Mohammed T. Abou-Saleh

PSYCHIATRIC DIAGNOSIS AND OLD AGE 119required that the delusions be the ‘‘predominant feature’’.Lastly, DSM-IV clarified that depressive presentations meetingcriteria for a major depressive episode should be included underthe ‘‘with depressed mood’’ subtype, in addition to milderforms.Even with these changes, the basic reasoning behind the DSM-III, DSM-III-R and DSM-IV subtypes was flawed. Beyondincluding only a small portion of the array of behavioral,psychological or emotional signs, symptoms or syndromes thatcan be caused by Alzheimer’s disease, the structured hierarchy ofthe classification implied that these manifestations were asecondary or subordinate feature of the cognitive symptoms andsigns of dementia. Ample data now demonstrate that, whenpresent, they are most often manifestations of fundamental brainpathophysiology, as much as memory or other cognitive dysfunctions.In sum, for a classification that was intended to guidetherapeutics as well as communicate information regarding signs,symptoms and prognosis, the system did not work.A change in coding adopted by ICD-9-CM rendered thesesubtypes obsolete. In anticipation of planned changes for ICD-10-CM, the October 1997 ICD-9-CM coding recommendationsindicated that the preferred diagnostic code for Dementia of theAlzheimer’s Type should be 294.1 (for ‘‘Dementia in DiseasesClassified Elsewhere’’) instead of 290.xx. Thus, the three subtypesthat had been coded with a fifth digit could no longer be captured.These changes are being used to revise the approach in DSM-IVas well.When a patient has emotional, mood or psychologicalsymptoms or signs that are in need of therapeutic interventionsarising from Alzheimer’s disease, the clinician will be asked tocode these conditions on Axis I as one of the ‘‘mental disordersdue to a general medical condition’’. As with other etiologicallyorpathologically-defined medical conditions, Alzheimer’s diseasewill be recorded on Axis III. Like other secondary or symptomaticpsychiatric conditions, these problems must substantially interferewith a patient’s functional integrity to warrant a formal diagnosis.Beyond dementia itself, the secondary conditions to be codedon Axis I (with an associated Axis III diagnosis of Alzheimer’sdisease) include psychotic disorder, mood disorder, anxietydisorder, personality change (types include labile, disinhibited,aggressive, apathetic, paranoid, other, combined, and unspecified)and sleep disorder. As there are no data indicating that AD causesdelirium, despite the frequent occurrence of delirium amongpatients with dementia of the Alzheimer’s type, the clinician willbe pressed to define the specific etiology of the delirious conditionwhen possible. Sexual disorders due to AD also should not bediagnosed, again reflecting an absence of clinical or researchfindings tying Alzheimer’s disease to sexual dysfunction. Thosepatients who are uncontrolled in their sexual behaviors can becaptured under the ‘‘with behavioral disturbance’’ subtype. Thus,for a man with AD having dementia and delusions associated withcombative behavior, one would use the diagnoses 294.1 and293.81, the latter for Psychotic Disorder due to Alzheimer’sDisease, with Delusions. For a woman with delirium superimposedon DAT, the diagnosis will reflect the presumed etiologyof the delirium (e.g. delirium due to anticholinergic use isdiagnosed 292.81, Anticholinergic-induced Delirium).Starting in October 2000, a new fifth digit will allow one toindicate whether the dementia is ‘‘with behavioral disturbances’’(294.11) or ‘‘without behavioral disturbances’’ (294.10). Theinclusion of a codable behavioral descriptor and the conventionsregarding the diagnosis of DAT and other symptoms due toAlzheimer’s disease will be included in DSM-IV-TR, with ananticipated publication in May 2000. (The DSM-IV text revisionproject is an empirically-based updating of the text only, withoutany changes being made to the criteria sets.)The term ‘‘behavioral and psychological symptoms of dementia’’(BPSD) has not been adopted during the DSM-IV revisionprocess. There are two explanations. The first relates to the labelitself. It implies that the signs and symptoms in question are adirect outgrowth of dementia, which is not a fundamental diseaseprocess but itself a secondary clinical syndrome, rather thansuggesting that the behavioral and psychological symptoms aredue to AD-caused brain degeneration. The second reservationreflects a concern that behavioral, psychological and emotionalsymptoms and signs are not a unitary phenomenon. It is mostparsimonious at this time to use the extant, discretely defined‘‘mental disorders due to . . .’’ and avoid creating yet anotherunitary diagnostic label that has no established reliability orvalidity 4 .A major topic for discussion during the development of DSM-IV was a recommendation that ‘‘age-associated memory impairment’’(AAMI) be included as a diagnostic entity, in keeping withcriteria proposed to standardize the definition of aging-associatedchanges in intellect 5 . Aging-related changes in intellectual abilityare robust and demonstrable psychometrically when comparinghealthy older subjects with younger control groups, encompass avariety of tasks beyond those related to memory, and are at timestroubling for particular individuals. However, doubts wereexpressed regarding the use of a disease diagnosis for a normativephenomenon. There were no objectively defined standards forestablishing a cut-off or threshold to separate it from the earliestmanifestations of specific diseases (e.g. the early manifestations ofAlzheimer’s disease). Indeed, review of available data suggestedthat mild intellectual declines relative to age-matched peers oftenpresaged the development of progressive disease. In contrast,there was clear evidence that AAMI was not associated withsignificant functional or social impairment. Ultimately it wasconcluded that there were insufficient data to establish a formalpsychiatric diagnosis of AAMI 6 . DSM-IV finally included ‘‘agerelatedcognitive decline’’ as a Z code designation, one of thoseconditions ‘‘not attributable to mental disorders that are a focusof attention or treatment’’.Other Axis I IssuesOther Axis I disorders provided focal points for heated debate,but concrete recommendations for classificatory changes weredifficult to establish in the absence of well-developed researchfindings. The problem of mood disorders was illustrative. DSM-III-R criteria amply described many of the features of severemood disorders seen in elderly patients coming to outpatientclinics or hospital inpatient services. However, they were far lesssatisfactory for describing the features of affectively impairedpatients encountered in the offices of primary care physicians,evaluated in nursing home settings or ascertained throughcommunity surveys.Many suffer ‘‘subsyndromal’’ presentations, either dysthymicstates that generally conform phenomenologically to dysthymicdisorder but are not sustained for the requisite 2 years, ormanifestations that include mood, ideational or somatic featuresof an affective disorder but without the array of symptoms neededto qualify for a strictly defined diagnosis. A diagnostic system thatexcludes the majority of potential patients fails to fully serve itsdescriptive function 7 . But suggestions for change remain incompleteand are not yet supported by a sufficiently large body ofcareful clinical research. (So-called ‘‘minor depression’’ was addedfor research purposes to the Appendix of DSM-IV, but it remainsuncertain how to apply this construct to the conditions encounteredamong elders.)The deletion from DSM-III-R of age 45 years as a cut-off forthe onset of schizophrenia removed a major impediment for