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Objectives: To examine the costs and cost-effectiveness of mirtazapine compared to placebo over 12-week follow-up.Design: Economic evaluation in a double-blind randomized controlled trial of mirtazapine vs. placebo.Setting: Community settings and care homes in 26 UK centers.Participants: People with probable or possible Alzheimer's disease and agitation.Measurements: Primary outcome included incremental cost of participants' health and social care per 6-point difference in CMAI score at 12 weeks. Secondary cost-utility analyses examined participants' and unpaid carers' gain in quality-adjusted life years (derived from EQ-5D-5L, DEMQOL-Proxy-U, and DEMQOL-U) from the health and social care and societal perspectives.Results: One hundred and two participants were allocated to each group; 81 mirtazapine and 90 placebo participants completed a 12-week assessment (87 and 95, respectively, completed a 6-week assessment). Mirtazapine and placebo groups did not differ on mean CMAI scores or health and social care costs over the study period, before or after adjustment for center and living arrangement (independent living/care home). On the primary outcome, neither mirtazapine nor placebo could be considered a cost-effective strategy with a high level of confidence. Groups did not differ in terms of participant self- or proxy-rated or carer self-rated quality of life scores, health and social care or societal costs, before or after adjustment.Conclusions: On cost-effectiveness grounds, the use of mirtazapine cannot be recommended for agitated behaviors in people living with dementia. Effective and cost-effective medications for agitation in dementia remain to be identified in cases where non-pharmacological strategies for managing agitation have been unsuccessful. [ABSTRACT FROM AUTHOR]

'Caring for carers' is high on the United Kingdom policy agenda for community care. Although recent policy advocates the provision of services directly to the carer, research suggests that an alternative way of helping carers is through targeting enhanced services towards the cared-for person. This paper reports a randomised controlled trial of the effects on carer distress of an additional specialist clinical assessment for vulnerable older people at risk of residential or nursing home placement. The sample was composed of 142 informal carers of older people, randomly assigned to receive either the additional specialist assessment or the usual social services assessment. Carers were assessed using the modified Social Behaviour Assessment Schedule (SBAS), and data were also collected on older peoples' service use throughout the study period. Regression analyses indicated that changes in older peoples' behaviour, as opposed to carer of service related factors, predicted changes in carer distress, and that the carers of the older people who experienced depressive symptoms received the greatest benefit from the specialist assessment. The study suggests that an effective means of improving outcomes for carers may be to target services towards the distressing behaviours of the person for whom they care, with symptoms of depression being particularly important. KEY WORDS--carers, older people, assessment, depression, distress.

Background: To produce a practice guideline that includes a set of detailed consensus principles regarding the prescription of antipsychotics (APs) amongst people with dementia living in care homes.Methods: We used a modified Delphi consensus procedure with three rounds, where we actively specified and optimized statements throughout the process, utilizing input from four focus groups, carried out in UK, Norway, and the Netherlands. This was done to identify relevant themes and a set of statement that experts agreed upon using the Research and Development/University of California at Los Angeles (RAND/UCLA) methodology.Results: A total of 72 scientific and clinical experts and 14 consumer experts reached consensus upon 150 statements covering five themes: (1) General prescription stipulations, (2) assessments prior to prescription, (3) care and treatment plan, (4) discontinuation, and (5) long-term treatment.Conclusions: In this practice guideline, novel information was provided about detailed indication and thresholds of symptoms, risk factors, circumstances at which APs should be stopped or tapered, specific criteria for justifying long-term treatment, involvement of the multidisciplinary team, and family caregiver in the process of prescription. The practice guideline is based on formal consensus of clinicians and consumer experts and provides clinicians relevant practical information that is lacking in current guidelines. [ABSTRACT FROM AUTHOR]

