International Journal of Geriatric Psychiatry

Heinik, Jeremia; Werner, Perla; Mendel, Anda; Raikher, Boris; Bleich, Avi

doi: 10.1002/(SICI)1099-1166(199912)14:12<1006::AID-GPS47>3.0.CO;2-5pmid: N/A

Background and purpose The CAMCOG is the second most popular cognitive testing instrument in use by Israeli clinicians. The present study examines the reliability and validity of a Hebrew version of the CAMCOG in a group of dementia sufferers in a clinical setting. Method Study participants included 36 dementia sufferers and 19 control non‐demented, depressed elderly subjects, consecutive referrals to an outpatient psychogeriatric service and an ‘open’ ward of a psychiatric hospital. Operational clinical criteria for dementia and its subtypes and for the various forms of depression were used as the ‘gold’ standards. The CAMCOG was translated into Hebrew and then back to English. Seven items needed modifications for local usage. Results Interrater and test–retest scores calculated as exact agreement rates ranged from good to excellent for all items, although test–retest reliability scores were generally lower than interrater scores. Kappa statistics ranged from good to excellent for all but one item in the interrater scores and for two items in the test–retest scores. A strong convergent validity was found with the MMSE score (r=0.89, p<0.01). The 79/80 cutoff point provided moderate sensitivity (57.9%), excellent specificity (97.2%) and a strong predictive value (83.6%). Conclusion The Hebrew version of the CAMCOG was found to be an appropriate instrument to discriminate between demented and non‐demented depressed controls in a clinical setting. In light of the demographic, cultural and linguistic heterogeneity of the Israeli elderly population, further studies should examine the psychometric characteristics of the CAMCOG in a more varied sample and also using other cutoff points in order to establish if an increase in its discriminatory power is obtainable. Copyright © 1999 John Wiley & Sons, Ltd.

Marraccini, Rory L.; Reynolds, Charles F.; Houck, Patricia R.; Miller, Mark D.; Frank, Ellen; Perel, James M.; Cornes, Cleon; Mazumdar, Sati; Kupfer, David J.

doi: 10.1002/(SICI)1099-1166(199912)14:12<1014::AID-GPS52>3.0.CO;2-Ipmid: N/A

The authors assessed the severity of nortriptyline's side‐effects in older patients with recurrent major depression during placebo‐controlled, double‐blind maintenance therapy. Data were from 37 patients completing 2–3 years of maintenance therapy; 29 were on nortriptyline and eight were on placebo. The authors detected a time‐by‐treatment interaction for dry mouth (greater in nortriptyline‐treated patients), but no increased association of nortriptyline with constipation, weight change or orthostatic symptoms. Heart rate was consistently higher in nortriptyline‐maintained patients as compared with placebo. The total ‘side‐effect’ score on the Asberg Rating Scale, as well as complaints of physical tiredness, daytime sleepiness and nocturnal sleep disturbance, were related primarily to residual depression rather than treatment with nortriptyline. Copyright © 1999 John Wiley & Sons, Ltd.

Derouesné, Christian; Thibault, Stéphanie; Lagha‐Pierucci, Samira; Baudouin‐Madec, Véronique; Ancri, Daniel; Lacomblez, Lucette

