Diagnosing dementia in a developing nation: an evaluation of the GMS-AGECAT algorithm in an older Korean population

BACKGROUND: Numbers of older people are increasing rapidly in many developing nations and there is a pressing need for epidemiological studies of psychiatric morbidity, particularly dementia. Valid methods for case identification are an important first step. The Geriatric Mental State (GMS) is a widely used diagnostic instrument but has received little formal evaluation in developing nations. The objective of this study was to investigate the screening properties of GMS organic disorder with respect to clinically diagnosed dementia in an older Korean population, about half of whom have received no formal education. METHODS: 746 people aged 65+ in Kwangju, South Korea who were participants in a community survey of psychiatic morbidity, completed a GMS interview (with diagnoses assigned through the AGECAT computerised algorithm) and, independently, received a clinical assessment for dementia. RESULTS: GMS organic disorder was diagnosed in 262 participants (35%) and DSM-IV dementia in 110 (15%). Increased age, female gender and lower education independently predicted disagreement between the two diagnoses. In these groups, GMS sensitivity to a clinical diagnosis of dementia remained high but specificity was markedly reduced. CONCLUSIONS: Dementia may be overestimated in developing nations if the GMS-AGECAT diagnosis of organic disorder is used alone. The validity of other diagnoses, such as affective disorder, may also be affected if the hierarchical diagnostic algorithm is used (i.e. where the diagnosis of organic disorder affects the likelihood of other diagnoses).     

A community study of mental disorders in elderly Singaporean Chinese using the GMS-AGECAT package.

A random sample of 612 elderly Chinese aged 65 and over living in the community in Singapore was assessed with the community version of the Geriatric Mental State (GMS) and the data analysed by the AGECAT program to provide computerised diagnoses. The prevalence of organic disorder (dementia) was 2.3%, depression 5.7%, neuroses 1.5% and paranoid disorder 0.5%. The results were generally lower compared to the study of elderly people in Liverpool using the GMS-AGECAT package. Concordance between AGECAT and the psychiatrist's diagnoses for organic disorder, depression, neuroses and paranoid disorder achieved kappa values of 0.87, 0.88, 0.58 and 1.0 respectively.     

Behavioral and psychological symptoms of dementia and caregivers' stress appraisals: intra-individual stability and change over short-term observations

Dementia is commonly associated with memory loss, but Behavioral and Psychological Symptoms of Dementia (BPSD) such as disruptive behaviors, agitation, and problems with mood, usually have a more significant impact on caregivers' stress. It is known that BPSD and caregivers' stress reactions vary in frequency over the long-term course of dementia, however little is known about the variability over the short-term. The current study included 85 people with dementia and their primary caregivers assessed over three months. Caregivers used a 24-hour log on multiple, consecutive days to report behavioral symptoms of dementia on seven domains of behavior, as well as their stress reactions for each domain. Using latent growth curve analysis, most BPSD and caregiver stress appraisals were found to be, on average, stable over the three-month time frame. For many BPSD and stress appraisal models, however, intra-individual differences in rate of change were significantly different from the mean trend, indicating behaviors and stress are not stable over three months when assessed at the level of the individual. Covariates were used to explain individual differences in rates of change; however few variables were significantly associated with intra-individual short-term change over time.     

Prevalence and recognition rates of psychiatric disorder in the elderly clients of a community care service

One hundred and sixty-nine people over the age of 65 receiving home care services in Lewisham were interviewed using the Geriatric Mental State (A) (GMS(A)) and diagnostic output was obtained using AGECAT. The prevalence of psychiatric disorder in this group is reported and is compared with that found in community surveys which have used the GMS/AGECAT package. Of note is the 26.0% prevalence rate of cases of depression. The prevalence rate of AGECAT ‘depressive psychosis’ was found to be 13.6%, which was significantly higher than expected. Measures of agreement between AGECAT diagnostic cases and assessments made by home care staff are presented—‘kappa’ values and negative predictive values are higher for organic cases than for cases of depression. These ‘recognition’ rates are compared with reported recognition rates of psychiatric disorder in the elderly by health care professionals. Suggestions for further research are made so that the stated aims of the White Paper Caring for People can be achieved.     

