SUMMARY Clinical investigations of senile dementia of the Alzheimer type require establishment of explicit clinical diagnostic criteria before histological confirmation is possible. Criteria for selection of mildly impaired subjects with senile dementia of Alzheimer type, free of other major disease, are proposed. Problems of recruitment of this select population for a longitudinal study are discussed. A study population with matched healthy control subjects has been enrolled and described. Short term follow-up has provided preliminary support for the diagnostic criteria.The most frequent cause of dementia in persons over age 65 is senile dementia of the Alzheimer type (SDAT), multi-infarct dementia being much less common.`-Increased awareness has led investigators to focus on SDAT and to search for means of identifying subjects in the less advanced stages, before the illness is complicated by effects of chronic debility and/or institutionalisation.Establishing presumptive diagnostic criteria without resorting to histologic study of the brain is an essential goal of clinical investigation. The importance of this goal is underscored by the difficulties inherent in distinguishing among the many disorders leading to brain failure3`and by the dearth of valid information on aetiology, natural history, pathophysiology, and therapy of SDAT. Concurrent needs include a reliable means of quantifying the degree of dementia9 and a comparison of the effects of healthy aging with those of SDAT. The Dementia Study Group of Washington University has met frequently for several years to discuss and investigate topics related to dementia.`0-17 The needs listed above led to the group to establish explicit clinical diagnostic criteria for SDAT and to initiate a longitudinal study of mild cases and healthy aging. In this paper is Address for reprint requests: L Berg, MD.,

We assessed language function, using a brief clinical Aphasia Battery and psychometric measures, in 150 subjects with senile dementia of the Alzheimer type (SDAT) and 83 elderly controls. Aphasia occurred only in demented subjects, and its prevalence increased with severity of dementia. Aphasia in mildly demented subjects was associated with both an earlier age of onset and more rapid progression of SDAT than in similarly demented nonaphasics. Language dysfunction in SDAT subjects was characterized by early decline in measures of comprehension and written expression, whereas other components, including oral naming, were less profoundly affected. Performance on the verbal psychometric measures, the Sentence Repetition and the Token tests, correlated strongly with Aphasia Battery scores and declined only minimally in nonaphasics, despite increasing dementia. We conclude that aphasia is a common feature of SDAT subjects and identifies a subgroup with more rapid progression of dementia. Furthermore, it represents language-specific dysfunction beyond the global cognitive impairment of SDAT.

Forty-three subjects with mild senile dementia of the Alzheimer type, diagnosed and staged by clinical research criteria, were studied with clinical, psychometric, EEG, visual evoked potential, and CT measures. During the 12 months following entry into the study, 21 subjects progressed to moderate or severe dementia, 21 remained mild, and one was lost to follow-up. Many of the clinical and psychometric measures of impairment were predictive of the progression to moderate or severe dementia. Electrophysiologic and CT measures were not. In a discriminant function analysis, the scores on two measures (the digit symbol subtest of the Wechsler Adult Intelligence Scale and an Aphasia Battery) correctly predicted the stage of dementia 1 year later in 95% of the subjects.

In 26 depressed patients, a high correlation (0-89) was found between the Hamilton score and a psychiatrist's global rating and between the change (0-68) in these ratings during treatment. The Hamilton scale was able to differentiate at the o-01 level four degrees of severity based on the global rating. Limiting the range of severity measured was found to lower significantly the correlation between the ratings. A prospective examination of a six-item sub-scale of the Hamilton scale developed by Beck and associates failed to confirm its claimed improvement in sensitivity or validity.

Side effects from antipsychotic medications can have a profound effect on patients' lives and may adversely affect their willingness to comply with treatment. Identification of side effects through improved communication between psychiatrists, other members of the healthcare team, and their patients might increase treatment compliance. The Approaches to Schizophrenia Communication (ASC) Steering Group developed two simple, practical checklists for use in the busy clinical setting. The ASC–Self-Report (ASC-SR) checklist is completed by the patient and comprises a list of the more common or clinically important side effects of antipsychotic treatment. The ASC-Clinic (ASC-C) checklist is completed by both clinician and patient together, being used as the basis for a semi-structured interview. In a multicenter pilot study set up to evaluate the utility of checklists, 86% of patients responding considered the ASC-SR to be useful in communicating their problems to psychiatrists and other members of the healthcare team. All healthcare team respondents found both checklists to be helpful when discussing side effect problems with their patients. Moreover, 41% and 47% of healthcare team respondents reported that the ASC-SR and ASC-C, respectively, had assisted them in identifying side-effect problems not previously acknowledged. Preliminary evaluation of the ASC-SR and ASC-C in this multicenter pilot study suggests that both tools were user-friendly, encouraged communication between patients and healthcare professionals about antipsychotic drug side effects, and could readily integrated into everyday clinical practice.