Behavioral problems are thought to be pervasive and devastating to patients with dementia of the Alzheimer's 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 Alzheimer's 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 patient's age, gender, duration, or age at onset of dementia. These findings are discussed as they relate to the phenomenology of dementia of the Alzheimer's 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.

We prospectively studied the evaluation of dementia in 107 unselected outpatients; 83 had so-called "irreversible" dementias, including 74 who had an Alzheimer-type dementia. Fifteen patients had potentially reversible dementias, of which hypothyroidism and drug toxicity were the commonest causes. Distinguishing features of reversible dementia were shorter duration, use of more prescription drugs, and less severe dementia. Almost half of the patients had other previously unrecognized treatable medical diseases. Most diagnoses were made from patient history and physical and mental status examination. Patients with reversible dementia improved but rarely reverted to normal. Objective improvement occurred in 25 patients after treating unrecognized coexistent medical and psychiatric diseases, or stopping unnecessary medication. Careful clinical observation is the most useful part of the evaluation and extensive testing may not be required for all patients. Overemphasis on distinguishing reversible from irreversible forms of dementia may detract from recognition of commoner, treatable causes of dysfunction and suffering.

The relation between head trauma and Alzheimer's disease was one of four major risk factors 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, Washington, and controls were friends or nonblood relatives of the cases. Subjects were matched by age, sex, and relationship between the case and his or her surrogate respondent. Head injuries which resulted in a loss of consciousness or which caused the subject to seek medical care were documented by means of interviews with surrogate respondents. A history of head injury was recorded for 24% of the cases and 8.5% of the controls, yielding an odds ratio of 3.5 (95% confidence interval 1.5-8.3) in conditional logistic regression analysis adjusted for age at onset of disease symptoms and family history of Alzheimer's disease. The estimated risk of Alzheimer's disease increased as the time between the last head trauma event and the onset of disease symptoms diminished (p = 0.002). This trend remained statistically significant (p = 0.006) when head injuries which occurred within 5 years of onset of the disease were excluded from the analysis. There was some difference between cases and controls for the average duration of unconsciousness in events accompanied by such a loss, but this was not statistically significant. The two groups were also similar in the circumstances surrounding the injuries and in the frequency of alcohol problems. This is the third case-control study to find a statistically significant association between head trauma and Alzheimer's disease.

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Cognitive impairment and depression each compromise functional status in the elderly, but it is not known whether their coexistence is associated with additive functional impairment. The effect of the presence or absence of a diagnosis of major depression on functional status was examined in a group of 50 community-residing patients with dementia of the Alzheimer's type (DAT). Patients were diagnosed as depressed (N = 20) or not (N = 30) according to DSM-III criteria. Cognitive status was assessed with the Mini-Mental State Exam (MMSE), and functional status was assessed by family report of Instrumental Activities of Daily Living (IADLs). Consistent with previous reports, patients with a depression diagnosis were less cognitively impaired than their nondepressed counterparts. When cognitive status was controlled for, depression diagnosis was found to have a main effect on functional impairment. Although the direction of effects between depression and functional limitations was not determined here, these results suggest that alleviating depression may decrease functional limitations in DAT patients.