Background:Charles Bonnet syndrome (CBS) is defined as complex persistent visual hallucinations in the absence of mental disorder. It is common in conditions causing significant visual impairment. Many authors advise reassurance, considering the condition benign. However, others have suggested that CBS may in some patients represent the early stages of dementia. This review seeks to systematically examine the evidence for any link between CBS and cognitive impairment.Methods:Literature search using OVID Medline, PsychINFO, and Embase.Results:Three studies where cognitive functioning was the primary focus of the research were found. All were small, did not properly apply diagnostic criteria, and reported conflicting results. Eight other studies commented on cognitive functioning, but none used tests sufficiently sensitive to detect changes seen in early dementia. One hundred and thirty four case reports were scrutinized, and reports found of 16 patients with CBS where dementia emerged. High rates of partial insight at diagnosis of CBS were seen in these patients.Conclusions:There have been no adequately powered studies, using accepted diagnostic criteria, where changes in cognitive functioning were the primary outcome. Existing studies are of limited methodological quality and allow no conclusion regarding a relationship between cognitive impairment and CBS to be reached. Numerous case reports of dementia developing in patients with CBS and partial insight raise the possibility of a link between these conditions. There is a clear need for properly constructed studies to investigate this. [ABSTRACT FROM AUTHOR]

Background: Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes.Aims: To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia.Method: A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0-13 weeks and 0-39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods.Results: There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively.Conclusions: In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers. [ABSTRACT FROM AUTHOR]

Background: There is a high prevalence of subjective memory complaints (SMCs) amongst older adults, many of whom experience significant distress. It remains unclear why some older adults with SMCs experience more distress than others. The Common Sense Model of Illness Perceptions has been used to explain patients’ differential response to illness based on the beliefs they hold about their illness and subsequent selection of coping strategies. The present study aimed to examine the role of perceptions and coping styles in predicting anxiety and depression in older adults with SMCs.Methods: 98 participants with SMCs completed the Illness Perception Questionnaire for Memory Problems (IPQ-M), Ways of Coping Questionnaire (WCQ), Geriatric Depression Scale (GDS) and Beck Anxiety Inventory (BAI). Multiple regression analysis was used to determine the contribution of illness perceptions and coping to the explanation of variance in depression and anxiety.Results: Perceptions of SMCs were found to predict both depression and anxiety while coping strategies did not. Perceptions of serious consequences of SMCs and causal attributions predicted greater depression, while attribution of memory problems to lack of blood to the brain was the only predictor of increased anxiety.Conclusions: Illness perceptions predicted depression and anxiety in older adults with SMCs. Contrary to the Common-Sense Model coping style was not found to be an important determinant of psychological distress. The findings provide a basis for developing interventions to reduce psychological distress in older adults with subjective memory complaints. Targeting causal attributions and perceived consequences of SMCs may help to improve well-being. [ABSTRACT FROM AUTHOR]

Background: This study explores how the views of a panel of experts on dementia would affect projected long-term care expenditure for older people with dementia in England in the year 2031.Methods: A Delphi-style approach was used to gather the views of experts. The projections were carried out using a macro-simulation model of future demand and associated expenditure for long-term care by older people with dementia.Results: The panel chose statements that suggested a small reduction in the prevalence of dementia over the next fifty years, a freeze in the numbers of people in care homes, and an increase in the qualifications and pay of care assistants who look after older people with dementia. Projections of expenditure on long-term care that seek to capture the views of the panel suggest that future expenditure on long-term care for this group will rise from 0.6% of GDP in 2002 to between 0.82% and 0.96% of GDP in 2031. This range is lower than the projected expenditure of 0.99% of GDP in 2031 obtained under a range of base case assumptions.Conclusions: This paper attempts to bridge the gap between qualitative forecasting methods and quantitative future expenditure modelling and has raised a number of important methodological issues. Incorporating the panel's views into projections of future expenditure in long-term care for people with dementia would result in projected expenditure growing more slowly than it would otherwise. [ABSTRACT FROM AUTHOR]

