A 51 year old former mid-wife presented with a 2 year history of increasing forgetfulness, with significant impairment to her daily function.

She was diagnosed with non-familial early-onset Alzheimer's Disease (AD) and started on 8mg b.d. of Galantamine.

We gathered patient notes, consultant, collateral and personal accounts.Outpatient consultations were used to monitor Mrs LF's global, functional and behavioral progress. These were supplemented with the mini mental state examination (MMSE) which served as an objective test for her cognitive impairment, and a guide for her response to treatment.

The patient showed a marked improvement in MMSE from 23 (four months after the commencement of treatment in June 2004) to 29 (in September 2008). The MMSE has remained at 29 until the last consultation in September 2009. The patient accounts of social dysfunction due to her memory impairment pre-treatment highlights her gradual but significant recovery with Galantamine, to the point of being able to return to independent living arrangements and recently entering into a new relationship.

The case raises interesting questions as to whether EOAD should be considered distinct to traditional AD, given the greater than expected response to Galantamine. The details of this single case, also lend themselves to supporting a reconsideration of the NICE guidelines for when treatment can be started, which would require further research. Such research may benefit from a long-term database in which data regarding MMSE scores of patients treated with Galantamine is serially recorded.

In patients diagnosed with amnestic mild cognitive impairment (aMCI) cognitive functions are also affected in addition to memory. The aim of the present study was to characterize these cognitive impairments in detail.

So far 35 patients with aMCI and 26 matched controls were investigated using following subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB): Delayed Matching to Sample, Spatial Recognition Memory, Spatial Working Memory, Rapid Visual Processing, and Stockings of Cambridge. Additionally, we used Corsi Block Tapping from the Wechsler Memory Scale Revised to examine spatial working memory and spatial attention.

The aMCI group performed significantly worse than the control group in Delayed Matching to Sample, Spatial Working Memory, Rapid Visual Processing, Stockings of Cambridge, and Corsi Block Tapping backwards.

In summary, patients with aMCI demonstrate reduced skills in visual memory, spatial planning, spatial working memory, and sustained attention compared to healthy subjects. Furthermore, this suggests that CANTAB may be a tool for diagnosis of the cognitive status of aMCI patients.

Mental care of elder people has became very important in the last decades because of the development of gerontopsychiatry as an specialized area.

The aim of our proyect is to study the first admission in people over 60 years old in a psychiatric hospital.

This is a descriptive, retrospective study. There are analyzed clinical features of the first hospitalization of people over 60 that entered the hospital of zamudio during one year.

65 people over 60 years old were admitted in the hospital for the first time. The main diagnoses were dementia (35%), bipolar disorder (35%) and psychotic disorders (24%). We didn’t find a relation neither between the days of hospitalization and the destination when release (t=-0,0503; p=0,617); nor between the days of hospitalizations and the diagnoses (ANOVA; F=0,17; p=0,841). In the other hand, there is a statistical signification between diagnoses and derivation when release, resulting that 60% of patients that went to asiles suffered from dementia (Fisher's exact test, p=0.012)

There is more evidence that some kinds of illness that start when people are old appeared to have different characteristics and probably a diverse ethiology. To resituate elder people when release depends on both psychological and social factors.

To alert to apathy as a sub-syndrome in the spectrum dementia-depression.

Review of literature relevant in medline database.

The modern concept of apathy implies a reduced volition. Apathy may occur in depression and dementia and the differential diagnosis is difficult. Symptoms of apathy may constitute a sub-syndrome in the spectrum depression-dementia, that are characterized by lack of interest, psychomotor retardation, loss of energy and loss of appetite. Apathy may occur in dementia without depression and is significantly associated with more severe cognitive deficits. In dementia, depression may primarily result from a combination of symptoms of anxiety and apathy. Most patients with dementia and apathy had concomitant depression, but less depressed patients had concomitant apathy. The key to diagnosis may be the mood symptoms: dysthymia could be a negative emotional reaction to the progressive cognitive decline in dementia, whereas major depression could more strongly related to biological factors.

The nosological position of apathy remains obscure, with some studies suggesting that apathy and depression are independent constructs, and other studies showing a significant overlap between apathy and depression. The major interest to the type of syndrome has therapeutics implications.

To alert to manic like symptoms in frontotemporal dementia (FTD).

Review of literature relevant in medline database.

Frontotemporal dementia (FTD) is a behavioural syndrome caused by generation of the frontal and anterior temporal lobes.

Bipolar disorder in dementia and the temporal relation between the two conditions have rarely been studied. There is a increased probability of developing a manic episode in patients with dementia.

Those with temporal FTD have impairments in emotional processing and hypomania like behavior. Moria (childish excitement or tendency to joke) or frivolous excitement are common presenting symptoms, and is difficult to distinguish to features in bipolar disease.

The correlation between mania like symptoms and FTD can be make with the help of informations of the family and computed tomography imaging. Those with temporal involvement are particularly at risk of developing deficits in emotional processing secondary to atrophy in the amygdale, anterior temporal cortex, and adjacent orbitofrontal cortex.

Early temporal involvement in FTD is associated with frivolous behavior and right temporal involvement is associated with emotional disturbances.

Moria or frivolous behavior are common presenting symptoms of FTD and the differential diagnosis is made with the help of informant's reports and computed tomography imaging.

In this review we examined the involuntary admissions to a purpose-built Psychiatry of Old Age (POA) specialist unit under the care of the North Dublin Psychiatry Of Old Age Service, Dublin, Ireland.

Our objectives were to examine the source of referral, progress in hospital and outcomes of all involuntary admissions, under the Irish Mental Health Act, to this Psychiatry of Old Age specialist inpatient unit over a one year period. All patients were divided into two groups, those who were diagnosed with Dementia and those patients who had a functional mental illness. We specifically examined the characteristics of both groups to identify any differences their outcomes.

