The aim of this study was to examine predisposing and precipitating factors of acute confusional state (ACS) retrospectively in medical records of patents examined in an acute medical unit (AMU) who had a preliminary diagnosis of confusion/anxiety. The study comprised all 221 patients who were 65 years old and older among the 18,015 patients examined in the AMU during 1 year who, after a preliminary examination in the AMU, received a diagnosis of confusion/anxiety without any other etiologic diagnosis. Fifty-six cases fulfilled the DSM-III-R criteria for ACS. The control group comprised 165 patients, with anxiety, depression, or psychosis the main finding in 135 cases. Among patients further examined in other departments or for whom consultations were made, the medical records showed that the ACS group had on average 2.6 predisposing factors for ACS, with dementia, cerebrovascular disease, and sensory deficits the most common. Three to six predisposing factors were found among 46% of the ACS patients, compared to 4% of the control group. A precipitating factor of ACS was found in 78% of the ACS cases, and the average number of precipitating factors was 1.6. Dementia (32%), metabolic disturbances (30%), and cardiovascular diseases (16%) were the most frequent precipitating factors among the ACS group. The mortality rates 2 years after examination in the AMU were 32% for the ACS group and 20% for the control group (p < .05). The study suggests that the causes of ACS are often multifactorial and that it is important to seek several precipatating factors when treating this potentially reversible condition.

Personality data gathered in a psychological autopsy study indicate that completed suicides obtain higher neuroticism scores than age- and gender-matched controls. Older suicide victims obtained lower openness to experience (OTE) scores than both younger suicide victims and normal controls. Although the role of neuroticism and negative affect in psychopathology has been discussed extensively, OTE has been accurded relatively little attention in the psychiatric literature. The apparent role of OTE in completed suicide warrants its closer examination. In this article, I offer the testable hypotheses that persons low in OTE are at risk for taking their own lives because their affective dampening, cognitive certainty, diminished behavioral repertoire, and rigidly defined self-concept have decreased their capacity to adapt to the expectable age-associated changes in role, health, and function that accumulate over time. Concrete thinking and excessive focus on proximal, low-level goals place them at risk for descending into states of suicidal meaninglessness in times of stress or crisis. This state of awareness increases the desirability of suicide as an action oriented solution to the stressors of aging. Other lines of investigation are suggested. These include research on OTE in attempted suicide; OTE and the neurobiology of suicidal behavior; OTE and gender differences in suicidal behavior; and clinical intervention designed to increase the degree to which one is open to experience.

This article reviews the evidence that antidepressants have improved the prognosis of geriatric depression. It examines studies carried out in the acute, continuation, and maintenance stages of treatment. Naturalistic studies carried out after the introduction of electroconvulsive therapy indicate that about one quarter of patients with major depression in later life remain symptom-free, approximately one third experience at least one relapse but with further recovery, and the remainder have residual symptoms. In about 10% of all cases, depressive symptoms remain severe and intractable. These proportions appear to have altered little since tricyclic antidepressants became available, although recent research into drug prophylaxis suggests that better outcomes may be possible. The article reviews some of the methodological problems that research workers must address. The role of newer antidepressants in prognosis is also discussed.

Cognitive and neuropsychological tests are often employed to help describe the functioning of patients with multi-infarct dementia (MID) or patients with dementia of the Alzheimer's type (DAT). In this study, the Halstead-Reitan Neuropsychological Battery (HRNB), Wechsler Adult Intelligence Scale-Revised (WAIS-R), and Wechsler Memory Scale (WMS) were completed by 20 MID patients and 62 patients with DAT. Total scores on these measures did not differentiate DAT and MID patients. Contrary to clinical observations, cognitive tasks assessing social judgment did not differentiate between the groups. However, MID patients demonstrated greater variability in test scores. Compared with DAT patients, the MID patients demonstrated better preserved memory as shown on the WMS in comparison to the WAIS-R IQ.

Observed cognitive decline in the elderly has been widely reported in the literature. The relation of experimental cognitive ability measures to real-world cognitive competence has been questioned. This research examines the validity of English-language versions of two measures of everyday competency: the Memory in Reality test involving object placement recall and the Coin Test, a money-sorting task. The measures were developed as part of a Swedish epidemiologic study. Validity was evaluated by comparison of these tasks with standard cognitive tests and with a measure of metamemory. It was expected that the ecological measures would have a stronger association with metamemory than the standard tests. Subjects were 93 community-dwelling women, aged 75 and older. The ecological tasks correlated positively with the standard tests, but there were inconsistent relations of both standard and ecological measures with metamemory. The results partly support use of these measures for evaluating everyday functioning.

Although one would expect a relationship on the basis of anecdotal evidence, there is little objective evidence for a hypothesized relationship between the social environment provided in institutional settings and the psychological well-being of the residents. In an attempt to operationalize this hypothesis, the present study examined the effect of nursing staff turnover, frequency of visitors, and the presence or absence of close friends on depressive symptoms among nursing home residents. Once physical dependency and past history of depression were taken into account, there was no demonstrable relationship between staff turnover and depressive symptoms among the residents of this sample of nursing homes. There was, however, a significant relationship between absence of close friends among other residents and depressive symptoms, although only 13% of the total variance was explained.