Selenium concentrations in blood and serum from patients with mental diseases

Blood and serum concentrations of selenium have been determined in a group of psychiatric patients and in 35 healthy controls. The psychiatric group consisted of 14 schizophrenics, seven paranoid disorders, six affective psychosis (manic-depressive), four reactive psychosis, 11 dementia senilis, 17 with a diagnosis of neurosis and two with delirium tremens. Normal values were found in all groups except for delirium tremens where decreased blood and serum values were found.     

Paranoid disorders following war brain damage. Preliminary report.

Roughly 3,000 war veterans with moderate or severe brain injury have suffered from a psychiatric disturbance. Psychotic disorders are found in approximately 750 cases. The material of this preliminary report consists of the first 100 veterans with paranoid disorders. Delusional psychosis is the most common main diagnosis (28% of veterans), followed by major depression (21%), delirium (18%) and paranoid schizophrenia (14%). Paranoid schizophrenia and paranoid schizophreniform psychosis develop earlier (in 23% of cases within 1 year) than delusional psychosis (4%). Delusional psychosis lasted less than a year in 28% of the cases and more than 5 years in 40% of cases. The corresponding figures for paranoid schizophrenia and paranoid schizophreniform psychoses are 26 and 63%. Jealousy or fear of being sexually betrayed constitutes the most prominent individual content of delusions.     

RELIABILITY AND VALIDITY OF THE SPANISH VERSION OF THEGMS–AGECAT PACKAGE FOR THE ASSESSMENT OF DEMENTIA AND COGNITIVE DISTURBANCES

This report confirms the reliability and validity of the Geriatric Mental State–Automated Geriatric Examination for Computer Assisted Taxonomy (GMS–AGECAT) package in a Spanish elderly population. No changes in the original English version are considered necessary. A representative sample (N=1080) of the elderly (65+ years) community in Zaragoza, Spain, stratified by age and sex was assessed. A two-phase screening was designed: phase I (lay interviewers): Spanish versions of GMS–AGECAT and Mini-Mental (MMSE); phase II (psychiatrists,N=324): the same instruments and History and Aetiology Schedule (HAS). Diagnosis: DSM-III-R criteria. Stringent test–retest reliability coefficients were calculated by comparing lay interviewers’ (phase I) vs psychiatrists’ (phase II) ratings. DSM-III-R psychiatric diagnoses in phase II were the gold standards for the validity study. Test–retest reliability coefficients of the cognitive sections of GMS were: case/no case distinction, mean kappa=0.71; dementia/no dementia distinction, mean kappa=0.80. GMS validity coefficients: detection of cases, sensitivity=98.4%; specificity=76.5%. Test–retest reliability coefficients of AGECAT: case/no case distinction, mean kappa=0.59; organic syndrome, dementia, mean kappa=0.68. Validity coefficients of AGECAT (psychiatrists’ outputs): case/no case distinction, sensitivity=90.6%; specificity=89.3%; dementia/no dementia distinction, sensitivity=86.4%; specificity=94.3%.     

Psychiatric diagnoses made by the agecat system in residents of local authority homes for the elderly: Outcome and diagnostic stability after four years

Eighty-six residents of 12 local authority homes for the elderly were interviewed with the Geriatric Mental State (GMS) in 1985/6 after having been classed as depressed by a screening interview. The data so gathered were analysed by the computerized diagnostic program AGECAT in order to derive psychiatric diagnoses for these residents. All were traced after four years; 61 were dead. The 25 survivors were reinterviewed and given a second AGECAT diagnosis. In 1985/6 70 of the 86 examined were ‘diagnostic cases’ of psychiatric disorder. After four years 22 of the 25 survivors were classed as diagnostic cases. AGECAT diagnoses of organic psychosis were stable over four years within this population though the majority of subjects so diagnosed died within four years. Cases of depression had a more varied prognosis, with death, continunce as cases of depression or progression to organic psychosis being the most common outcomes. Recovery from any class of AGECAT disorder was an uncommon event.     

