Faculty Bibliography

Behavioral disturbances in dementia are some of the most burden-some features with which the caregivers must cope. These symptoms are particularly important because they are likely to be responsive to both pharmacological and nonpharmacological intervention strategies. Before the 1980s, rating scales for patients suffering from dementia did not separate cognitive features from noncognitive behavioral symptoms. This was a major problem because the evolution and course of behavioral symptoms in dementias, such as Alzheimer's disease, is different from the evolution and course of cognitive and cognition-related symptomatology. Before appropriate rating scales could be developed for the assessment of behavioral disturbances in dementia, the specific nature of these disturbances had to be described in the medical literature. Publications in the late 1980s described the specific behavioral disturbances occurring in dementia patients in detail for the first time. The rating scales that have been developed from these studies are as reliable as cognitive assessment measures. Instruments are now available that are based on information provided by the caregiver or that are based on observation of the patient made by the clinician. Construct validity, reliability, and the differences in methodology of these scales are compared in this overview. Using these scales will enable clinicians to assess pharmacological and nonpharmacological intervention strategies for behavioral symptoms in dementia with enhanced sensitivity

Alzheimer's disease (AD) is associated with an increased mortality in comparison with aged control populations. The relationship between the clinical and the temporal course of AD has not been well studied over significant intervals. Community-residing patients with probable AD (N = 103, 42 men, mean age = 70.2 +/- 8.0 years) were studied at baseline on demographic and clinical variables, including measures of global deterioration (Global Deterioration Scale; GDS), mental status and cognition (e.g., Mini-Mental State Examination; MMSE), and functional impairment (Functional Assessment Staging; FAST). Baseline characteristics included a GDS range of Stage 4, 5, or 6 (38.8%, 39.8%, and 21.4%, respectively) and a mean MMSE score of 15.4 +/- 5.6. The mean follow-up interval was 4.6 +/- 1.4 years. Follow-ups were done blind to baseline measures and when necessary were conducted in residential and nursing home settings. Of locatable subjects (n = 95, 92%), 30 (31.6%) were decreased. Survivors (n = 65) had a mean GDS stage of 6.2 +/- 0.9 and a mean MMSE score of 5.1 +/- 6.9; 51% had MMSE scores of 0. Increased age and male gender, but not baseline clinical dementia variables, increased the risk of death (ps < .01). Change in clinical variables correlated significantly with time elapsed (r = .32, p < .05, for MMSE change, to r = .48, p < .001, for GDS change). Significant variance in temporal change (i.e., time elapsed) was accounted for by change in two of the five clinical measures studied (i.e., GDS and FAST; multiple r = .53). The results support previous estimates of mean duration of the GDS and FAST stages. For subjects with probable AD followed over approximately 5 years, clinical variables changed significantly over time in survivors. However, the majority of temporal variance in the course of AD remains unexplained

A clinician should not rely entirely upon a caregiver's report regarding behavioral pathology when planning a treatment strategy. Direct observational evaluation instruments as well as caregiver-based assessments are necessary. A new scale for the empirical (observational) evaluation of behavioral symptoms in Alzheimer's disease (AD) and related dementias, the Empirical Behavioral Pathology in Alzheimer's Disease Rating Scale (E-BEHAVE-AD) was developed. Interrater reliability of this new assessment instrument was examined. Additionally, the relationship between the observed occurrence of behavioral symptomatology on this new rating instrument was compared with the occurrence using a similarly designed, caregiver-based instrument. The interrater reliability study consisted of two raters who simultaneously evaluated 20 dementia patients. The comparative study employed a cross-sectional design (N = 49). Individuals were evaluated in an outpatient clinic setting. The study population consisted of cognitively normal individuals and dementia patients. Evaluations included the new, observationally based behavioral assessment (the E-BEHAVE-AD), a caregiver-based behavioral assessment (the Behavioral Pathology in Alzheimer's Disease Rating Scale; BEHAVE-AD), a clinical global measure (the Global Deterioration Scale), and a mental status assessment (the Mini-Mental State Examination). The interrater reliability study revealed an intraclass correlation coefficient of .97 (p < .01) for total scores on the new E-BEHAVE-AD rating scale. The correlation coefficient for the amount of agreement on the presence of symptoms in six symptomatic categories between caregiver-based information about the patient's behavioral pathology assessed on the BEHAVE-AD and the clinician's observations assessed with the new E-BEHAVE-AD rating instrument was .51 (p < .01). The new E-BEHAVE-AD rating instrument showed excellent interrater reliability. Furthermore, there was a statistically significant relationship between clinician observation of the occurrence of behavioral pathology assessed using the E-BEHAVE-AD and caregiver-reported pathology assessed with the BEHAVE-AD. However, the magnitude of the correlation between these measures indicated that the majority of variance was independent and nonoverlapping. Consequently, these data support theoretical models suggesting that the assessment of behavioral pathology in dementia might ideally encompass both direct observational and caregiver-report approaches, using measures such as the E-BEHAVE-AD as well as measures such as the BEHAVE-AD