Background: Subjective Memory Complaints (SMCs) are common among middle-aged and older adults and are often a source of distress and worry. However, rates of help-seeking are low. Investigating perceptions of SMCs may help us better to understand psychological reactions to SMCs and help-seeking behavior. The present study had two aims: (i) to investigate whether the dimensions drawn from the Common Sense Model of Illness Perception (Leventhal et al., 1984) provide a valid model of perceptions held by patients with SMCs; and (ii) to develop a questionnaire to measure these perceptions.Methods: Qualitative interviews to explore perceptions of SMCs were conducted with 32 participants recruited from a memory clinic and community groups. Information from these interviews was utilized to adapt the Illness Perception Questionnaire-Revised (IPQ-R) for use with patients with SMCs. Ninety-eight such patients then completed the adapted questionnaire along with measures of cognition, depression and subjective memory function.Results: The dimensions of illness perception measured by the IPQ-R were present in participant accounts of SMCs with the exception of Timeline Cyclical. The adapted measure (IPQ-M) showed good validity and reliability.Conclusions: The development of the IPQ-M provides opportunities for further investigation of illness perceptions and their relationship to psychological distress and help-seeking behavior in SMCs. Furthermore, investigation of these relationships may provide a basis from which to develop interventions to improve well-being and help-seeking in older adults with SMCs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Delirium is common in the elderly and is associated with high mortality and negative health outcomes. Reduced activity in the cholinergic system has been implicated in the pathogenesis of delirium. Cholinesterase inhibitors, which increase cholinergic activity, may therefore be beneficial in the treatment of delirium. METHODS: This is a double-blind, placebo-controlled randomized pilot study of the treatment of delirium with a cholinesterase inhibitor of patients admitted to hospital medical wards. Patients over the age of 65 years were identified as having delirium by the Confusion Assessment Method (CAM). Patients with delirium were randomized to receive rivastigmine 1.5 mg once a day increasing to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days). RESULTS: Fifteen patients entered the trial; eight received rivastigmine and seven received placebo. All of the rivastigmine group, but only three of the placebo group, were negative for delirium on the CAM when they left the study and eventually discharged home. There was no significant difference in the duration of delirium between the two groups (rivastigmine group 6.3 days versus placebo group 9.9 days, p = 0.5, 95% confidence interval -15.6-8.4). CONCLUSIONS: The numbers of patients who screened positive for delirium was very small and as a result the sample size was too small to make any meaningful inferences about treatment of delirium. Despite the small numbers included in the study, there are some indicators that rivastigmine may be safe and effective in treating delirium. [ABSTRACT FROM AUTHOR]

Background: Mental illness and cognitive impairment are risk factors for poor dental health. Methods: We conducted a cross-sectional study to compare the dental health of older patients attending outpatient clinics and day hospitals of old age psychiatry services (the psychiatry group, n = 103) with those attending general/geriatric medical services (the medical group; n = 99). Those living in care homes, and those with diagnosed mental illness (in the medical group) were excluded. A registered mental health nurse assessed mental and general health using validated and previously published instruments. A registered dentist made an independent assessment of dental health (examination to assess oral pathology, status of remaining teeth, and dentures) and made an overall judgment about whether the patient needed any dental treatment (a "normative" need). Results: The normative need for dental treatment was significantly higher among the psychiatry group compared to the medical group (85% vs 52%; p<0.001); even after taking account of the effect of age, gender, teeth status, physical comorbidity, cognition, depressive symptoms, and overall mental and social health [adjusted odds ratio, OR (95% confidence interval): 4.32 (2.09, 8.91)]. The presence of any natural remaining teeth [OR: 4.44 (2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)] were the two other independent predictors of the need for treatment. Conclusion: Dental problems are common in community-living older people, especially those with some natural remaining teeth and those with mental illness. There is a need to develop integrated mental health and dental care services for older people with emphasis on prevention of dental problems. [ABSTRACT FROM AUTHOR]

Background: Agitation is common in people with dementia, is distressing to patients and stressful to their carers. Drugs used to treat the condition have the potential to cause particularly severe side effects in older people with dementia and have been associated with an increased death rate. Alternatives to drug treatment for agitation should be sought. The study aimed to assess the effects of bright light therapy on agitation and sleep in people with dementia. Methods: A single center randomized controlled trial of bright light therapy versus standard light was carried out. The study was completed prior to the mandatory registration of randomized controls on the clinical trials registry database and, owing to delays in writing up, retrospective registration was not completed. Results: There was limited evidence of reduction in agitation in people on active treatment, sleep was improved and a suggestion of greater efficacy in the winter months. Conclusions: Bright light therapy is a potential alternative to drug treatment in people with dementia who are agitated. [ABSTRACT FROM AUTHOR]

