Pinner and Bouman's review article “To Tell or Not to Tell: On Disclosing the Diagnosis of Dementia” (pp. 127–137 in this issue) outlines the pros and cons of diagnosis disclosure to this diagnostic group. It is only over the past 10 years that the question of informing patients with dementia of their diagnosis has become topical, although the hard evidence for and against telling remains sparse, with much of the argument on either side being anecdotal. Paternalism is a common theme of surveys that examine the attitudes of spouse caregivers, relatives, and nonaffected older adults toward telling the diagnosis of dementia (Connell & Gallant, 1996; Erde et al., 1988; Holroyd et al., 1996; Maguire et al., 1996).

Research suggests there has been a cultural change in the disclosure of diagnosis with most evidence held in cancer literature. This article reviews how disclosure of diagnosis relates to the field of dementia. Practitioners' attitudes and practice are being discussed, as are the attitudes and views of carers, peer groups, and patients. Practitioners show great variations in practice, with only around 50% of clinicians regularly telling patients with dementia their diagnosis. The majority of carers also appear to prefer the diagnosis to be withheld from the patient with dementia. However, most practitioners and carers would wish to know themselves if they had the illness. Although in contrast, studies on the views of elderly peer groups show that the vast majority wishes to be fully informed, views of patients with dementia regarding the area of disclosure are still lacking. Factors influencing the decision to disclose the diagnosis, including the degree of certainty of the diagnosis of dementia, the degree of insight of the patient, and the severity of the dementia, are investigated. The advantages and disadvantages of disclosure and the ethical issues are examined, as well as when or whether and how to disclose the diagnosis of dementia. Flexible guidelines regarding the process of disclosure are introduced.

Background: Studies on normal aging and cognitive functioning commonly describe early and more pronounced age-related changes in executive functions (EFs) compared to other cognitive abilities. Two of the three most common neurodegenerative disorders associated with aging (vascular dementia [VaD] and extrapyramidal [EP]-related dementia) show executive dysfunctions in their clinical presentation; and these cognitive deficits are not uncommon in the third one: Alzheimer's disease (AD). Methods: Nine EF tests (yielding 12 measures) were administered to 123 randomly selected community dwellers, aged 81 years and over, with the view to determine the effect of age on performance. Markers of AD, VaD, and EP-related dementia, as well as sociodemographic and psychological variables, were selected and their contribution to EF performance was investigated. Results: Multiple linear regression analyses revealed the greatest contribution to EF scores from the markers of AD and estimated IQ but not from the markers of VaD and EP-related dementia or from age. Conclusions: These findings suggest that chronological age acts as a proxy variable mediating the impact of other factors such as subclinical signs of neurodegenerative disorders and that it has little independent contribution to make. They also indicate the importance of cognitive abilities supported by posterior cortical circuits in EF problem resolution. This study demonstrates that cognitive decline is not an ineluctable process that is associated with “normal” aging but rather represents, in many cases, a byproduct of neurodegenerative disorders, albeit themselves highly age-related.

Background: The study was conducted to examine the relationships between functional decline, health risk factors, lifestyle practices, and demographic variables in two culturally diverse, community-based samples of White and Japanese American older adults. Design: The study was an analysis of data from two ongoing studies of aging and dementia in King County, Washington. Functional status at baseline was evaluated, and factors associated with functional decline over a 4-year follow-up period were identified. The sample included 1,083 Japanese American and 1,011 White cognitively intact, community-dwelling adults aged 65 and older, who had no functional limitations at baseline and participated in at least one follow-up examination. Results: In 4 years of follow-up, 70% of the subjects reported no increase in functional limitation, and fewer than 5% of subjects declined in five or more activities. Risk factors associated with functional decline included increased age, female gender, medical comorbidity (particularly cerebrovascular disease, arthritis, and hypertension), elevated body mass index, poorer self-perceived health, and smoking. Depression and diabetes were also significant for persons with the greatest functional decline over the 4-year follow-up. Japanese speakers were significantly less likely to decline over the follow-up period than White or English-speaking Japanese American subjects. However, Japanese speakers were more likely to discontinue participation during the follow-up period, and may also have been more likely to underreport symptoms of functional decline. Conclusions: The present study provides further support that healthy lifestyle practices and prevention of chronic disease are important for maintaining functional independence in older adults. Japanese-speaking subjects were less likely to decline over time, although this could be due in part to differential dropout and reporting bias. These findings have important implications for the design and interpretation of longitudinal studies of older adults. Researchers interested in the effects of ethnicity on health and aging should be cognizant of differences in recruitment and enrollment strategies among studies, and the ways in which these affect study findings. This study also demonstrates the importance of devoting adequate resources to minimize dropouts, and of including measures of health and functioning that are culturally equivalent and less reliant on self-report data.

