Staging methods for the assessment of dementia: Perspectives.

Most dementias in old age are characterized by a progressive course with interindividual variability in pattern and rate of progression. Developing a system for staging such dementia poses a challenge in capturing this variability in a system that will afford comparisons among individuals and predictions of future change. Several core questions underlie the development of such systems: (1) Is there a definable order in which abilities are lost? (2) Which skills and functions should be considered essential for the staging of dementia and what is their relative weight? (3) Can the different skills be captured within one staging system? (4) How is the whole range of function captured, and are the differences between stages clearly defined? (5) Which populations can be rated with each staging system? The determination of this last question is based on understanding which other medical conditions may interfere with the course of dementia and how prior characteristics, such as education, affect ratings on specific scales for the staging of dementia. Several systems for staging dementia in older adults are described. These include the Clinical Dementia Rating, the Global Deterioration Scale/Brief Cognitive Rating Scale/Functional Assessment Staging System, the Six Clinical Phases of Cognitive Decline, the Hierarchic Dementia Scale, and the Functional Capacity Scale. Some aspects of the utility of these systems are reviewed, and the issues for further research are discussed.

The Hierarchic Dementia Scale: conceptualization.

The Hierarchic Dementia Scale is an instrument for measuring the severity of mental impairment based on Piagetian concepts, neuropsychological findings, and the hierarchic nature of decline in mental function. Performance of 20 specific functions such as orienting reflexes and comprehension can be rapidly pinpointed over a wide range of impairment. The scale is reliable, valid, responsive, safe, inexpensive, and easy to use.

Skills training with supporters of the demented.

This study examined the effects of Supporter Endurance Training (SET) on family supporters of elderly demented patients. Single case methodology was used in evaluating the outcome of providing eight supporters with eight weekly training sessions in meditative relaxation and assertiveness. Four such supporters received no special training. A videotape dramatizing typical problem situations encountered with a demented family member was used to elicit information about supporters' coping styles. Post-training and six-month follow-up evaluation indicated improvements among trained individuals on measures related to assertiveness, problem solving, and stress reduction. Trained subjects' estimates of the length of time they would be able to cope with problems involved in caring for their relatives also increased. Few such improvements occurred among untrained subjects. These results suggest the usefulness of brief structured skills training programs in helping supporters to improve their coping abilities.

Existential issues in the management of the demented elderly patient.

Four major existential themes are explored, as they relate to the predicament of the relative supporting a demented elderly dependent at home. These issues, namely, death, isolation, freedom, and meaning are discussed with respect to their dynamic impact on the stressed supporter as well as their implications for anxiety management.

Coping with dementia: a pilot study.

Ten supporters of demented elderly dependents were studied in order to examine their coping behavior in the context of caring for their relatives at home. Coping skills were described with respect to programs, solutions, and cognitive aspects of motivation and stress tolerance. The observations made suggested the hypothesis that tolerance of debility in a demented relative is related not only to the number and type of problems in the dependent but also to the availability and quality of coping skills in the supporter. This hypothesis was explored through the elaboration of a skills training program (Supporter Endurance Training), which was designed and employed to improve and expand the coping skills of a supporter. Supported Endurance Training may prove to be a useful approach to the maintenance of the demented elderly person at home as a possible alternative to institutionalization.

A psychogeriatric assessment program. V. Three-year follow-up.

In 1974, a 10-month diagnostic evaluation of 80 newly admitted psychogeriatric patients was undertaken. The diagnostic categories were functional versus organic brain disease. The present report deals with results of a follow-up evaluation three years later. To assess the prognostic validity of our measures, the initial 1974 data on survivor and nonsurvivor groups were studied, and some of the tests were repeated in 35 of the 40 survivors. Statistically significant differences between survivors and nonsurvivors were found in both "organic" and "functional" groups, with respect to performance on psychologic and psychophysiologic tests, and the level of social functioning before admission. The death rate was significantly higher in the group with organic disease.

Amantadine in senile dementia: electroencephalographic and clinical effects.

Nineteen patients with senile brain disease (including 2 with parkinsonian symptoms) were treated with amantadine in an oral dosage of 200--300 mg daily. Seven showed definite clinical benefits such as increased alertness and decreased agitation, and 2 others showed slight benefits. However, in only one instance was the benefit maintained without complications. Toxic effects such as overactivity, anxiety and visual hallucinations were observed in 8 patients. Withdrawal effects (e.g., lethargy and staggering) occurred when amantadine was discontinued. The electroencephalograms (EEGs) of all 19 patients showed a frequency increase, chiefly of occipital alpha activity, and sometimes a return to normal, irrespective of clinical changes. Toxic side effects were associated with particularly prominent EEG acceleration. In 10 of the 19 patients, the clinical changes were further validated by by additional psychologic assessments. Although the value of amantadine is limited when given in this way to patients with senile brain disease, it seems important to observe its effects in drug combinations aimed at correction of neurotransmitter imbalances.

A psychogeriatric assessment program. IV. Interdisciplinary aspects.

The interdisciplinary aspects of the psychogeriatric assessments described in three previous papers are discussed on the basis of factor-analysis findings and their significance in diagnosis, treatment, planning and theory. The difference between basic biopsychologic dysfunctions (including pathohistologic changes and various counter-regulations) and psychosocial dysfunctions (lifestyle) becomes clear statistically as well as clinically. This difference probably is fundamental, in the sense that intact biopsychologic functions are elementary tools for the psychosocial functions.

A psychogeriatric assessment program. III. Clinical and experimental psychologic aspects.

Variables stemming from standard psychologic tests, psychophysiologic tests, and operant conditioning procedures were employed in assessing the status of 80 psychogeriatric patients with either organic brain syndromes or functional psychoses. Differences were observed in the responses between the two groups. In general, the performance of the patients with organic brain syndromes was more deviant than that of the patients with functional psychoses, and the performance of the hospitalized geriatric patients (regardless of diagnosis) was worse than that of the normal control groups.

A psychogeriatric assessment program. I. Social functioning and ward behavior.

Eightly newly admitted psychogeriatric patients were intensively investigated by a variety of disciplines -- medical, laboratory, and psychologic-psychiatric tests, including a Minimal Social Behavior Scale and an Integrative Social Functioning Scale. The sample of patients and methods of study for this 10-month Geriatric Assessment Program are described. Assessment of present and past social functioning revealed good agreement between ratings made by different staff members. A decline in social functioning with time differentiated organic from functional psychiatric illness. Some of the scales employed may be of value for social screening purposes in the community.