Pattern of Cognitive Decline with Age in the Elderly

OBJECTIVE: Examination of the changing pattern of cognitive function in old age. METHOD: Cross-sectional observation of MMSEK performances of the elderly living in a rural community. The mean and standard deviation, coefficient of variability, and 95% confidence interval and difference between the upper and lower limits by the 5-year age interval were employed as indicators of the change. RESULTS: Characteristics of the change of the MMSEK score by age were (1) overall decline and (2) widening of variance in terms of the standard deviation, coefficient of variability and difference between upper and lower limits of the 95% confidence interval. CONCLUSION: The changing pattern of cognitive function with age in the elderly is decline with 'fan-spread' shape. Heterogeneity, genetic effect on cognitive function in the old age, cerebral reserve gained before the old age, and different extent of physical activities might suggest some explanation for the phenomena.

Two Consecutive 6-Year Follow-ups of the MMSEK in the Rural Elderly / 신경정신의학

OBJECTIVES: To examine the changing pattern of cognitive function in old age. METHODS: Longitudinal observation of MMSEK performances of the elderly living in a rural community through 2 consecutive 6-year follow-ups. The mean, standard deviation, and coefficient of variability of the three consecutive MMSEK performances with 6-year interval were indicators of the changing pattern. Paired t-test was used for comparison of two consecutive MMSEK performances : MMSEK-90 vs MMSEK-96 and MMSEK-96 vs MMSEK-02, while Student's t-test for comparison between the first and second 6-year changes of the MMSEK performance. RESULTS: In all age groups, the MMSEK performance declined significantly during the two consecutive 6-year periods, the standard deviation and coefficient of variability widened with age, and the second 6-year decline of the MMSEK performance was significantly greater than the first 6-year decline. CONCLUSION: Decline of the cognitive function is steeper in the elderly with age and the declining pattern is the 'fan-spread' shape.

Two Consecutive 6-Year Follow-ups of the MMSEK in the Rural Elderly / 신경정신의학

OBJECTIVES: To examine the changing pattern of cognitive function in old age. METHODS: Longitudinal observation of MMSEK performances of the elderly living in a rural community through 2 consecutive 6-year follow-ups. The mean, standard deviation, and coefficient of variability of the three consecutive MMSEK performances with 6-year interval were indicators of the changing pattern. Paired t-test was used for comparison of two consecutive MMSEK performances : MMSEK-90 vs MMSEK-96 and MMSEK-96 vs MMSEK-02, while Student's t-test for comparison between the first and second 6-year changes of the MMSEK performance. RESULTS: In all age groups, the MMSEK performance declined significantly during the two consecutive 6-year periods, the standard deviation and coefficient of variability widened with age, and the second 6-year decline of the MMSEK performance was significantly greater than the first 6-year decline. CONCLUSION: Decline of the cognitive function is steeper in the elderly with age and the declining pattern is the 'fan-spread' shape.

Mini-Memory Test (MiMeT): A New Brief Memory Screening Test / 신경정신의학

OBJECTIVES: Development of the Mini-Memory Test (MiMeT). METHODS: Subjects were 332 memory-impaired and 354 memory-unimpaired psychiatric patients. Discriminant validity, sensitivity and specificity, and receiver operating characteristic curve were employed for the validity test. RESULTS: In the memory-unimpaired group, the effects of age, education and sex on MiMeT scores were either statistically insignificant or negligiblely little if significant. Correlations between the subtest scores ranged from .444 to .673. The Cronbach's alpha was .790. The subtest and total scores were much lower in the memory-impaired group. Correlations of the total score to Barthel Activities of Daily Living, Blessed Dementia Rating Scale, Short Form of Samsung Dementia Questionnaire, Lawton Instrumental Activities of Daily Living, and Cognitive Impairment Diagnosing Instrument were between .287 and .790 in the memory-impaired group. The MiMeT's AUC was .964 and the sensitivity and specificity of the total score were .916 and .887, respectively, at the cutoff of 17/18. Diagnosis alone was able to account for 61.2% of the variation. Inclusion of age, education and sex in the linear multiple regression increased it to 63.5% only. CONCLUSION: Performances of the MiMeT, a brief and easily administrable test for memory screening, is affected little affected by age, education and sex. It is reliable and valuable for detection of memory impairment in the elderly.