A 1-year follow-up study of behavioral and psychological symptoms in dementia among people in care environments

BACKGROUND: Behavioral and psychological symptoms in dementia (BPSD) are common and distressing for patients and caregivers, but little is known about the natural history of these symptoms, particularly among patients in care facilities. This information is essential for informed clinical management. We report a 1-year follow-up study of the prevalence, incidence, and outcome of the 3 main BPSD (agitation, depression, and psychosis) in care facilities. METHOD: 136 elderly residents with dementia (29% living in social care facilities and 71% in nursing home care) were assessed longitudinally on 2 occasions a year apart using a range of standardized psychiatric schedules, including the Neuropsychiatric Inventory. RESULTS: The overall prevalence of BPSD was stable over the year (76% at baseline and 82% at follow-up). Subjects with subclinical symptoms at baseline were more likely to develop clinically significant BPSD during follow-up than those who were symptom free (83% vs. 52%; Mann-Whitney U test, z = 2.36, p = .01). Agitation was the most common individual syndrome (55%). Although overall BPSD were persistent, > or = 45% of dementia patients with any of the major syndromes experienced resolution, indicating the development of different BPSD in many residents. There was no evidence that residents taking neuroleptics were more likely to experience resolution of BPSD than neuroleptic-free residents. CONCLUSION: BPSD are highly frequent and persistent among residents of care facilities with dementia. This emphasizes the need for ongoing treatment trials. The pattern of resolution with the development of new symptoms indicates that short focused periods of treatment may be a more effective management approach. In addition, the potential value in treating patients with subclinical BPSD to prevent the development of full-blown syndromes needs to be investigated.     

Psychiatric disorders in elderly from the Indian sub-continent living in Bradford

In our community study of the prevalence of psychiatric disorders among elderly South Asian immigrants from the Indian sub-continent (India, Pakistan and Bangladesh) living in Bradford (UK), we found depression in 20%, dementia in 4% and anxiety neurosis in 4%. Subjects were interviewed at their place of residence by a consultant psychiatrist familiar with their culture and language. The Hindi translation of the community version of the Geriatric Mental State schedule (GMS-A) was also administered. Psychiatrist's ICD-9 diagnosis was compared with GMS–AGECAT computerized diagnosis. We found low-level agreement in dementia cases (kappa 0.33) whereas the agreement in subjects with depression was high (kappa 0.81). In many subjects GMS-A made a diagnosis of dementia not diagnosed as cases by the psychiatrist, who had the benefit of additional history information from carers in this population from a different culture and educational background. These findings are discussed along with suggestions and present limitations of GMS-A in the diagnosis of dementia in cross-cultural research. Larger studies are needed in this population (a) to find out prevalence rates in countries of origin and (b) to investigate the author's (KB) observation of low rates of Alzheimer's type dementia in this population, which may have aetiological significance. © 1997 John Wiley & Sons, Ltd.     

Association between cognitive function, behavioral syndromes and two-year clinical outcome in Chinese subjects with late-onset Alzheimer's disease

OBJECTIVE: To examine associations between behavioral and psychological symptoms of dementia (BPSD), cognitive function and clinical deterioration over 2 years. METHODS: One hundred and four Chinese subjects with late-onset Alzheimer's Disease (AD) who presented to psychogeriatric clinics were followed for an average of 22.5 months. BPSD subgroups were categorized by latent class analysis using the Neuropsychiatric Inventory. Comprehensive cognitive profiles were performed with the Mattis Dementia Scale, the Hong Kong List Learning Test (HKLLT) and the Category Verbal Fluency Test. Interactions between cognitive function and behavioral syndromes were evaluated. Potential predictors for clinical deterioration were computed with logistic regression analysis. RESULTS: Three latent classes of subjects with similar behavioral syndromes were identified: Low BPSD (44%), Affective (32%) and Psychosis (24%) groups. Association between cognitive functions and BPSD was not significant. At follow-up, a higher proportion of subjects in the Affective (70%) and Low BPSD (49%) groups remained stable at the same Clinical Dementia Rating. Baseline scores in the "recognition" test of the HKLLT and age were significant predictors for "deceased" status at 2-year follow-up. CONCLUSION: The lack of association between behavioral syndromes and cognitive function suggests that these relatively independent dimensions of dementia should be examined individually for different prognostic significance.     