doi: 10.1002/(SICI)1099-1166(199912)14:12<1019::AID-GPS61>3.0.CO;2-Fpmid: N/A

Objective To study the unawareness of cognitive deficits in patients with mild dementia of Alzheimer type (DAT). Design Retrospective study. We surveyed the medical records of outpatients meeting the NINCDS–ADRDA criteria for probable DAT who were able to complete the Cognitive Difficulties Scale (CDS) and had a close informant relative (IR) who could complete the family form of the same questionnaire. Setting A department of neurology in a general teaching hospital. Subjects Eighty‐eight patients, aged 73.2±8.6 years with a mean MMSE score of 22.5±3.2. Fifty‐two of the 88 patients had a follow‐up examination after a mean interval of 21 months. Methods Awareness of cognitive deficits was mainly assessed as the difference between the scores on the CDS completed by the IR and the patient (Index of Unawareness, IU). Two secondary assessments of unawareness were performed: (1) an assessment by the clinician on the basis of the patient's answers to questions probing the awareness of memory deficits; (2) an evaluation by the IR of the frequency of behavioural manifestations of unawareness in everyday life. SPECT was performed in 78 patients to study the relationship between unawareness and the topography of perfusion deficits. Results Awareness of the cognitive deficits varied greatly between patients, according to the assessment method used and the stage of progression of the disease. Most patients with mild DAT were cognitively aware of their cognitive deficits but failed to appraise their severity and their consequences in everyday life. Decreased awareness was positively correlated with age and perfusion deficits in the frontal regions and negatively with the anxious symptomatology. However, the main correlate of unawareness was apathy. Conclusion The nature of unawareness of cognitive deficits appeared to be more dimensional than categorical. In patients with mild dementia, decreased awareness appeared to be more related to affective disturbances, especially to emotional deficit or apathy, than to cognitive deficits. Copyright © 1999 John Wiley & Sons, Ltd.

Saz, Pedro; Launer, Lenore J.; Día, José‐Luis; De‐La‐Cámara, Concepción; Marcos, Guillermo; Lobo, Antonio

doi: 10.1002/(SICI)1099-1166(199912)14:12<1031::AID-GPS59>3.0.CO;2-Vpmid: 10607970

Objective To analyse the relationship between mental disorders and mortality rates in the elderly community of Zaragoza, Spain. Methods Baseline, cross‐sectional study (two‐stage screening) of a representative, stratified sample (N=1080) of the elderly (65+ years) living in the community. Follow‐up study (4.5 years). Instruments: Spanish versions of Geriatric Mental State, AGECAT computerized diagnostic program and Mini‐Mental Status Examination. Results Two hundred and sixteen subjects died during the follow‐up period (global mortality rate 4.8% per year). Using a logistic regression model with sex, age, educational level, physical illness and AGECAT diagnoses as explanatory variables and alive/dead as response, the following odds ratios (95% confidence intervals in parentheses) were obtained (reference group: non‐cases): ‘subcases’ 1.3 (0.9–2.0), ‘organic’ (dementia) 3.7 (2.0–6.7), global depression 3.0 (1.7–5.3), ‘psychotic’ depression (melancholic type) 3.7 (1.7–8.4), ‘neurotic’ depression 2.7 (1.4–5.3) and ‘neuroses’ 0.8 (0.2–3.6). Both pure ‘organic’ and pure ‘depressed’ cases had higher mortality when compared with comorbidity cases. Conclusion There is a significant association between psychiatric morbidity and mortality in the elderly living in a Spanish community. Mortality risk in psychiatric cases are higher than previously reported in the literature. Copyright © 1999 John Wiley & Sons, Ltd.

Treloar, A. J.

doi: 10.1002/(SICI)1099-1166(199912)14:12<1039::AID-GPS60>3.0.CO;2-Cpmid: 10607971

Advance directives (ADs) are increasingly used and are seen as a way of directing care after the loss of mental capacity. There are, however, major potential problems associated with their use. They may require the withholding of treatment that will alleviate suffering, and have the potential to cause patients to lose abilities and live with unnecessary suffering or handicap. In short, they may fail to achieve what the patient intended, and may cause outcomes that the patient never intended. The requirements for a valid AD are discussed and a simple model for doctors to assess the validity of ADs is proposed. Doctors will need to become much better at understanding the limitations of mental capacity, and quick mechanisms for rebutting ADs will be needed. In general, this is likely to be when ADs appear to conflict with good clinical care and the best interests of the patient. The prospect of legislation on ADs is not welcomed by the author. Copyright © 1999 John Wiley & Sons, Ltd.

Sheehan, Bart; Banerjee, Sube

doi: 10.1002/(SICI)1099-1166(199912)14:12<1044::AID-GPS55>3.0.CO;2-0pmid: 10607972

Somatization is a common medical problem encountered at all levels of medical care. It is strongly associated with use of services and may be difficult to treat. Somatization in the elderly has been traditionally seen as a masked presentation of depression. Population studies have shown no consistent increase in somatization among the elderly, and the elderly may downplay physical symptoms. Among the elderly depressed, somatization is common and may be commoner if physical illness is also present. Psychological distress is usually acknowledged, not masked, in the elderly depressed. Neuroticism, as well as psychiatric illness, may be an important aetiological factor for somatization in the elderly. Treatment strategies must attend to underlying psychiatric disorders, but there is a need for studies of treatment of the phenomenon in the elderly. Copyright © 1999 John Wiley & Sons, Ltd.