Identity of the Korean Association for Geriatric Psychiatry

Identity of the Korean Association for Geriatric Psychiatry (KAGP) was discussed in terms of identity of geriatric psychiatry, past history and current status of the KAGP, and KAGP's future tasks. To sum up, the KAGP was successful in a variety of scientific and educational activities for a decade since its coming out to the world 10 years ago. However and at the same time, it has many long ways to go in the future.

Alzheimer's Disease: A Typical Model for Neuropsychiatry / 신경정신의학

Even until the early 20th century psychiatry and neurology had been one. However, the chasm had been wider and wider between the two, at least in this country and the United States, until three decades before when chemical treatments were popular for schizophrenia and mood disorders. During the past three decades there have been many revolutionary progresses in neurosciences. Thanks to those developments, psychiatry and neurology are going gradually closer to each other and expected to become a single clinical specialty not far ahead. It may be called neuropsychiatry or clinical neuroscience. Alzheimer's disease seems to be a very good model bridging again the rift between the two medical specialties. It is so in terms of both from basic molecular genetics to clinical symptoms and from causes of to therapeutic interventions of cognitive, behavioral, and psychological manifestations.

Future of Geriatric Psychiatry in Korea

No abstract available.

The role of Video-Urodynamic Study in the Diagnosis of Benign Prostatic Hyperplasia

PURPOSE: Benign prostatic hyperplasia (BPH) frequently combines other geriatric diseases, which affect voiding in complicated manner. However, differential diagnosis of BPH attributable to voiding dysfunction in such complicated cases has been difficult. Videourodynamic study, allowing the better correlation of structure and function, have had an important position in the diagnosis of various kind of voiding dysfunction. We compared diagnostic values between traditional pressure-flow study and videourodynamic study in the evaluation of the BPH. MATERIAL AND METHODS: Forty-seven men were subjected to this study, who showed lower urinary tract symptoms (LUTS) secondary to BPH combined with other underlying diseases (cerebrovascular disease, spinal cord injury, diabetes mellitus, Parkinson's disease) which could affect the voiding pattern. Included was patients older than 50 years, with a total International Prostate Symptom Score (IPSS) of 8 points or more. All patients were evaluated with detailed history, physical examination including digital rectal examination, prostate specific antigen (PSA), transrectal ultrasonography (TRUS), and videourodynamic study. Pressure-flow study was additionally performed in 27 patients who had been diagnosed as equivocal or obstructed or unobstructed on videourodynamic findings. RESULTS: The sensitivity of videourodynamic study and pressure-flow procedures was 87% and 55%, respectively, as complete pressure-flow data are not available in 12 patients due to difficult urination by catheterization. The specificity of videourodynamic study and pressure-flow study was 76% and 100%, respectively. Videourodynamic study additionally showed uninhibited bladder contraction and/or detrusor sphincter dyssynergia (internal or external) in 65.1% of the patients, which are not available from pressure-flow study. CONCLUSIONS: To diagnose voiding dysfunction from BPH in complicated case, videourodynamic study showed advantages over pressure-flow study in terms of diagnostic sensitivity, both functional and anatomical informations on lower urinary tract. It is likely that the videourodynamic study is the method of choice for the assessment of voiding dysfunction in BPH combined with other diseases.

Significance of Non-Alzheimer Dementia

Most of the research activities on dementias have been and are focused on Alzheimer's disease. With regard to the treatment possibility and the cause and pathogenesis of cognitive impairment, however, non-Alzheimer dementias are also very important. We should extend our efforts to other dementing diseases than Alzheimer's disease.

Reliability and Analysis of Symptom Category Scores of the Behavior Pathology in Alzheimer's Disease Rating Scale, Korean Version(BEHAVE-AD-K)

OBJECTIVE: The aims of this study were to (1) validate the inter-rater reliability of the BEHAVE-AD, Korean version, to (2) analyze the quantitative relationship between severity of Alzheimer's disease (AD) and mean scores on each of the BEHAVE-AD categories and mean total BEHAVE-AD score. DESIGN: Cross-sectional study of geriatric patients with AD evaluated at a mental hospital for the elderly. SAMPLE: Fifty-two consecutive patients diagnosed with probable Alzheimer's disease (AD) according to NINCDS-ADRDA diagnostic criteria. RESULTS: In reliability study, significant correlations were obtained for all BEHAVE-AD symptoms category scores and for mean total BEHAVE-AD scores. Analysis of BEHAVE-AD scores as a function of disease severity demonstrated a non-linear relationship between severity of behavioral symptoms and the global and cognitive advance of AD. Score analysis of the BEHAVE-AD indicates that these behavioral disturbances become most severe in the moderate and moderately severe stages of AD. CONCLUSION: All the results proved the cross-cultural validity and reliability of the BEHAVE-AD, Korean version. Furthermore, these results have implications for the methodology of pharmacological trials of putative cognitive enhancer compounds in AD.