Psychiatric morbidity in dementia patients in a neurology-based memory clinic

The behavioral and psychological symptoms of dementia (BPSD) often present major problems for patients and their caregivers. In the past, neurologists paid less attention to such symptoms than to the cognitive symptoms of dementia. This prospective study investigated the prevalence of psychiatric morbidity in a neurology-based memory clinic and the stress of caregivers. Our patients with dementia were found to have a high prevalence of BPSD. The most frequent were anxiety, apathy, and delusion; the most distressing to caregivers were agitation, anxiety, delusion, and sleep disturbance. Using Clinical Dementia Rating (CDR), we compared BPSD between patients with mild dementia and those with moderate dementia. Only hallucinations and agitation were different significantly. Moderate dementia patients experienced these symptoms more frequently. The high prevalence of these symptoms might be explained by the fact that the cognitive symptoms were neglected or no enough information were received by many family members of patients with dementia until their own life quality was interfered and then they began to seek medical help. These symptoms and their effect of caregiver distress can be effectively reduced by pharmacologic and nonpharmacoloic managements, caregiver-focused training and education. They can be better approached by assessing neuropsychiatric symptoms regularly, educating the general population better, and treating these patients earlier.     

Phenomenology and clinical correlates of delusions in Alzheimer disease.

OBJECTIVES: The objectives of this study were to determine whether anosognosia, depression, and elevated mood are associated with delusions in Alzheimer disease (AD), and to examine the validity of standardized diagnostic criteria for psychosis of dementia. METHOD: The authors assessed a consecutive series of 771 patients with AD attending a dementia clinic with a comprehensive neuropsychologic and psychiatric evaluation that included specific measures of delusions, hallucinations, anosognosia, depression, and elevated mood. RESULTS: Delusions were found in one-third of the patients and hallucinations in 7%. Most patients with hallucinations also had delusions. A principal component analysis of the Psychosis Dementia Scale, which rates the presence and severity of delusions, produced the factors of paranoid misidentification and expansive delusions. Paranoid, but not expansive, delusions increased across the stages of the illness. Anosognosia and depression were significantly and independently associated with the presence of delusions, whereas elevated mood was significantly associated with expansive, but not paranoid, delusions. A multiple logistic regression analysis demonstrated that delusions in AD were significantly associated with depression, anosognosia, overt aggression, and agitation. CONCLUSIONS: Anosognosia, depression, global cognitive deficits, and elevated mood are the main psychiatric correlates of paranoid misidentification and expansive delusions in AD, whereas overt aggression and agitation are the most frequent behavioral concomitants of psychosis in AD.     

An integration of the DSM-III and ICD-8 by global severity assessments for measuring multidimensional outcomes in general hospital psychiatry

A multiaxial classification system has been developed in which three ICD-8 derived axes of psychiatric syndromes, personality disorders and somatic syndromes, and two DSM-III axes of psychosocial stressors and social functioning have been included. Global assessment scales were annexed the three ICD-8 axes. This DSM-III/ICD-8 system was used for registration of 880 consequetively admitted psychiatric patients in a general hospital setting. The results showed that six psychiatric syndromes (substance use disorders, schizophrenia, manic-depressive psychosis, reactive psychosis, neurosis, and adjustment reactions) were responsible for 80% of the diagnostic variance. Of these syndromes, manic-depressive psychosis had the highest improvement rate both concerning symptoms and social functioning. Manic-depressive psychosis had also the lowest coefficient of variation in the stay in hospital indicating a high degree of homogeneity in accordance to the diagnose-related group system. However, patients within the categories of reactive psychosis and neurosis who received antidepressants also had a low coefficient of variation, although the neurotics were significantly more depressed than the manic-depressives at discharge from hospital.     