Meyer, John S.; Rauch, Gaiane M.; Crawford, Kate; Rauch, Ronald A.; Konno, Shizuko; Akiyama, Hisanao; Terayama, Yasuo; Haque, A.

doi: 10.1002/(SICI)1099-1166(199912)14:12<1050::AID-GPS56>3.0.CO;2-Zpmid: 10607973

Objectives Factors accelerating cerebral degenerative changes represent potentially modifiable risks for cognitive decline. Putative risk factors accelerating subtle cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT densitometry, perfusions and cognitive testing among neurologically and cognitively normative ageing volunteers. Methods Two hundred and twenty‐four normative subjects at increased risk for cognitive decline were admitted to the study. Mean entry age was 59.5±15.8 years. Mean follow‐up is 4.3±3.1 years. At follow‐up, 22 developed subtle cognitive decline (δCCSE≥−3), 19 became demented, eight with vascular type (VAD) and 11 with Alzheimer's type (DAT) and 183 remain cognitively unchanged. Standardized questionnaires, medical, neuropsychological, neurological and blood work examinations were obtained. Cerebral atrophy, tissue densities and perfusions were measured by xenon‐enhanced CT. Results After age 60, cerebral atrophy, ventricular enlargement, polio‐ and leuko‐araiosis geometrically increased as perfusions declined. Risk factors accelerating perfusional decline, cerebral atrophy, polio‐araiosis and leuko‐araiosis (thinning of grey–white matter densities) were: transient ischaemic attacks (TIAs), hypertension, smoking, hyperlipidemia, male gender. At age 71.5±11.9, subtle cognitive decline began, accelerated by TIAs, hypertension and heart disease. Leuko‐araiosis began before cognitive decline. TIAs, hypertension and hyperlipidemia correlated with VAD. Excessive cortical perfusional decreases and cerebral atrophy correlated with cognitive decline. Family history of neurodegenerative disease correlated with DAT. Conclusion TIAs, hypertension, hyperlipidemia, smoking and male gender accelerate cerebral degenerative changes, cognitive decline and dementia. Copyright © 1999 John Wiley & Sons, Ltd.

Sinoff, Gary; Ore, Liora; Zlotogorsky, David; Tamir, Ada

doi: 10.1002/(SICI)1099-1166(199912)14:12<1062::AID-GPS67>3.0.CO;2-Qpmid: 10607974

Introduction The Short Anxiety Screening Test (SAST), an easily administered rating scale, was developed to standardize the detection of anxiety disorder in the elderly, even, and especially, in the presence of depression. The instrument also included somatic complaints, often the manifestation of anxiety in the elderly. Failure to relate to the anxiety component in depression may result in the initial failure of antidepressant therapy. Objective To validate the SAST in the elderly, especially in the presence of depression. Design The SAST was validated against a psychiatric evaluation in consecutive patients attending a geriatric service, both inpatient and outpatient. The initial validity of the SAST was tested in all the sample and subsequently in the subgroups of depressed and non‐depressed. Setting An urban geriatric service in Israel. Patients One hundred and fifty medical inpatients and outpatients, 95 females, aged 70 years and older. Measures Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM‐IV as criterion standard for anxiety and depression, SAST for anxiety and short Zung Interview‐Assisted Depression Rating Scale for depression. Results By the psychiatrist's evaluation, 40.7% suffered from anxiety. Mean SAST scores in the presence and absence of anxiety were significantly different (25.3 and 20.1; p<0.0005). The overall validity of the SAST was high (sensitivity 75.4%, specificity 78.7%). In the presence of depression, sensitivity was 83.3% and specificity 70.5%. Conclusion The SAST was valid in detecting anxiety in the elderly, as well as in depressed patients. The study proved the usefulness of the SAST in a geriatric assessment programme. Copyright © 1999 John Wiley & Sons, Ltd.