Background: Knowledge of suicide in people with dementia is limited to small case series.Aims: To describe behavioural, clinical and care characteristics of people with dementia who died by suicide.Method: All dementia cases (n=118) from a 9-year national clinical survey of suicides in England and Wales (n=11 512) were compared with age- and gender-matched non-dementia cases (control group) (n=492) by conditional logistic regression.Results: The most common method of suicide in patients with dementia was self-poisoning, followed by drowning and hanging, the latter being less frequent than in controls. In contrast to controls, significantly fewer suicides occurred within 1 year of diagnosis in patients with dementia. Patients with dementia were also less likely to have a history of self-harm, psychiatric symptoms and previous psychiatric admissions.Conclusions: Known indicators of suicide risk are found less frequently in dementia suicide cases than non-dementia suicide cases. Further research should clarify whether suicide in dementia is a response to worsening dementia or an underappreciation of psychiatric symptoms by clinicians. [ABSTRACT FROM AUTHOR]

Background: The vascular depression hypothesis and our recent findings of increased frequency of spontaneous cerebral emboli in dementia suggest that such emboli may be involved in the causation of depressive symptoms in dementia.Aims: To evaluate the association between spontaneous cerebral emboli and depressive symptoms in Alzheimer's disease and vascular dementia.Method: In a cohort of 142 patients with dementia (72 with Alzheimer's disease and 70 with vascular dementia), the association between spontaneous cerebral emboli and clinically relevant depressive symptoms was examined using multiple logistic regression analyses.Results: Spontaneous cerebral emboli were significantly more frequent in the patients with clinically relevant depressive symptoms (66 v. 37%, P=0.03). After adjustment for age, gender, Mini-Mental State Examination score, type of dementia and significant cardiovascular risk factors, the relationship remained significant (OR=3.47, 95% CI 1.10-10.97).Conclusions: Spontaneous cerebral emboli are associated with clinically relevant depressive symptoms in dementia, and further research is needed to explore the nature of this relationship. [ABSTRACT FROM AUTHOR]

Background: Although there is good evidence that interventions for carers of people with Alzheimer's disease can reduce stress, no systematic studies have investigated psychotherapeutic intervention for patients themselves. This may be important in the earlier stages of Alzheimer's disease, where insight is often preserved.Aims: The aim was to assess, in a randomised controlled trial, whether psychotherapeutic intervention could benefit cognitive function, affective symptoms and global well-being.Method: Individuals were randomised to receive six sessions of psychodynamic interpersonal therapy or treatment as usual; cognitive function, activities of daily living, a global measure of change, and carer stress and coping were assessed prior to and after the intervention.Results: No improvement was found on the majority of outcome measures. There was a suggestion that therapy had improved the carers' reactions to some of the symptoms.Conclusions: There is no evidence to support the widespread introduction of brief psychotherapeutic approaches for those with Alzheimer's disease. However, the technique was acceptable and helpful individually. [ABSTRACT FROM AUTHOR]

Background: Organic factors are thought to be important in late-life depressive disorder but there have been few studies specifically of neurological signs.Aims: To compare neurological signs in a group of patients with late-onset depression and in healthy controls.Method: A case-control study comparing 50 patients with depression and 35 controls on three measures of central nervous system (CNS) signs: a structured CNS examination, the Neurological Evaluation Scale (NES) and the Webster rating scale for parkinsonism.Results: After adjusting for major depression at the time of evaluation and prescription of tranquillisers, ratings on two of the NES sub-scales (complex motor sequencing and 'other' signs) and on the Webster scale were significantly higher (more impaired) in patients compared with controls (P<0.05). With logistic regression, the NES was the main measure predictive of group outcome. There were no differences in scores of vascular risk or white matter but patients had patients had more atrophy.Conclusions: The findings add to the evidence that late-life depression is associated with organic brain dysfunction, perhaps mediated by neurodegeneration or subtle vascular impairment. The use of the NES in subjects with depression should be replicated. [ABSTRACT FROM AUTHOR]

Behavioral and psychological symptoms in dementia (BPSD) are an important aspect of the disorder that are now receiving more attention. The design of the trials in vascular dementia needs to account for these features. The specific area of BPSD in vascular dementia, their assessment, and relationship to the design of trials are considered in this article. [ABSTRACT FROM PUBLISHER]