Donepezil has been shown to improve aspects of cognitive functioning in persons with Alzheimer's disease (AD), but its impact on instrumental activities of daily living has received little attention. In a within-subject design, 24 community-dwelling persons with AD were treated with open-label donepezil over a 12-month period. To assess functional abilities, a brief, objective measure of instrumental activities of daily living skills was used (Texas Functional Living Scale; TFLS). Global cognitive abilities were assessed with the Mini-Mental State Examination (MMSE). Changes in TFLS and MMSE scores were much the same. Improvements on the TFLS and MMSE were seen over a 3-month period. At 12 months, both TFLS and MMSE scores declined slightly below baseline. These results support an effect of donepezil on cognitive measures and day-to-day function and also suggest that the MMSE reflects well the actual functional ability of persons with moderate AD.

The correlates of dropout, efficacy, and adverse events in the tratment of Alzheimer's disease (AD) with acetylcholinesterase inhibitors (ChEI) are unclear. To investigate these issues, a 26-week prospective, randomized, open-labeled trail with donepezil or rivastigmine was undertaken. Sixty-four Korean patients with AD were recruited, and data on sociodemographic and clinical characteristics and several assessment scales were collected. Characteristics of available caregivers were also gathered. Information on adverse events and dropout was recorded. Thirty-five (55%) patients dropped out during treatment with ChEI, for reasons mainly related to financial burden of caregivers. Of the 29 patients who completed the 26-week trial, 16 (55%) were responsive to ChEI. Lower scores on the Clinical Dementia Rating and Blessed Dementia Scale at baseline were associated with the efficacy of ChEI. Of the total participants, 26 (41%) experienced adverse events, although these seemed to be mild and appeared to be associated with the psychological state of patients or coadministration of psychotropic drugs. In conclusion, ChEI seemed to be effective and well tolerated in the treatment of Korean patients with AD, but the use of this drug was limited mainly by the financial burden of caregivers.

The objectives of this randomized clinical trial were to investigate the impact of the discontinuation of long-term antipsychotics in residents with dementia in chronic care institutions and to identify clinical predictors of safe discontinuation. Subjects included 34 residents with dementia who were on antipsychotics for more than 6 months and whose behavior was currently stable. Subjects were randomized to either continue receiving their regular dosage of antipsychotics or to receive placebo for 6 months. Early withdrawal from the study was not statistically different between the groups (relative risk [RR] = 1.57, 95% confidence interval [CI] 0.76–3.26), and though not significantly different, subjects in the placebo group were more likely to be withdrawn from the study because of worsening behavior (RR = 1.25, 95% CI 0.33–4.76). Three subjects in the placebo group were withdrawn from the study due to worsening of extrapyramidal symptoms. The active treatment group had more behavioral problems (e.g., physical aggression towards others, p < .05) compared to the placebo group. The placebo group developed more apathy, but balancing this outcome was a relative improvement in congitive functioning. Baseline antipsychotic dose was predictive of behavioral worsening upon discontinuation of long-term antipsychotic drugs. The primary limitation of the study was the small sample size. In conclusion, a trial of discontinuation of antipsychotics should be considered in this population.

Dementia with Lewy bodies (DLB) is the second most common neuropathologically diagnosed cause of degenerating dementia after Alzheimer's disease. We report the first autopsy-confirmed case in sub-Saharan Africa in a Nigerian patient. The case presented highlights the varied clinical presentation of DLB, and is intended to raise awareness about another possible cause of dementia in Nigerian subjects.

Objective: To test the validity and reliability of the Chinese Geriatric Mental State Schedule (CGMS) in Taiwanese elders. Methods: The CGMS has gone through a standardized two-way translation, a pretest phase, and consensus focus group meetings in order to modify relevant culture-related terms of the original English version. The interrater reliability of the CGMS among eight psychiatrists was conducted after a training course was given to them. Diagnoses generated by the CGMS-AGECAT (Automated Geriatric Examination for Computer Assisted Taxonomy) were compared with psychiatric diagnoses according to the DSM-III-R criteria. The sample subjects were aged 65 and over and recruited from a community (n = 36) and an “old age home” (n = 56). Results: Four of the eight diagnostic categories generated by the CGMS-AGECAT had a generalized kappa value of 1.0, and the figures for the remaining four categories were acceptable: .8 for depressive neurosis, .6 for anxiety disorder, .5 for schizophrenia, and .5 for depressive psychosis (generalized kappa = .5). The overall agreement between the CGMS-AGECAT and independent psychiatric diagnosis (based on the DSM-III-R criteria) was satisfactory. Conclusion: The CGMS has been found to be a crossculturally valid and reliable instrument for use in Taiwan.