The brain undergoes many changes in chemistry and structure during normal aging. For example, it dries and shrinks. Neurons are lost from some regions and there is also neuronal atrophy and loss of synaptic branching. The extent of such losses remains controversial for all but a few subcortical regions of the brain. Decreases in glucose metabolism and in some pre-and post-synaptic neurotransmitter indices have also been reported. Many systems, however, remain entirely unexplored. The evidence to date also indicates that there is great regional specificity in the effects, and that humans show considerable variability between individuals. Of interest is the fact that some of the changes most clearly demonstrated in normal aging - such as loss of dopaminergic neurons of the substantia nigra and cholinergic neurons of the medial basal forebrain - also occur in a much accentuated form in neurodegenerative diseases such as Parkinson's disease and Alzheimer disease. The small loss of these systems in normal aging may account for the shuffling gait, stooped posture and memory loss in the elderly. A phenomenon seen in neurodegenerative diseases, but not in normal aging, is the appearance of chronic inflammation in the brain. The suggestion that the progress of such diseases might be slowed by treatment with anti-inflammatory agents has, in the case of Alzheimer disease, gained some support from 19 epidemiological studies and one very small clinical trial. Clearly more detailed clinical trials are required, and caution must be used because of the undesirable side effects of currently available anti-inflammatory agents.

Previous studies in this series of papers investigated the associations between aluminum (Al) water concentrations and relatively high risks of a measure of mental impairment and also various possible other drinking water characteristics, particularly pH, turbidity, fluoride and silica. The results were based on one measure of mental impairment, which would not be expected to give the same results as the more definitive endpoint (outcome variable) of a record of Alzheimer's Disease (AD) as the underlying cause of death on a death certificate. The present paper therefore investigates the relevant associations, based both on the measure of mental impairment and on death certificates in which AD and presenile dementia are listed as the underlying causes of death. As expected, the associations were not identical, but they were similar. More specifically, Al water concentrations were strongly associated with the recording of AD on death certificates, as were pH, fluoride, and silica concentrations. The implications of these results are discussed, and it is suggested that the evidence is sufficiently strong for methods of water purification to be modified, at least on a trial basis, because of the likelihood that this will reduce the incidence of AD.

Based on a hypothesis that the cause of Alzheimer's Disease (AD) is multifactorial, we explored the possible links between the geographical distribution of 102 subjects diagnosed as “definite,” “probable” or “possible” cases at the onset of the disease and the social ecology of the Chicoutimi-Jonquière (CJ) urban area in the Saguenay region of Québec. We were also interested in the level of education of the 74 “definite” and “probable” cases. The use of factor analysis (principal components) and cluster analysis (Ward method) made it possible for us to identify socioeconomic zones and homogeneous social areas in CJ. The first results indicate that on the one hand, the male/female ratio of the cases differs statistically from that of the at-risk age group in the general population. The disease affects more women than men. On the other hand, there is significant social differentiation in CJ. Nevertheless, the 102 subjects are randomly distributed among the three socio-economic zones as well as among the eight social areas. Analysis of the geographical distribution of “definite” and “probable” cases also suggests a random distribution. The random nature of the distribution of subjects is confirmed by a very strong correspondence between the distribution of cases observed when counting them by enumeration area or census tract and Poisson's theoretical distribution. There was a significant difference between the subjects' level of education and that of the 65 years old and over in the reference population. A more in-depth case-control study might shed more light on this aspect.

Dementing illnesses, such as Alzheimer's disease, cause great changes in individuals – sometimes even leading us to say that they are “different persons”. Professional caregivers to these individuals may better understand them and their suffering (and thus provide more compassionate care), if they look at the illness in the context of the individual's life. Although their personhood has been threatened by dementia, appreciating the gestalt, or integrity of their lives may help preserve it. The clinical focus, which currently looks only at problems, should also assess the individual's remaining strengths, positive functions and characteristics. A case scenario helps to illustrate these suggestions. Some recommendations to researchers, clinicians and bioethicists for further study in this area are included.

This article offers reflection on the validity of relational data such as used in social network analysis. Ongoing research on the transformation of the support network of caregivers of persons with an Alzheimer-type disease provides the data to fuel the debate on the validity of participant report. More specifically, we sought to understand the factors that might influence the description of the support network by persons involved in caregiving. The issue warrants special attention, given that social relations – in their form and their content – constitute the raw material of network analysis. We propose that how persons describe their social network corresponds to a subjective process that rests, in part, on their representation of their cultural and social universe.