Psychiatric disorders among elderly patients attending a geriatric medical day hospital: Prevalence according to clinical diagnosis (DSM-III-R) and agecat

One hundred and fourteen elderly medically ill day patients were interviewed in order to assess the prevalance of DSM-III-R main psychiatric disorders. Dementia affected 14.0% of the subjects, major depression 20.3%, dysthymic disorder 4.4%, atypical depression 13.2%, other disorders 3.6%. Overall, 60.5% of the patients had a psychiatric disorder. The computerized case designation (AGECAT) showed an acceptable concordance with clinical diagnoses (kappa value for dementia 0.59, for depression 0.58). Some issues related to the high prevalence of major depression are discussed.     

The role of norepinephrine in the behavioral and psychological symptoms of dementia

The behavioral and psychological symptoms of dementia (BPSD) are common serious problems that are a major contributor to caregiver burden. Despite their significance, the underlying neurobiology of these disturbances is still unclear. This review examines the role of norepinephrine (NE) on BPSD, including depression, aggression, agitation and psychosis. A number of lines of evidence suggest that NE dysfunction leading to BPSD may result from increased NE activity and/or hypersensitive adrenoreceptors compensating for loss of NE neurons with progression of Alzheimer's disease (AD). With greater appreciation of the underlying neurobiology of behavioral and psychological symptoms of dementia (BPSD) more effective, rational, targeted pharmacotherapy will hopefully emerge.     

Concurrent validity of the GMS­AGECAT (A3) package in a Danish nursing home population

Aim. To validate the Danish version of the GMS–AGECAT (A3), the Standardized Mini Mental State Examination (SMMSE) and the Geriatric Depression Scale-15 (GDS-15) by comparing them to clinical ICD-10 criteria in a Danish nursing home population. Methods. With a participation of 91%, the study included 100 residents. All residents were interviewed with the GMS–AGECAT (A3), SMMSE and GDS-15 by an MD and then blindly diagnosed by a consultant geriatric psychiatrist. All residents approached for an interview were included, also those who were not able to communicate (the non-accessibles). Results. The prevalence of clinical psychiatric ICD-10 main diagnoses was 56%. The non-accessibles had significantly higher psychiatric morbidity and lower ADL scores (modified Barthel ADL index) compared to those who were able to communicate. With the non-accessibles (N=100) included, the optimal screening and diagnostic cutpoint for the GMS–AGECAT organic diagnoses was 2/3, with 96% sensitivity, 73% specificity, 77% predictive value of a positive test and 95% predictive value of a negative test. The SMMSE and GDS-15 had better screening properties compared to the GMS–AGECAT but only 60% of the residents were able to complete the SMMSE and 78% were able to complete the GDS-15. Conclusion. The Danish version of the GMS–AGECAT has relevant diagnostic and screening properties for organic disorders in Danish nursing home populations. © 1998 John Wiley & Sons, Ltd.     

Prevalence of sub-threshold depression in elderly patients with chronic obstructive pulmonary disease