Background: There is a vast array of scales available to assess all aspects of mental and physical health in older people which may be of relevance to the work of old age psychiatrists.Aims: To summarise some of the scales that may be commonly used in clinical and research practice and to give the reader guidelines as to where further information can be obtained.Method: The scales were selected on the basis of the authors' own clinical and research knowledge and information was gathered from a comprehensive text on assessment scales in old age psychiatry. Results The selected scales are described in brief and a table outlines the purposes for which they are most suitable.Conclusions: Although many scales are available, the choice of the individual scale relies specifically on the question that is to be asked. The ideal scale does not exist. [ABSTRACT FROM AUTHOR]

Background: The majority of patients with Alzheimer's disease live outside institutions and there is considerable serious psychological morbidity among their carers.Aims: To evaluate whether family intervention reduces the subjective burden of care in carers of patients with Alzheimer's disease and produces clinical benefits in the patients.Method: A prospective single-blind randomised controlled trial with three-month follow-up in which the experimental group received family intervention and was compared with two control groups.Results: There were significant reductions in distress and depression in the intervention group compared with control groups at post-treatment and follow-up. There were significant reductions in behavioural disturbance at post-treatment and an increase in activities at three months in patients in the intervention group. Based on an improvement on the General Health Questionnaire resulting in a carer converting from a case to a non-case, the number to treat was three immediately post-treatment and two at follow-up.Conclusions: Family intervention can have significant benefits in carers of patients with Alzheimer's disease and has a positive impact on patient behaviour. [ABSTRACT FROM AUTHOR]

Background: Older people in nursing and residential homes often have complex disabilities and behavioural disturbances. Recent publicity has highlighted the dangers of medication in this group, and controls over prescribing have been suggested.Aims: To investigate the effect of a review of medication by a pharmacist.Method: An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.Results: The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).Conclusion: This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality. [ABSTRACT FROM AUTHOR]

The article comments on the cholinesterase inhibitors, which is a new class of drugs for treating Alzheimer's disease. These include: tetrahydroaminoacridine or tacrine, which was found to enhance cognitive function in up to 30 percent of patients; donepezil hydrochloride; and rivastigmine, which was licensed on May 12, 1998 in the European Community for treating mild to moderately severe Alzheimer's disease.

Background: The symptoms of dementia are the most obvious stressors to which caregivers are exposed and many studies have investigated the association of such symptoms with the adverse consequences of caring. The present paper represents the only dedicated review of this literature.Method: Manual and computer (MEDLINE) literature searches were performed.Results: Seventeen empirical studies were found.Conclusions: Variability in conceptual and methodological approaches and inconsistencies in the reported findings have prevented firm conclusions from being drawn. However, the literature provided support for a relationship between non-cognitive features in dementia and psychological problems in caregivers, and suggested possible associations between cognitive deficits and some negative care-giver outcomes. New methodological and conceptual approaches are required if decisive evidence is to be forthcoming. This information is a prerequisite for investigations into the causal mechanisms that sustain these relationships, and for rationally designed interventions. [ABSTRACT FROM AUTHOR]

Background: There is increasing awareness of the importance of psychopathological and behavioural changes in dementia and a need for an instrument to measure these features which achieves an appropriate compromise between brevity and breadth. We describe a newly developed 59-item instrument: the MOUSEPAD.Method: Reliability, sensitivity and validity were examined with 30 carers, each of whom was interviewed four times over six weeks.Results: For different symptom groups, kappa ranged from 0.43 to 0.93 for test-retest reliability, from 0.56 to 1.0 for inter-rater reliability, and from 0.43 to 0.67 for the validation study.Conclusions: The scale may be useful as an outcome measure in drug trials, for correlating psychopathological and behavioural changes with post-mortem findings, and in epidemiological surveys. [ABSTRACT FROM AUTHOR]