Prediction of Diagnosis of Dementia Using Cognitive Impairment Diagnosing Instrument(CIDI) / 신경정신의학

OBJECTIVES: This study aimed at investigating the diagnostic predictability of Cognitive Impairment Diagnosing Instrument(CIDI) in diagnosing dementia of elderly people aged 60 years or more. METHODS: The subjects were 129 patients with other mental diseases than dementia whose ages were more than 60 years and 86 patients with dementia. Psychiatric diagnoses were made by according to the DSM-IV criteria. Converted age(chronological age minus 59) was employed for the statistical reason. The length of education was classified into 4 intervals:1 for less than one year schooling, 2 for grade schooling, 3 for junior or senior high schooling and 4 for college or more schooling and each number expresses ordinal scale. The converted age, length of education expressed by one of 4 interval scores, and total CIDI score were independent variables while the diagnosis(dementia vs nondementia) was dependent variable in the logistic regression analysis. RESULTS: -2 log likelihood was 102.773 when the length of education, converted age and total CIDI score were included while it was 289.395 when only the constant was included(K 2=186.622, df=3, p=0.000). The goodness-of-fit statistic was 156.798(K 2=6.5843, df=8, p=0.5821), and the overall concordance of diagnostic classification was 90.2%. The logistic regression equation for the diagnosis of dementia was generated as follows:y=7.5752+0.0940*X 1+0.9820*X 2-0.1811*X 3(y=ln{pai/(1-pai)}, X 1:converted age, X 2:education intervals, X 3:total CIDI score, pai:possibility of dementia, > OR =0.50 indicating dementia and <0.50 indicating nondementia). The e bs(95% C.I.) for the converted age, education interval and total CIDI score were 1.0985(1.0107-1.1940), 2.6699(1.4134-5.0436), 0.8344(0.7898-0.8815), respectively. CONCLUSIONS: The CIDI could be considered as a useful diagnostic tool for dementia using the logistic regression analysis.

Revised Cognitive Impairment Diagnosing Instrument (CIDI): A Semi-Structured Interview Form for Assessment of Cognitive Functions / 신경정신의학

OBJECTIVES: This study was conducted in order to evaluate reliability and diagnostic validity of the CIDI. METHODS: 64 patients with DSM-IV dementia and 90 elderly patients with other mental disorders entered this study. Inter-subtest Pearson's correlations, corrected subtest-total correlations and Cronbach's alpha were computed for reliability while correlations of the total scores on CIDI with the performances on other scales relating to dementia, sensitivity and specificity, area under curve using the receiver operating characteristic curve, and group comparison were used for the assessment of validity. RESULTS: The CIDI's inter-subtest correlations ranged from 0.596 to 0.813, with a mean of 0.707. The corrected subtest-total correlations were between 0.759 and 0.890. Cronbach's alpha of the subtests was 0.941 and the Cronbach's alpha were between 0.928 and 0.948 when any subtest was deleted. In the demented subjects, the correlation coefficients of the total CIDI score with the performances on S-SDQ, IADL, BADL, BDRS, and MMSEK were around 0.5. Area under the receiver operating curve of CIDI was 0.933 with the standard error of 0.021(95% CI, 0.891-0.975). At the CIDI cutoff point of 65/66, sensitivity and specificity were 95.3% and 85.6%, respectively. The corresponding values of MMSEK were 0.930, 0.020 (95% CI, 0.891-0.969), 22/23, and 89.1% and 85.6%. The demented scored much poorer in all CIDI subtests than the nondemented mental patients, and the differences were highly significant. CONCLUSIONS: The CIDI was satisfactory regarding to reliabilities and diagnostic validities. The CIDI and MMSEK are thought to be reciprocal in assessment of cognitive functions: CIDI is preferable for clinical assessment of cognitive dysfunction and MMSEK for as a screening test.

