 patients with ‘probable Alzheimer's disease’ (AD), 14 patients with vascular dementia (VAD), and 13 healthy individuals. The mean concentration of Ub in CSF (110 ± 20 ng/mL) was about 20% of that in serum (940 ± 120 ng/mL) in healthy controls. There was no significant correlation between S-Ub and CSF-Ub, or between the CSF/S Ub ratio and the CSF/S albumin ratio. These findings suggest that a major portion of CSF-Ub is intrathecally produced. CSF-Ub was increased while S-Ub was decreased in both AD and VAD patients as compared with controls. As a consequence, the CSF/S Ub ratio showed good discrimination between patients and controls: 22/29 (76%) of the AD patients and 9/14 (64%) of the VAD patients had a CSF/S Ub ratio that was higher than the highest control value. No significant differences in any of the parameters were found between AD and VAD. Ub is involved in an ATP-dependent proteolytic pathway and also acts as a heatshock protein. The increase in CSF-Ub in AD and VAD may therefore be interpreted as a cytoprotective response to abnormal or damaged proteins, and CSF-Ub may have a potential as a non-disease-specific marker for cerebral degeneration.

In the last year, there has been increased research interest in the sensitivity and applicability of activities of daily living (ADL) scales for the detection of early behavioral dysfunction and efficacies in drug trials. At the September 1993 meeting of the Sixth Congress of the International Psychogeriatric Association (IPA) in Berlin, Germany, no fewer than three symposia and 16 papers focused on the use of ADL scales. For example, a symposium chaired by Hindmarch and Erzigkeit (1993) described an international collaborative effort to improve the sensitivity of ADL scales, and a paper by Sclan, Schmidt-Gollas, and Erzigkeit (1993) addressed the following issue: “Clinical drug trials and assessment of functional changes in cognitively impaired elderly persons: Do we need another rating scale?”

To determine the relationships between clinical and brain function in persons with a familial risk for Alzheimer's disease, the authors assessed subjective and objective cognitive abilities, mood state, and cerebral glucose metabolism (using positron emission tomography) in 43 persons with age-associated memory impairment, with and without first-degree relatives with a clinical diagnosis of Alzheimer's disease. Subjective complaints of memory loss, mood state ratings, and objective memory measures were similar in persons with a family history of Alzheimer's disease (n = 29) compared to those without such a history (n = 14). Metabolic ratios in the frontal regions correlated with a decrease in a specific type of subjective memory complaint (mnemonics usage; p < .001) and some mood state ratings. These results indicate that parietal and temporal hypometabolism is not evident in persons with mild age-related memory complaints, even when such subjects have a familial risk for Alzheimer's disease. Moreover, self-reports of mnemonics usage may be sensitive indicators of decreased frontal lobe function. Longitudinal study will determine whether such clinical and metabolic measures will predict eventual disease progression.

The Cognitive Abilities Screening Instrument (CASI) has a score range of 0 to 100 and provides quantitative assessment on attention, concentration, orientation, short-term memory, long-term memory, language abilities, visual construction, list-generating fluency, abstraction, and judgment. Scores of the Mini-Mental State Examination, the Modified Mini-Mental State Test, and the Hasegawa Dementia Screening Scale can also be estimated from subsets of the CASI items. Pilot testing conducted in Japan and in the United States has demonstrated its cross-cultural applicability and its usefulness in screening for dementia, in monitoring disease progression, and in providing profiles of cognitive impairment. Typical administration time is 15 to 20 minutes. Record form, manual, videotape of test administration, and quizzes to qualify potential users on the administration and scoring of the CASI are available upon request.

In this article a cost-comparison study of psychogeriatric outpatient and home consultations (if all outpatients are seen at home) is reported. The cost of home visits was estimated to be less than that for outpatient consultations. The results are discussed in the context of methodological difficulties and the advantages and disadvantages of home and outpatient consultations. In view of the many advantages of home-based consultations, including lower costs, it is concluded that we should be developing and evaluating services with greater emphasis on home-based consultations.

During the Sixth Congress, Dr. Barry Reisberg, Chair of the IPA Research Awards Committee, posed questions to the 1993 Research Awards Winners regarding the research presentations. Queries and the awardees' responses are presented in the formal discussion.

Similarities and differences in the way geriatric rehabilitation is viewed in the Federal Republic of Germany and in the United States are highlighted. The philosophy and goals of geriatric rehabilitation in both countries are basically similar. However, there are some differences, particularly in practice applications and in how the historical and social contexts of each country influence what is emphasized. This article traces the relevant knowledge components and practice application in each country and makes some comparisons. In addition, differences in how members of the geriatric team function are described, as well as the varying educational preparations of team members. Developments in both countries suggest that substantial integration of knowledge already has taken place. The continuation of this trend should bode well for the future.