The Functional Transitions Model (FTM) integrates the theoretical notions of progressive functional decline associated with Alzheimer's disease (AD), excess disability, and transitions occurring intermittently along the trajectory of functional decline. Application of the Functional Transitions Model to clinical practice encompasses the paradox of attempting to minimize excess disability while anticipating the progressive functional decline associated with AD. It is suggested that times of functional transition are times of decision making and opportunities for interdisciplinary collaboration to identify and minimize excess disability, for revision of goals and expectations, and for provision of support to patients and caregivers. The model also is applicable as a conceptual framework for education and research.

Physicians (N = 803) were contacted via postal survey and given two sets of efficacy measures for drug treatments in Alzheimer's disease: (a) the time that patients spend in a mild or moderate state of disease; (b) levels of modification to disease progression in the areas of cognition, behaviour, and mood, and ability to perform basic activities of daily living. Physicians reported that they would prescribe a hypothetical, new Alzheimer's disease medication if it would allow patients to remain in their current disease state for 15 (mild) or 11 (moderate) additional months. Most physicians required a permanent halt to, or some reversal of, disease progression as a prerequisite for prescribing; a few required substantial reversal. More stringent efficacy requirements were negatively associated with physicians' current prescribing of cholinesterase inhibitors to persons with Alzheimer's disease, although the effects were either small (odds ratio = 0.99) or not statistically significant at the 5 per cent level. The results suggest that physicians with stringent efficacy requirements for clinically relevant efficacy measures are less likely to prescribe cholinesterase inhibitors.

Numerous studies suggest that the clinical presentation of Alzheimer's disease (AD) is varied and that AD is thus a heterogeneous disorder. Evidence of this inter-individual variability has had an important impact on the approaches to the cognitive rehabilitation of AD, particularly in the early stages of the disease. Research has shown that, despite variable cognitive profiles, many preserved capabilities are observed in the first stages of AD and that the disease does not affect all cognitive functions globally. These preserved capabilities make it possible to apply cognitive interventions. However, numerous methodological difficulties are encountered in evaluating the effectiveness of these interventions, many of which are related to the heterogeneity of the deficits. The purpose of this article is to discuss this heterogeneity and its impact on methodological characteristics, especially participant selection and research design.

Drawing on a qualitative study of families' experience with Alzheimer's disease, this paper examines family members' reaction to identity transformation or loss of self in the afflicted loved one, using a symbolic interactionist perspective. The findings show that family members find this aspect of the disease emotionally stressful. Refusing to let go of what remains of the loved one's former self, they employ a number of strategies in an effort to protect her/his social and self-identity. These strategies include concealing information, medicalizing inappropriate behaviour, fostering independence, managing appearance, and perceiving selectively.

To understand the impact of ongoing reform of mental health and dementia care in Ontario, an examination of prevalence and health services utilization rates is needed. However, there exists a gap in current prevalence and health services research specific to dementia care in Ontario. The objective of this study was to address these concerns using linked administrative databases to determine the incremental use of health services by elderly Ontarians with dementia. Overall, study results demonstrated that individuals with dementia used services in a pattern similar to non-demented persons, albeit at a higher level. Exceptions were women's use of hospital and home care services, where the most elderly women received significantly fewer services. Thus, the study provided important insight regarding the relative levels of health services used by demented Ontarians. Research in this area will become increasingly important as the population ages and the settings integral to dementia care and management shift and evolve.

Specially designed outdoor spaces (SDOS) have been developed to improve the quality of life of people with dementia. However, few follow-up studies have been done to examine their use once implemented. The purpose of this study was to gain a better understanding of how SDOS are used and the objectives of their design fulfilled. A qualitative descriptive study was conducted of a SDOS 3 years after it was built to answer the following questions: How has the garden changed from the original design? What are the current patterns of use of the garden? What factors facilitate use of the garden? What are the barriers to use of the garden? Four main sources of data were used: landscape architectural drawings, non-participant observation, focus groups, and in-depth interviews. The results lend support to the theoretical principles of garden design in the literature. The garden was considered an important part of the service program. However, factors such as garden maintenance, organizational support, staff training, and accessibility may limit its impact.