Two reliability studies were performed on a recently developed cognitive assessment battery for severe dementia. The method, the Modified Ordinal Scales of Psychological Development (M-OSPD), is based on the Piagetian developmental model of sensorimotor functions. Procedures have been adapted from this test battery, which was originally applied to infants and small children, for the assessment of remaining cognitive capacity in severe dementia. Two independent interrater reliability studies were conducted. In these studies, two different raters simultaneously evaluated patients with severe dementia. One interrater reliability study was performed in a nursing home setting (Study 1), and the other reliability study consisted of a sample of community-residing patients (Study 2). The Global Deterioration Scale and the Mini-Mental State Examination were used to assess dementia severity. Study 1 (N = 22) resulted in an intraclass correlation coefficient (ICC) of .99 (p < .01) for the M-OSPD total score. Study 2 (N = 19) resulted in an ICC of .96 (p < .01) for the M-OSPD total score. The M-OSPD proved to be a reliable instrument in these studies. This cognitive assessment measure can provide meaningful information regarding the cognitive abilities of late-stage dementia patients. Until recently, these late-stage dementia patients had been considered untestable in studies that utilized conventional psychometric and mental status evaluation measures

To address the issue of mild, moderate, and severe Alzheimer's disease (AD), it is necessary to initially establish some agreement on terminology. In recent decades, these terms have frequently been defined using screening instrument scores with measures such as the Mini-Mental State Examination (MMSE). There are many problems with this approach, perhaps the most salient of which is that it has contributed to the total and tragic neglect of patients with severe AD. An alternative approach to the classification of AD severity is staging. This approach has advanced to the point where moderately severe and severe AD can be described in detail. Procedures for describing this previously neglected latter portion of AD have recently been extensively validated. Staging is also uniquely useful at the other end of the severity spectrum, in differentiating early aging brain/behavior changes, incipient AD, and mild AD. Temporally, with staging procedures, it is possible to track the course of AD approximately three times more accurately than with the MMSE. The net result of the advances in AD delineation is that issues such as prophylaxis, modification of course, treatment of behavioral disturbances, loss of ambulation, progressive rigidity, and the development of contractures in AD patients can now be addressed in a scientifically meaningful way that will hopefully bestow much benefit in AD patients and those who care for them

OBJECTIVE: The order in which cognition and the ability to perform activities of daily living (ADLs) are lost in an institutionalized aged population was examined. Understanding the order of loss of function is important for preparing caregivers and planning of care. METHOD: The conditional probabilities of the inability to perform activity A when there exists the inability to perform activity B were explored in secondary analyses of cross-sectional data describing 408 nursing home residents. Residents' abilities to perform ADLs were rated by nursing staff using Linn and Linn's Rapid Disability Rating Scale (RDRS-2); cognitive functioning was rated by social workers and nursing staff using a modified version of Reisberg et al.'s Brief Cognitive Rating Scale (BCRS, with 4 axes: orientation, concentration, recent memory, and past memory). RESULTS: The results regarding ADLs confirm previous findings of a natural order of loss of ability (from the one lost first to last): bathing, dressing, grooming, toileting, walking, and eating. The examination of order in the loss of concentration, recent memory, past memory, and orientation revealed that these seem to be lost concurrently when the cutpoint was 3 (i.e., relatively normal functioning vs. moderate and severe dementia). When the cutpoint was 6 (i.e., severe dementia vs. higher levels of functioning), the order that emerged was: recent memory, past memory, concentration, and orientation. CONCLUSIONS: Although there is a significant relationship between loss of ability to perform ADLs and stage of cognitive impairment, the loss of any specific ADL is not uniquely related to any one stage of cognitive deterioration in this diverse population. This may be explained by the high prevalence of disease in this institutionalized population, as exemplified by the 60% suffering from arthritis and the 17% suffering from neurological disorders other than dementia