In 1962, based on a study of nursing home residents, Kral suggested a distinction between benign and malignant senescent forgetfulness, the latter evolving to dementia and early death and the former remaining relatively static. Although this concept was never operationally described or validated, it clearly rang true with those working with the nascent specialty of geriatric psychiatry and rapidly entered standard textbooks on the subject. The burgeoning of interest in the elderly and the massive expansion of clinical and research work in the field of dementia in the eighties led to a widely expressed need for the development of criteria to categorize a group of subjects with memory problems falling short of dementia. The National Institute of Mental Health (NIMH) responded with the formation of a working group that published its suggested criteria for what Crook et al. (1986) called “age-associated memory impairment” (AAMI). Although some of the detailed components of these criteria have proved controversial, the term has been increasingly quoted in relevant literature and has given rise to specific studies. It has led to wide discussion, and related entities have been incorporated both in the draft of DSM-IV (as “aging-associated cognitive decline [AACD]” [American Psychiatric Association, 1993], an “additional condition that may be the focus of clinical attention”) and in the research criteria for ICD-10 (World Health Organization, 1993), where it is potentially classifiable under FO6.7 Mild Cognitive Disorder, although this does not specifically give aging as a cause. In arriving at our provisional criteria we have drawn to a great degree on these and other related publications that we are pleased to acknowledge.

In order to analyze whether the referral system and nature of care exert any effect on the characteristics of patients, subjects aged 60 or above attending three medical centers on the Hong Kong Island between August and December 1990 were studied with respect to their age, sex, and psychiatric diagnosis. Psychiatric diagnoses were made in 98% of subjects at the psychogeriatric assessment service (PAC) (predominantly chronic organic brain syndrome), in 79.6% at the university psychiatric unit (mainly acute psychiatric problems, substance abuse, and deliberate self-harm), and in 20% at the general outpatient clinic (largely sleep and anxiety-related disorders). There was overrepresentation of the very old (above 80) and underutilization of counseling service at PAC. In Hong Kong, the psychogeriatric needs of the very old and of those with minor emotional disturbances associated with aging, retirement, and bereavement deserve reassessment.

The 5-year prognosis for 264 depressed elderly Finns (60 years or older) living in the community and treated through the primary health care service is described. The majority of the patients were suffering from dysthymic disorder. It was found that 25% of the men and 35% of the women had recovered, 29% of the men and 24% of the women were still suffering from depression after the five-year period, 9% of the men and 11% of the women had become demented, 33% of the men and 26% of the women had died, and 4% of the cases were not contacted. The prognosis did not differ between the sexes, neither was it associated with age.

Poor psychic health and pronounced depressive symptoms at the beginning of the treatment, and the occurrence of a serious disease or a decline in functional capacities during the follow-up were related to a poor prognosis in both sexes. The specific disease group related to a poor prognosis in women was that of cardiovascular diseases. A close connection between a poor prognosis and a low socioeconomic status was found in the depressed men, while a favorable prognosis was shown for relatively healthy, even widowed, depressed women who moved to live alone during the follow-up period, women who increased their amount of physical exercise, and men and women whose hobby activities increased.

Estimates of the prevalence rates for dementia vary significantly among countries. Such variation may be explained, at least in part, by methodologic differences in studies. The disparities in prevalence rates of dementia subtypes, particularly Alzheimer's disease and multi-infarct dementia, are especially apparent in studies conducted in Eastern and Western countries. In Japan and China, the prevalence of multi-infarct dementia exceeds that of Alzheimer's disease, whereas in the West, Alzheimer's disease predominates in the vast majority of studies. Clearly, cross-cultural studies of incidence using standard methods are needed to investigate whether a true difference in risk exists, and which risk factors differentially contribute to this variation. Migrant studies of genetically homogeneous populations offer a unique opportunity to answer these questions. This article explores the value of migrant studies, their application to etiologic questions of dementia and its subtypes, and recommendations concerning how to conduct such studies.

Individuals with Alzheimer's disease (AD) have been shown to have abnormalities in response to fluid restriction. Twelve subjects with AD and ten elderly controls underwent overnight fluid restriction followed by measurement of plasma and urine vasopressin and serum osmolality. Estimates of “thirst” were determined after one hour of ad libitum water intake. All subjects were tested with a Mini-Mental State Examination (MMSE) and Global Deterioration Scale (GDS). Individuals with AD had a greater degree of overnight dehydration than the elderly control group (serum osmolality 310 +/−1 vs. 305 +/−1 mosmol/kg, p = 0.02). There was no difference between the groups in the plasma or urinary levels of vasopressin. There was a direct correlation (r = 0.45, p = 0.03) of the amount of water intake as a measure of “thirst” with the MMSE score as a measure of cognitive functioning. Individuals with advanced cognitive impairment may be at risk of dehydration due to loss of protective “thirst” responses with secondary complications of dehydration.