The 5-year prognosis of 42 elderly patients with major depression (mean age 73.2 ± 6.3 years for men and 73.0 ± 7.3 years for women) is described. Furthermore, the clinical outcome of elderly patients with major depression is compared to that of 199 elderly patients with dysthymic disorder (mean age 69.6 ± 7.2 years for men and 71.3 ± 7.7 years for women) described in a previous article.

Twelve percent of patients with major depression recovered, 26% still had depression after 5 years, 12% had possible dementia, 45% had died, and 5% could not be contacted. The outcome did not significantly differ between the sexes or the two age groups (65–74 and 75+). A poor clinical outcome of patients with major depression was related to a greater number of diagnosed diseases, strong feelings of restlessness, and higher sexual interest at the beginning of the follow-up. A poor prognosis was also found for the patients whose functional abilities and hobby activities declined during the follow-up. A poor prognosis tended to be related to absence of hypertension, frequent trembling of hands, low activity in listening to music, and high activity in watching TV at the onset, and to absence of malignant disease and occurrence of a high number of negative and positive life events during the follow-up period.

Thirty-six percent of dysthymic patients recovered, 26% still had depression after 5 years, 9% had possible dementia, 25% had died and 4% could not be contacted. The outcome of dysthymic patients did not significantly differ between the sexes or the two age groups (65–74 and 75+). The clinical outcome of dysthymic patients tended to be more favorable than that of patients with major depression. The factors related to a poor outcome differed between patients with major depression and dysthymic patients.

This article explores how a life-course perspective and narrative methodology can be used to study risk factors for late-life suicide. A life-course approach to aging and suicide requires consideration of age as both social and personal construction. “On-” and “off-time” events and their impact on adjustmenta are used to illustrate these social and personal constructions. Cohort, period, and histrorical events have potentially profound effects on risk for suicide, yet the study of these effects is difficult because they are so often confounded in longitudinal study. Lifelong personality characteristics that are not life-threatening in earlier life may be of greater risk in later life depending on life circumstances such as physical dependencies. A life-story or narrative approach offers an alternative method for incorporating these complicated factors when studying late-life suicide. The psychological autopsy can be considered a type of “narrative” used by various individuals to gain understanding about a suicide.

Previous efforts to define the case mix of psychiatric inpatients have generally relied on the use of psychiatric diagnosis, and have had little success elucidating the relationship between clinical outcome and resource utilization. The Severity of Psychiatric Illness (SPI) rating scale, a reliable chart-based system using nine clinical rating dimensions, has been developed by one of the authors for use in studying the case mix of psychiatric inpatients. This report is the first describing this scale. For a sample of 244 psychogeriatric patients, all but one of the dimensions were significantly correlated with at least one of the five baseline clinical assessments, and all but one of the SPI items were correlated with outcome assessment. Four dimensions of the SPI were related to clinical outcomes. The SPI also predicted length of stay (predicting 23% of the variance for patients discharged to their homes). This study provides strong evidence for the construct and predictive validity of the SPI among older adult psychiatric inpatients.

Two methods of interpreting the videotaped facial expressions of four patients with severe dementia of the Alzheimer type were compared. Interpretations of facial expressions performed by means of unstructured naturalistic judgements revealed episodes when the four patients exhibited anger, disgust, happiness, sadness, and surprise. When these episodes were assessed by use of modified version of the Facial Action Coding System, there was, in total, 48% agreement between the two methods. The highest agreement, 98%, occurred for happiness shown by one patient. It was concluded that more emotions could be judged by means of the unstructured naturalistic method, which is based on an awareness of the total situation that facilitates imputing meaning into the patients' cues. It is a difficult task to find a balance between imputing too much meaning into the severely demented patients' sparse and unclear cues and ignoring the possibility that there is some meaning to be interpreted.

Apparent treatment-resistant depression (TRD) is frequently encountered by and poses particular challenges for the old-age psychiatrist. The prevalence of true nonresponse to treatment is not known with accuracy but reports put it at 18% to 40% for the elderly. This article reviews the concept of TRD in the elderly, discussing the factors involved in apparent resistance and the treatment of this group. We suggest that absolute TRD may be a rarer entity than the estimated 18% to 40% if depressed patients are treated carefully and vigorously.

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.

In a 1-year period, 6 of 11 suicides in a rural Wisconsin county were committed by people over the age of 60. At the request of the local coroner, the American Medical Association sent a team of investigators to perform psychological autopsies. Family member survivors, friends, and attending physicians were interviewed. The majority of suicide victims had evidence of major depressive episodes, delusions that they had a terminal physical illness, and knowledge of family/friends who had committed suicide. Most had seen their physician within 48 hours before their death. Continuing education efforts focused on increasing a physician's abilities to recognize depression and suicidal ideation have ensued, based on this experience.