Epidemiology of Vascular Dementia

The concept of vascular dementia is not still established. Its pathogenesis is not completely understood, either. It may be different among the subtypes, e.g., ischemic, hemorrhaginc, or Binswanger's disease. In this article epidemiology of vascular dementia was reviewed, based on the important findings regarding to prevalence, ethnic difference in prevalence, incidence, risk factors, and natural history and survival. We have to wait for more elegant concept of and better understanding of vascular dementia.

Cognitive Function and Survival among the Elderly in a Rural Korean Community / 신경정신의학

OBJECTIVES: To investigate the relationship between cognitive functions and death in the elderly. METHOD: The MMSEK was administered to a community elderly population aged 65 or more. The initial MMSEK score and age were compared between the 6-yr survivors and 6-yr decedents. Relative risks of death were calculated in terms of sex, age, and educational level. RESULTS: The decedents were older and poorer in MMSEK performances except for orientation in place. The relative risk of death was 1.08 in the persons with questionable cognitive impairment and 1.94 in the persons with definite impairment. It was 1.13 in the illiterates and 1.26 in the educated. CONCLUSIONS:In the elderly the prospective survival and death may be related to severe cognitive decline, male sex, and old age, but not to mild cognitive decline, educational level, and remote memory.

Effects of Gender, Age, and Education on the Performances of the Korean Version of the Mini-Mental State Examination in an Elderly Rural Population / 신경정신의학

OBJECTIVES: To study of the effects of gender, age and education on the MMSEK performances in the elderly. METHOD: The MMSEK was administered to a total of 702 persons aged 65 or more in a rural area. The effects on the total and subtest MMSEK scores of the 3 independent variables were analyzed by Student t-test, Pearson's correlation, oneway analysis of variance, analysis of covariance, and stepwise multiple regression. RESULTS: The total and all subtest scores of MMSEK were found to be affected by age. All subtest, except memory registration and memory recall, scores were affected by education and sex. 39.6% of the variance of total MMSEK score could be accounted for by the 3 variables. CONCLUSIONS: 40% of the variance of the total MMSEK score could be accounted for by age, gender and education while the remaing 60% is assumed to be affected by other variables than age, sex, and education. Memory registration and memory recall seems to be resistant to sex and education effect, but sensitive to aging.

A 6-Year Follow-up of Cognitive Function in a Rural Elderly Population / 신경정신의학

OBJECTIVES: This study was conducted to delineate the long-term natural change of cognitive functions in aged community residents, using the Korean version of the mini-mental state examination (MMSEK) METHODS: The first MMSEK was administered to as the screening test for identification of dementia between January and December, 1990 in a total of 702 persons. They were residents of a Myun area, Pohang, Kyungpook Province and 65 or more as of December 31. 1990. The MMSEK was repeated from November, 1995 to June, 1996, using the Cognitive Impairment Diagnosing Instrument and was successful in 440. RESULTS: The 6-year mean(+/-SD) decline of the total MMSEK score was 1.52+/-3.45 and 6.42%. Of the subtests, memory registration showed no significant decline while comprehension/judgement improved significantly. The decline was most prominent in attention/calculation and memory recall, and then language, orientation in time and orientation in place in order. Change of the total score was not related to sex, education and the first total score. Decline of language function was more severe in the educated than in the noneducated-illiterate. Performances of all subtests declined significantly with aging and improvement of the comprehension/judgement was less prominent in the group aged 75 or more. Relations of the change with the first total score were inconsistent among the subtests. The stepwise multiple regression analysis revealed that age, the first total score and education were the variables significantly affecting the decline of MMSEK score. However, they could account for only 16.4% of the variance of decline of the total MMSEK score. CONCLUSIONS:Decline of the cognitive function was small during the 6-year period, and the change pattern was not homogenous among the subtests. Age, the first total MMSEK score and education were idenrified as significant, but not so important, factors accounting for the variance of the cognitive decline.