Developments in information technology and the ongoing restructuring of health services to increase provision in community settings militate in favour of a streamlining of communications and the exchange of information about patients among health and social care providers. Yet the principles of confidentiality and privacy appear to inhibit this process. In order to explore the practical, ethical, and legal imperatives attendant upon personal health information exchange, we conducted a series of interviews with professional care providers, persons with early-stage dementia, and their family caregivers. The findings indicate some degree of discordance. Professionals reported valuing disclosure both to colleagues and family caregivers on the basis of its being in the patients' best interests. Patients also valued inter-professional exchange, but sought strong control over disclosure to family members. Family caregivers valued being kept informed of the patient's condition, even without the latter's consent. Implications for research and policy are discussed.

Implementing generationally appropriate activities for persons with dementia is a challenging task. Horticulture therapy (HT) addresses this challenge through the use of plants to facilitate holistic outcomes. Utilizing the model of environmental press, the current study sought to analyse adult day service (ADS) participants' responses to HT as compared to traditional activities.

HT activities were conducted once a week for a half an hour at four different ADS programs over the course of 9 weeks. Observational data were collected during HT and traditional ADS activities using a modified dementia care mapping (DCM) technique. Observers coded predominant behavioural and affectual responses for each participant.

HT activities facilitated higher levels of productive engagement and positive affect and lower levels of non-engagement than did traditional ADS activities. Therefore, HT offers dementia-care staff a viable activity alternative that is well received by clients and inclusive of all interested persons, despite cognitive limitations.

This study investigates three principal aspects of semantic memory processing in Alzheimer's disease: word finding, knowledge of the specific and generic attributes of concepts. Semantic memory is assessed by a range of verbal and visual tasks differentiated according to their level of complexity. Our hypothesis is that the processing of these types of information is modulated by the degree of effortful processing required by the tasks. The AD patients show more important difficulties on the tasks of high level of complexity. Nevertheless, although their performances improve when the level of complexity decreases, they significantly remain lower than those of the normal older subjects. These results are discussed with regard to the models of semantic memory, with particular reference to the debate in terms of a deficit of access or storage of this system in Alzheimer disease.

Caregivers play a determining role in choosing treatments for persons with Alzheimer's disease. The objective of this study was to examine caregivers' willingness to have persons with Alzheimer's disease continue taking cholinesterase inhibitors in the event that any 1 of 11 adverse effects was to occur. Data were gathered via postal questionnaire from 375 caregivers in Montreal. Sixty-four per cent of caregivers responded (n = 201), and most (≥59%) were willing to continue treatment if persons with Alzheimer's disease suffered from weight loss or loss of appetite. However, most (≥53%) were not willing to continue treatment in the event of headache, dizziness, nausea, diarrhea, vomiting, drop in blood pressure, insomnia, muscle cramps, or stomach bleeding. The use of cholinesterase inhibitors by persons with Alzheimer's disease was positively associated with caregivers' willingness to accept greater numbers of adverse effects (adjusted relative risk = 1.97; 95% CI = 1.11 to 3.61). Caregivers appear to make a risk–benefit assessment when they decide whether or not care-recipients should continue pharmacotherapy in the event of adverse effects.

The behavioural and emotional changes associated with Alzheimer's disease (AD) are compared for individuals with Down syndrome and AD and individuals with AD from the general population (AD-only). The primary caregivers of 30 people with Down syndrome and AD and 30 people with AD-only completed the BEHAVE-AD and the Apathy subscale of the CERAD. As well, behavioural observations at adult day programs were undertaken with selected participants (n = 26). The Down syndrome group experienced fewer delusions and had lower total scores on the BEHAVE-AD, indicating fewer problem behaviours overall. Day program observations suggested that the AD-only group were more likely to be sedentary and observe the activities of others, while the Down syndrome group were more physically active. Improving our understanding of the similarities and differences between these two groups may help facilitate the integration of individuals with Down syndrome into adult day programs for the general population.

Recent research aimed at discovering and developing new drugs for diseases of cognition focuses heavily on Alzheimer’s disease and emphasizes mechanistic/biochemical approaches. Originally, research was based on a pragmatic search for compounds that would protect animals front disruptors of learning and memory. A series of compounds called nootropics do protect animals against these disruptions and offer hope that cognitive deficits may be amenable to pharmacological treatment. However, clinical development of these compounds is complicated by a number of factors. Among these is the poor correlation between animal models of cognitive loss and clinical disease states, a notable exception being the amnesic effects of benzodiazepines. Moreover, the inverted U-shaped dose-response function obtained in animal models and the lack of standard clinical outcome measures further complicate the development process. Tests that are beginning to gain acceptance as “standards” need to be characterized in terms of their validity, variability, and stability. There is a dearth of normative, especially longitudinal, data on cognitive decline. However, the great efforts being made in basic and applied research warrant cautious optimism.