Age of onset of depressive episodes may serve as a useful marker of pathogenetic heterogeneity in late-life depression. Medical illness may play an important role in the pathogenesis of depression in the elderly, but its relationship to age of onset has not been carefully examined. We prospectively studied 110 older inpatients with DSM-III-R major depression. Using multiple regression techniques, we found that medical illness was not independently associated with age of onset. Independent predictors of older age of onset were age, male sex, absence of substance abuse history, and absence of melancholia. Our discussion reconsiders the usefulness of age of onset as a primary research variable for elucidating heterogeneity of late-life depression.

Mini-Mental State Exam (MMSE) scores for 247 community-dwelling, well-functioning individuals in their 60s (n = 88), in their 80s (n = 92), and 100 or older (n = 67) were compared to examine overall and component MMSE differences. The concomitant influences of visual or literacy deficits, gender, education, race, income, and activities of daily living on MMSE performance were analyzed. Mean MMSE scores of 27.8, 27.1, and 24.8, respectively, for the three cohorts were significantly different, even when all concomitant variables were controlled. After the concomitant variables were controlled, results indicated that there were no age group differences on five MMSE items: naming, repeating, listening and obeying, reading and obeying, and writing sentences. Participants with visual or literacy deficits scored 1.5 points lower than other partimcipants, and displayed performance deficits in four items form the Read & Write MMSE division: naming, reading and obeying, writing sentences, and praxis. Education and gender were significant covariates for total and divisional MMSE scores.

The limited attention paid to old-age suicide in Germany is likely related to society's lack of interest in the specific problems of old people. This is despite the fact that over half of all German suicides are committed by persons 65 and older. In reviewing what is known about elderly suicide based on retrospective studies, I submit that suicide in later life is not always based on pathologic mental processes. There may be a number of risk factors unique to elderly suicides, in addition to depressive disorders that involve broader cultural issues among the many motives likely present in any one suicide. Today's emphasis on individualized values may lead to a feeling of meaninglessness in the suicidal elderly. The uncertainty and fear of the inability to influence their own dying and a certain weariness of life are also likely unique risk factors for the elderly. Thus the reasons or motives for a suicide may be best considered by understanding the entire life situation and the biographical aspects of the person. Prevention of elderly suicides requires a number of approaches ranging from social assistance and improved training of care providers to more acceptance and valuing of older persons by society.

Thirty-seven subjects, 15 with a clinical diagnosis of Alzheimer's disease and 22 normal controls, participated in a study of the accuracy of telephone screening in identifying potential dementia cases. The telephone protocol and scoring algorithm resulted in 100% sensitivity and 91% specificity. The findings suggest that a brief telephone interview can serve as an efficient screening device to locate dementia cases in the context of a large-scale community-based investigation.

The aim of this article is to suggest that hostile behavior in elderly patients is often caused by a reversible mood disorder rather than by a personality disorder or dementia, even if these two last diagnoses are already well established. Sedatives, often prescibed for hostile behavior, can induce confusion, falls, and bedridden states, and can actually increase the rate of mortality. The mood disorder can be a hostile agitated depression or a mixed affective state. The hypothesis of a mood disorder calls for an antidepressant trial, possibly combined with a mood stabilizer.

Fourteen patients suffering from dementia of the Alzheimer type were treated with tacrine (tetrahydrominoacridine, THA) for 1 year in an open trial. Clinical results were evaluated every third month with neuropsychological tests and rating scales. During the dose-finding, two patients were temporarily withdrawn from medication and one patient was excluded because of elevated levels of liver enzymes. With individualized doses the treatment caused few side effects. Plasma levels of THA varied substantially among patients and correlated with elevation of liver enzymes but not with clinical response. Two patients showed a gradual increase in plasma levels of THA despite unchanged doses. Although results of the neuropsychological tests and clinical ratings were mostly negative, the study indicates that THA can be administered safely for prolonged periods of time. Clinical observations and dose-titration strategy in relation to side effects are discussed.

This study was made in an attempt to document the effects of early treatment of poststroke depression (including fluoxetine treatment) on neuropsychological rehabilitation (including cognitive function). Assessment measures used included the Schedule for Affective Disorders and Schizophrenia (SADS) and Research Diagnostic Criteria (RDC), as well as standard measures of severity of depression, functional ability, cognitive function, and neurological function. Thirty-seven patients with poststroke depression, treated with fluoxetine (n = 26) or nortriptyline (n = 11), were compared with 11 poststroke depressed patients who received no depression treatment and 82 poststroke nondepressed patients who received no depression treatment. Our findings about the prevalence of depression (37%), more frequent with anterior lesion (p = .009) and left hemisphere lesion (not statistically significant), tend to confirm previous reports. Early treatment (4th week poststroke) with either fluoxetine or nortriptyline significantly improved the depressed patients' mood, neurological function, functional ability, and cognitive ability. A close relationship between appropriate early treatment (including fluoxetine treatment) of poststroke depression and improved neuropsychological rehabilitation (including cognitive improvement) is suggested by our findings. This is the first report, to our knowledge, of the beneficial effects of early antidepressant treatment on the cognitive function of poststroke depressed patients.