Burton V. Reifler

Behavioral disturbance in dementia of the Alzheimer's type.

Behavioral problems are thought to be pervasive and devastating to patients with dementia of the Alzheimers type and their families. Despite this, little empirical data are available concerning the nature of such impairments, their rate of occurrence or their relationship to the disease process. This study investigated 127 patients with a primary diagnosis of dementia of the Alzheimers type. Two methods of behavioral assessment were employed: a standardized dementia rating scale and a checklist of behavioral problems. Results indicated a) the overall number of problems significantly increased with increased cognitive impairment, b) the types of problems reported varied with cognitive severity, and c) behavioral problems were not significantly associated with patients age, gender, duration, or age at onset of dementia. These findings are discussed as they relate to the phenomenology of dementia of the Alzheimers type and to suggestions for interventions at different stages of the disease process. Problems found associated with level of impairment such as wandering, agitation, incontinence, and poor personal hygiene are thought to be characteristic of the disease and therefore predictable. Problems found not associated with level of impairment such as hallucinations, irrational suspicions, falls, and restlessness are likely to be idiosyncratic. The former should probably be incorporated into education and intervention programs; the latter addressed as needed on an individual basis.

The association between aluminum-containing products and Alzheimer's disease

The association between exposure to aluminum through the lifetime use of antiperspirants and antacids and Alzheimers disease (AD) was explored in a case-control study of 130 matched pairs. Cases were clinically diagnosed between January 1980 and June 1985 at two geriatric psychiatric clinics in Seattle, Wash. Controls were friends or non-blood relatives of the case. Subjects were matched by age, sex, and the relationship between the case and his or her surrogate. For all antiperspirant/deodorant use, regardless of aluminum content, there was no association with AD (adjusted odds ratio (OR) = 1.2, 95% CI = 0.6-2.4). For aluminum-containing antiperspirants, the overall adjusted OR was 1.6 (95% CI = 1.04-2.4) with a trend toward a higher risk with increasing frequency of use (p for trend = 0.03), the adjusted OR in the highest tertile being 3.2. For antacids regardless of aluminum content, the overall adjusted OR was 3.1 (95% CI = 1.2-7.9). Here, a steep dose-response gradient was found (p for trend = 0.009), with an adjusted OR for the highest tertile of 11.7. However, when only aluminum-containing antacids were analyzed, the overall adjusted OR was only 0.7 (95% CI = 0.3-2.0) and there was no significant dose-response trend. These results are provocative but inconclusive due to methodologic problems relating to the necessary use of surrogate respondents and the long time period of potential exposure for this dementing disease.

Practice of geriatric psychiatry and mental health services for the elderly: results of an international survey.

The authors conducted a survey of members of the International Psychogeriatric Association (IPA) to determine the state of development of both the profession of geriatric psychiatry and services for mentally ill elderly. Ratings for both issues were based on a scale of 1 to 4, with 1 being little to no development and 4 being the highest. A rating of 2 was set as the desired minimum, and 12 countries met this goal in both categories, with 6 more countries reaching this goal in service development only. We conclude that although the field of geriatric psychiatry and services for mentally ill elderly are still underdeveloped in much of the world, in many countries they are developed sufficiently enough that the IPA is in an excellent position to provide both information and technical assistance to nations wishing to advance.

Depression coexisting with dementia: Evaluation and Treatment

Depression and dementia are the most common syndromes of geriatric psychiatry. Although emphasis is often placed on distinguishing the two, patients frequently have both disorders. Treating the complications of irreversible dementia, while unaltering the underlying disease process, can result in significant functional improvement in affected patients.

Dementia care and respite services program.

In 1987 The Robert Wood Johnson Foundation announced the creation of the Dementia Care and Respite Services Program (DCRSP), the first national demonstration project to focus on day center and respite services for persons with dementia. The intent of this

Home-Based Mental Health Services for Older Adults: A Review of Ten Model Programs

5.1 million, 4-year (1988–1992) program was to demonstrate that nonprofit day centers could provide financially viable programs and services needed by people with dementia and their caregivers. Seventeen grantees in 13 states, representing 21 different organizations and operating 24 day centers, participated in the project throughout the entire 4 years. The DCRSP has provided the first overview of dementia-specific day programs in the United States, with specific insight as to who is being served (e.g., participant and caregiver characteristics), types of assistance needed in relation to activities of daily living, and the most common behavior problems being exhibited. In addition, results of the 4-year project support the fact that community-based day centers can effectively care for people with dementia, a demand for these services does exist, and families consider these services of sufficient value that they are willing to pay for them out-of-pocket. Results also show that nonprofit day centers can become financially viable programs if attention is given to factors such as providing consumer-responsive services, charging what services actually cost, and having a high level of community visibility. The net result is increased net operating revenue with improved financial performance and enhanced long-term stability.

Service Use and Financial Performance in a Replication Program on Adult Day Centers

OBJECTIVE The objective is to provide information on successful programs providing home-based services to mentally ill elderly in order to assist other communities wishing to establish such programs. PARTICIPANTS The ten programs described in this article were selected by peer review from applications for an award given by the American Association for Geriatric Psychiatry and were participants in an invitational conference. RESULTS Eight of the programs were components of a community agency and two were components of a medical school department of psychiatry. Six of the programs focused primarily on individuals with anxiety and depression and utilized a range of individual psychotherapies. The other four accepted patients with any psychiatric diagnosis including dementia and included medication management as part of their services. The numbers served by the ten programs ranged from about 50 to 300 new cases per year, and the staffing ranged from 2 to 13 often with a combination of full and part time. The annual budget for the ten programs ranged from

A New Home-Based Mental Health Program for Older Adults: Description of the First 100 Cases

30,000 to

Diagnosing Alzheimer's Disease in the Presence of Mixed Cognitive and Affective Symptoms

1,250,000. Budget sources usually included some combination of public funds, philanthropy, and fee-for-service income. CONCLUSIONS Despite the logistic and fiscal challenges of providing home-based services to mentally ill older adults there are many long-standing successful programs that can serve as models for communities wishing to establish similar programs. A great opportunity exists for a unified outcome research endeavor as well as expansion into many more communities.

Financial Performance Among Adult Day Centers: Results of a National Demonstration Program

The authors describe results from Partners in Caregiving: The Dementia Services Program, and present information on service utilization and financial performance among a group of 48 adult day centers across the United States from 1992 to 1996. Centers, with nonrandom assignment, received either grant support (average value: