Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0142 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYMMSE 3 . However, in clinical practice informant questionnairesand cognitive screening tests are complementary rather thancompetitors. A simple graphical way of combining theIQCODE and the MMSE for screening purposes is providedby the Demegraph 4 . This can be downloaded from the Web athttp://www.mhri.edu.au/biostats/demegraph/.One weakness of the IQCODE and other informant scales isthat they can be biased by the affective state of the informant andthe quality of the relationship between the informant and thepatient. Cognitive decline is perceived to be greater where theinformant is anxious or depressed or where there is a poorrelationship.REFERENCES1. Jorm AF. Assessment of cognitive impairment and dementia usinginformant reports. Clin Psychol Rev 1996; 16: 51–73.2. Jorm AF, Jacomb PA. The Informant Questionnnaire onCognitive Decline in the Elderly (IQCODE): socio-demographiccorrelates, reliability, validity and some norms. Psychol Med 1989;19: 1015–22.3. Jorm A. Methods of screening for dementia: a meta-analysis of studiescomparing an informant questionnaire with a brief cognitive test.Alzheimer Dis Assoc Dis 1997; 11: 158–62.4. Mackinnon A, Mulligan R. Combining cognitive testing andinformant report to increase accuracy in screening for dementia. AmJ Psychiat 1998; 155: 1529–35.Staging DementiaBarry Reisberg, Gaurav Gandotra, Arshad Zaidi and Steven H FerrisAging and Dementia Research Center, New York University School of Medicine, USADementia is a progressive pathologic process extending over aperiod of many years. Clinicians and scientists have longendeavored to describe the nature of this progression. Suchdescriptions have generally been encompassed within two broadcategories, viz. global staging and more specific staging, sometimesreferred to as axial or multi-axial staging. A comparison ofthe major current dementia staging systems with the mostwidespread mental status assessments in Alzheimer’s disease, themajor cause of dementia, is shown in Table 1, which illustratessome of the major potential advantages of staging. Theseadvantages include: (a) staging can identify premorbid butpotentially manifest conditions that may be associated withdementia, such as age-associated memory impairment, a conditionwhich is not differentiated with mental status or psychometrictests; (b) staging can be very useful in identifying subtle,identifiable, predementia states, such as mild cognitive impairment(MCI), wherein mental status assessments and psychometrictests, while frequently altered, are generally within the normalrange and consequently are not reliable markers; and (c) stagingcan track the latter 50% of the potential time course of dementiassuch as AD, when mental status assessments are virtuallyinvariably at bottom (zero) scores. Furthermore, apart from itsutility in portions of dementia where mental status and psychometricassessments are out of range or clearly insensitive, there isevidence that staging procedures can more accurately andsensitively identify the course of dementia in the portion of thecondition that is conventionally charted with mental statusassessments. This latter evidence comes from longitudinalinvestigation of the course of AD 1 , pharmacologic treatmentinvestigation of AD 2 and study of independent psychometricassessments of AD 3 . Another seeming advantage of stagingprocedures in comparison with mental status or psychometricassessment of AD and other dementias is in identifying themanagement concomitants of severity assessments 4 . Stagingprocedures have also been successfully applied post mortem toassess retrospectively the diagnoses of a diverse assortment ofdementia-related cases available for ‘‘brain banking’’ but onwhich no ante mortem clinical data were available 5 . Similarly,Table SA27iii.1Typical time course of normal brain aging and Alzheimer’s disease*Stage range comparisons shown between the CDR and GDS/FAST stages are based upon published functioning and self-care descriptors.a Numerical values represent time from the earliest clinically manifest symptoms of Alzheimer’s disease.Adapted by permission from Reisberg et al. 52