Background: The prevalence of psychotic phenomena in confirmed Alzheimer's disease (AD) and their potential neuropathological correlates have rarely been the subject of prospective investigation.Method: Psychopathological disturbances were recorded prospectively according to the Geriatric Mental State Schedule and the CAMDEX: The frequency of these phenomena and neuropathological changes were examined in 56 patients with definite AD.Results: Hallucinations had been documented in 13 patients, paranoid delusions in 9 and delusional misidentification (e.g. the Capgras-type and the 'phantom boarder' symptoms) in 14 patients. Misidentifications were associated with lower neurone counts in the area CA1 of the hippocampus. Delusions and hallucinations were observed in patients with less severe cell loss in the parahippocampal gyrus and with lower cell counts in the dorsal raphe nucleus. A decrease of neurones in the locus coeruleus in a subset of depressed patients with AD had been reported earlier. Delusions and delusional misidentification were common in 5 patients with basal ganglia mineralisation, but there was no statistically significant association of these symptoms with the presence of Lewy bodies in the brainstem and neocortex of our patient sample.Conclusions: These findings are compatible with the view that morphological changes in certain brain areas may promote the development of psychotic phenomena in AD. AD may offer a model for the understanding of pathomechanisms underlying the development of psychopathological disturbances in other psychoses with more discrete neuropathological changes. [ABSTRACT FROM AUTHOR]

"The medial temporal lobe of the brain is important for normal cognitive function, notably for memory, and is the region with the most extensive pathological change in Alzheimer's disease (AD). We wanted to find out if atrophy of the medial temporal lobe could be detected in life in patients in whom a diagnosis of AD was subsequently established histopathologically. The minimum width of the medial temporal lobe, measured by temporal-lobe-oriented computed tomography (CT) about one year before death, in 44 patients with a histopathological diagnosis of AD (cases) was nearly half (0.56 of the median) that in 75 controls of the same age with no clinical evidence of dementia (95% confidence interval 0.51-0.61). There was little overlap between the distributions of measurements in cases and controls. A cut-off (< 0.79 MoM) selected to yield a 5% false-positive rate gave an expected detection rate of 92%. A cut-off selected to yield a false-positive rate of 1% (< 0.70 MoM) yielded a 79% detection rate. 20 of the 44 patients with histopathologically diagnosed AD had been scanned more than once before death, and the test (cut-off < 0.79 MoM) was positive in all 20 more than a year before and in 9/10 more than 2 years before death. In 10 subjects with dementia but with histopathology excluding AD, the mean minimum width of the medial temporal lobe was significantly greater than that in the cases with AD, but was not significantly different from that in controls.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

Clinico-pathological correlations were examined in 54 patients with neuropathologically verified Alzheimer's disease (AD) who were part of a prospective study. Behavioural disturbance was documented using an expanded version of the Stockton Geriatric Rating Scale (SGRS). The subscores for physical disability (P), apathy (A) and communication failure (C) (summation score PAC) were closely correlated and were high in most patients during the late stages of illness. High PAC scores correlated with an earlier onset and longer duration of illness, lower brain weight, more severe tangle pathology in the parahippocampal gyrus and the frontal and parietal neocortex, and lower neuron counts in the hippocampus and basal nucleus of Meynert. Features of the Klüver-Bucy syndrome (range behaviour and hypermetamorphosis) were significantly associated with lower counts of large neurons in the parahippocampal gyrus and parietal neocortex, but not with more severe plaque or tangle formation or with neuronal loss in the subcortical nuclei. No correction was made for multiple comparisons. These findings may signify decreased cortical inhibition in patients with relatively well preserved subcortical structures who show features suggestive of the Klüver-Bucy syndrome. High PAC scores on the SGRS could reflect more advanced and widespread cerebral pathology in the end stages of AD. [ABSTRACT FROM AUTHOR]

At post-mortem, Lewy bodies (LBs) were found in the brainstem and neocortex of eight out of 65 patients who had been collected during a prospective long-term study on clinically diagnosed Alzheimer's disease. All eight patients had accompanying Alzheimer pathology which was less severe than in a sample of eight age- and sex-matched patients from the same study with neuropathologically verified Alzheimer's disease. Parkinsonian features were more common in patients with LBs. There were no particular differences in duration of illness, severity of cognitive impairment, presence of hallucinations, or fluctuations in the course of illness. Frontal cerebral atrophy was more marked in patients with LBs, as was the loss of neurons in the basal nucleus of Meynert and the substantia nigra. Cognitive performance correlated with the number of pigmented neurons in the substantia nigra. We conclude that the differential diagnosis of LB dementia should be considered in patients satisfying NINCDS-ADRDA criteria for Alzheimer-type dementia who show marked Parkinsonian features and a frontal accentuation of cerebral atrophy. [ABSTRACT FROM AUTHOR]