OBJECTIVES: We hypothesized that COPD patients with sub-threshold depression would have levels of disability and impaired quality of life approaching that for major depression and significantly greater than for non-depressed COPD patients. SETTING: A university teaching hospital METHOD: 137 outpatients (69 men), with a mean age of 73 years (range 60-89 years) with symptomatic irreversible, moderate to severe COPD were recruited. Subjects were interviewed using the Geriatric Mental State Schedule (GMS), a structured psychiatric interview schedule, along with its diagnostic algorithm AGECAT. A GMS/AGECAT score of 3 or more is indicative of a case-level of depression, a GMS/AGECAT score of 1-2 indicates sub-threshold depression and GMS/AGECAT of 0, no depression. Physical disability was measured by the Manchester Respiratory Activities of Daily Living questionnaire (MRADL) and quality of life was assessed by the Breathing Problems Questionnaire (BPQ). RESULTS: Mean (SD) one second forced expiratory volume was 0.89 (0.33) litres. The prevalence of GMS/AGECAT case-level depression (>or= 3) was 57 cases (42%); of GMS/AGECAT sub-threshold depression (1-2) 34 (25%); and GMS/AGECAT non-depression (0) 46 (33%). Comparison of MRADL score in the three groups (mean, 95% confidence intervals) revealed [GMS >or= 3 = 9.9 (8.4 to 11.3) vs GMS = 1-2, 12.9 (11.2 to 14.4) vs GMS = 0, 15.6 (14 to 16.6) p < 0.0001]. BPQ scores (mean, 95% confidence intervals) showed [GMS >or= 3 = 54 (50 to 57) vs GMS = 1-2, 40 (36.3 to 44) GMS = 0, 33 (30.6 to 36.7) p < 0.0001]. There was no significant difference in FEV(1) between the three groups. CONCLUSION: Sub-threshold depression accounted for 25% of the sample. In this study disability associated with sub-threshold depression in patients with COPD was intermediate to that associated with case-level depression and no with depression and significantly worse than in the latter group. Sub-threshold depression is associated with substantial morbidity in COPD.     

Caregiver burden associated with behavioral and psychological symptoms of dementia in elderly people in the local community

BACKGROUND: Despite many studies about the association between caregiver burden and behavioral and psychological symptoms of dementia (BPSD), there have been no population-based studies to evaluate caregiver burden associated with each BPSD. OBJECTIVE: To evaluate caregiver burden associated with the individual BPSD in elderly people living in the community. METHODS: The subjects were 67 participants with dementia living with their caregivers (diagnosed in the third Nakayama study): 51 Alzheimer's disease, 5 vascular dementia and 11 other. The Neuropsychiatric Inventory (NPI) and NPI Caregiver Distress Scale (NPI-D) were used to assess subjects' BPSD and related caregiver distress, respectively. RESULTS: In the subjects exhibiting BPSD, aberrant motor behavior had the highest mean NPI score, and depression/dysphoria had the lowest. Agitation/aggression had the highest mean NPI-D score, and euphoria/elation had the lowest. Delusion, agitation/aggression, apathy/indifference, irritability/lability and aberrant motor behavior showed a correlation between the NPI and NPI-D scores. CONCLUSION: The burden associated with BPSD is different for each symptom and does not always depend on frequency and severity of BPSD. These findings suggest that some symptoms, such as agitation/aggression and irritability/lability, may affect the caregivers significantly, although their frequency and severity are low.     

Behavioral and psychological signs and symptoms of dementia: a practicing psychiatrist's viewpoint

Alzheimer's disease typically presents with two often overlapping syndromes, one cognitive, the other behavioral. The behavioral syndrome is characterized by psychosis, aggression, depression, anxiety, agitation, and other common if less well-defined symptoms subsumed under the umbrella entity "behavioral and psychological symptoms of dementia" (BPSD), itself divided into a number of subsyndromes: psychosis, circadian rhythm (sleepwake) disturbance, depression, anxiety, and agitation, it is BPSD with its impact on care providers that ultimately precipitates the chain of events resulting in long-term institutional care. The treatment challenge involves eliminating unmet medical needs (undiagnosed hip fracture and asymptomatic urinary tract infection or pneumonia). Pharmacologic intervention relies on risperidone and, increasingly cholinesterase inhibitors for the control of psychosis (but with response rates of only 65% at tolerable doses), olanzapine and risperidone for anxiety, and carbamazepine and valproic acid for agitation. However, evidence increasingly favors nonpharmacologic interventions, to the extent that these should now be considered as the foundation of BPSD treatment. Problem behaviors are viewed as meaningful responses to unmet needs in the therapeutic milieu. Because the progression and impact of BPSD varies between patients, interventions must be explored, designed, implemented, and assessed on an individual basis. They include: family support and education, psychotherapy reality orientation, validation therapy, reminiscence and life review, behavioral interventions, therapeutic activities and creative arts therapies, environmental considerations (including restraint-free facilities), behavioral intensive care units, and workplace design and practices that aid the ongoing management of professional caregiver stress.