Research in Korean Geriatric Psychiatry:Past, Present and Future

Research articles are rapidly increasing in number of publications in the regular journals on geriatric psychiatry and it's allied fields since 1989. However, they were mainly on dementia, depression, epidemiology and neurocognitive functions. Widening of research areas, refinement of study methodology and multidisciplinary approach based on clinical data are needed. And of importance is submission to the popular foreign scientific journals listed in medical indexes, including the Current Contents, Excerpta Medica, Index Medicus, Medline, Psychological Abstracts, Science Citation Index, and Social Science Citation Index. In the case of home journals, a meticulous peer review system of manuscripts could improve the quality of research activities and of publications. All these activities would help us open a new horizon in the research into mental health problems in Korea.

Effects of Gender, Age and Education on MMSEK Performances in a Non-Demented Elderly Rural Population

OBJECTIVE: The authors investigated effects of gender, age and education on the MMSEK performances in a non-demented elderly rural population. METHODS: The MMSEK was administered to 617 non-demented elderly people aged 65 or more in a rural area. The effects on the total and subtest MMSEK scores of gender, age and education were analyzed by Student t-test, Pearson's correlation, oneway analysis of variance, analysis of covariance and stepwise multiple regression. RESULTS: The three independent variables showed significant influence on the total score, orientation in time, orientation in place, attention/calculation, language function and comprehension & judgement of the MMSEK. The three variables could account for 40.0% of the variance of the total MMSEK score. Of the MMSEK subtests, memory registration and memory recall were resistant to the variables. MMSEK scores of the female, the older people and the undereducated were even less. CONCLUSION: Prevalence of dementia seems not to influence on the variance of total MMSEK score in a population in which its prevalence is about 10%. Gender, age and education have significant effects on orientation in time, orientation in place, attention/calculation, language function and comprehension & judgement, while not on memory registration and memory recall. Female sex, old age and undereducation are thought to be risk factors for development of dementia.

Memory Functions in Questionable Dementia of the Alzheimer Type / 신경정신의학

OBJECTIVE: Exploration of the questionable Alzheimer disease is important for accurate estimation of prevalence and incidence, understanding the natural history, and evaluation of treatment strategies for the Alzheimer disease. Subjects and METHODS: We compared neuropsychological test performances among 14 nondemented controls, 14 elderly persons with questionable dementia of the Alzheimer type and 14 elderly persons with mild dementia of the Alzheimer type. The test performances analyzed were the digit span of the Korean Adult Wechsler Intelligence Scale, registration, short term memory and long term memory of the Cognitive Impairment Diagnosing Instrument, and paired association learning and logical memory of the Wechsler Memory Scale. RESULTS: There was significant difference between questionable dementia of the Alzheimer type and controls in the long-term memory, short-term memory, immediate and delayed recalls of the logical memory, and easy association. But the subjects with questionable and mild dementia of the Alzheimer type scored similarly on all tests except the long-term memory. CONCLUSION: These findings suggest that questionable Alzheimer disease may be the very early Alzheimer disease.

Diagnostic Predictive Values of Cognitive Function Tests

OBJECTIVE: The positive and negative predictive values are more important as the diagnostic validity than the sensitivity and specificity in the general population with a low prevalence rate of a disease. The present study is about the diagnostic predictive values of the Korean version of mini-mental state examination and Cognitive Impairment Diagnosing Instrument in an unselected community elderly group. METHOD: The positive and negative diagnostic values were calculated based on the Bayes theorem, using the sensitivity and specificity of the Korean version of mini-mental state examination and Cognitive Impairment Diagnosing Instrument and a previously reported prevalence rate. RESULTS: When the prevalence of dementia is 10.8% among elderly people living in a community, the positive predictive value, negative predictive value and combined error were estimated as being 56.7%, 99.0%, and 8.4%, respectively, at cutoff score of 23 of the Korean version of mini-mental state examination for diagnosing dementia. In the case of the Cognitive Impairment Diagnosing Instrument, they were 64.2%, 99.1% and 6.3%, respectively, at the point of 57 or less in an unselected community sample with the same prevalence. If the sensitivity and specificity are constant, the positive predictive values of the Korean version of mini-mental state examination and Cognitive Impairment Diagnosing Instrument incresed markedly with the rising prevalence while the negative predictive values and combined errors changed little. CONCLUSION: If a variety of diagnostic tests available are similar in the diagnostic sensitivity and specificity, a test with higher positive predictive value should be prefered because the negative predictive value and combined error are not significantly influenced by the prevalence. In this regard, the Cognitive Impairment Diagnosing Instrument may be superior to the Korean version of mini-mental state examination.