One hundred and thirty-eight patients satisfying NINCDS/ADRDA criteria for Alzheimer's disease (AD) and 36 normal controls underwent cranial CT. A comparison of methods of scan analysis showed good agreement between computer-assisted methods and visual ratings and planimetry. The CT scans of controls differed significantly from patients and a discriminant analysis, based on all CT measures, predicted group membership (control or patient) in 81% of cases. Within the AD group, cortical atrophy correlated with age and duration of illness. Global tests of cognitive function correlated significantly with both cortical atrophy and ventricular size. Subjects who died in a three-year follow-up had more atrophy and larger third ventricles than survivors, but this effect was due entirely to increased age. [ABSTRACT FROM AUTHOR]

The article discusses the use of the technique of Computerized Tomography (CT) in the differential diagnosis of dementia of the Alzheimer type (DAT). The CT scan apparatus consists of a radiation source that emits collimated beam which rotates in a gantry around the head, which is placed between the X-ray source and a set of scintillation detectors. The diagnosis of DAT with CT scanning can be divided into three broad categories - assessment of cerebral surface atrophy (cortical or sulcal atrophy), assessment of ventricular size (subcortical or central atrophy) and CT studies involving the measurement of brain density.

Of 106 patients attending a gender-identity clinic, 73% satisfied DSM-III criteria for transsexualism. These DSM-III positives had a significantly younger age of onset and were less likely to experience sexual arousal with cross-dressing than those who did not satisfy DSM-III criteria. They were also significantly more likely to fulfil a definition of 'core transsexualism'. 'Core transsexualism' may represent a subgroup within DSM-III criteria for transsexualism and its defining features in this study were an early age of onset, low sexual activity, lack of sexual arousal with cross-dressing and homosexual orientation. Of the whole sample, 23% were referred for gender reassignment surgery, of whom 100% were DSM-III positive and 60% were 'core transsexuals'. [ABSTRACT FROM AUTHOR]

Of 178 patients with AD, at least one depressive symptom was reported by 63%, 24% were rated as being depressed by a trained observer, and 43% were considered depressed by their relatives. Ten per cent had a previous history of depression. Elevated mood was rare, occurring in only six patients (3.5%). Subjects with depressive symptoms had less cognitive impairment and less ventricular enlargement on CT compared with those without symptoms. Widening of the interhemispheric fissure was associated with symptoms of mania but was inversely related to presence of depressive symptoms. [ABSTRACT FROM AUTHOR]

In a sample of 178 patients with AD, visual hallucinations had been experienced by 13% and auditory hallucinations by 10%. Thirty per cent had misidentification syndromes; these were associated with a younger age and younger age at onset of illness, and proportionally more men than women were affected. There was a reduced 30-month mortality rate in this group. Subjects with hallucinations had a greater deterioration in cognitive function at 12-month follow-up, which could not be accounted for by neuroleptic medication. [ABSTRACT FROM AUTHOR]

In a sample of 178 subjects with Alzheimer's disease, diagnosed by clinical criteria (NINCDS/ADRDA), delusions had occurred in 16% of the sample since the onset of the illness and been present within the last 12 months in 11%. Simple delusions of theft and suspicion were the most common types and a greater proportion of men suffered delusions of theft. Subjects with other types of delusion had relatively well preserved lateral ventricular size and basal ganglia calcification. Twenty per cent of the group had experienced persecutory ideation short of delusions since the onset of the illness. Cognitive function at entry to the study and cognitive deterioration over the succeeding 12 months was not influenced by the presence of disorders of thought content. [ABSTRACT FROM AUTHOR]

Variation in quarter of birth was examined in patients with a clinical diagnosis of AD. There was a significant excess of first-quarter births among AD patients as compared with the expected birth rates derived from an age-matched census sample. This finding was due entirely to the significant excess of first-quarter births in AD patients without a family history of dementia. No seasonal variation was found in the birth dates of other clinical groups. [ABSTRACT FROM AUTHOR]