A retrospective chart review of all involuntary admissions over a one year period from January 1st 2008 to December 31st 2008 was conducted.

67% of all admissions to the Psychiatry of Old Age unit during 2008 were involuntary admissions. The detained patients were mostly male (71.4%).

The most common diagnoses were Alzheimer's Dementia (38.1%), Dementia Mixed Aetiology (14.3%) and Psychotic Illness (14.3%).

88.2% of Patients who had a diagnosis of Dementia required Long Term Care at the end of their admission, but only 25% of those patients who had a Functional Mental Illness were transferred for Long Term Care at discharge.

Patients with dementia had significantly longer involuntary admissions than patients with affective or psychotic disorders. Patients with dementia were also more likely to require long-term care on discharge than those patients who did not have dementia.

A clear distinction between schizophrenia and some clusters of dementia is sometimes difficult to do in clinical practice.

A 38-years-old-male patient, with history of alcohol dependence, was admitted in our unit for generalized tremor, sweating, agitation, auditive, visual and cenestesic hallucinations, thought broadcasting and persecutory delusion. Agitation and the vegetative symptoms gradually subsided within 48 hours. Lab work showed no clinically significant changes. EEG and EKG were normal. MRI showed augmented cortical encephalic sulci. 5 days after the admission 10 mg of olanzapine was prescribed due to psychotic symptoms persistence. Haloperidol was stopped. A gradually improvement occurred and 26 days after the admission the patient was discharged home asymptomatic. Neuropsychological testing revealed severe fronto-temporal cognitive defect suggestive of alcoholic dementia.

The difficulty to clearly distinct schizophrenia from some dementias may be because, as Kraepelin stated in the 19th century, schizophrenia is itself a form of early dementia. His concept of dementia praecox is supported nowadays by the knowledge acquired from several neuropsychological and neuroimaging tests that a progressive cognitive deterioration appears to occur in schizophrenic patients.

80% of people with dementia experience one or more recurrent or persistent symptoms such as hallucinations, delusions, aggression, agitation, shouting, screaming, repetitive actions, sleep disturbance or wandering behaviour during the course of their illness (Ballard et al, 1995).

These are collectively known as the behavioural and psychological symptoms of dementia.

The clinical management may include both psychosocial and pharmacological measures such as the prescription of medication, including antipsychotics.

Currently no drug is licensed for treatment of these symptoms in the UK and so clinicians need to be mindful of the fact that off label prescribing increases their professional liability in the event of an adverse event.

Studies suggest that between 54% and 88% of antipsychotic use in residential homes may be inappropriate (McGrath & Jackson, 1996).

To identify the current antipsychotics prescribing practice for behavioural and psychological symptoms in dementia and its compliance with the NICE guidelines.

A retrospective review of 50 case notes of the patients diagnosed with dementia after Nov 2006 was carried out.

Majority of the patients were male and were in the age group of 70-80 years.Alzheimer's Dementia followed by mixed dementia & vascular dementia were the main diagnosis. The main antipsychotic prescribed was Quetiapine, closely followed by Haloperidol & Promazine.The study showed that the prescription of antipsychotics was appropriate and all patients have their target symptoms recorded. However documentation of risk benefits analysis and discussion with patient and family about risk's and side effects were lacking.

To describe the relation of psychosocial factors of care (phase illness, years of care, free time, extra help and symptoms of depression) influence the care burden of dementia family caregivers. To measure the relation of the level of depressive symptoms on an intense level of burden of the dementia family caregivers.

Is selected a sample of 102 primary caregivers by criteria of inclusion to which a surveys do to those that the following information gathered: sociodemographic dates of the caregivers and of the dementia patients, care burden (Zarit Interview) and depressive symptoms (Beck Depression Inventory) of the family caregivers.

Most of the sample experiences an intense burden level (74%) opposite to a light level (26%). Psychosocial characteristics are as per statistics significant in increasing the care burden there were free time, extra help and presence of symptoms of depression. Presence of serious symptoms of depression on the intense burden level are differently front or those who had a minor burden, 22% and 5% respectively.

There are most of the daughter-father/mother and spouse-spouse caregiver couples with a high percentage of caregivers of feminine sex (as in most of the studies realized on caregiver of dependent persons at European and international level). The need for free time and psychic self-care are cost-effective strategies to prevent the depressive disorders, as well as, to improve their caregiver's work. The psychoeducation programs that have being realized at European level directed to family caregiver are necessary in our country.

The study intends to present the problems of elderly patients living in community residences, and the difficulties of staff and other residents. Solutions are also suggested.

Within the attempt of dwindling big psychiatric hospitals in Greece, and removing social and professional exclusion of patients, long-term supportive living units were established in 2001 by the General Hospital of Ioannina. Eleven patients were selected from the Psychiatric Hospital of Corfu, according to their functionality, medication compliance, and ability to take care of themselves. During the eight years of the unit's operation, four patients were forwarded in a supported flat where living is more independent. However, five psychotic patients, aged over 65, displayed new physical health problems, and deterioration of preexisting problems (epilepsy, chronic respiratory disease, kidney cancer). New disorders included hypertension, metabolic syndrome, hurt diseases, etc. The patient who suffered from respiratory disease died, an epileptic returned to the psychiatric hostel after 3 years in the protected flat, and the patient with the kidney cancer moved in a unit with more staff support.

Difficulties faced by elderly influenced hostel's operation and younger patients, and preoccupied stuff, depriving time from creative activities with patients. Furthermore, residents’ strain for physical health problems increased.

To secure regular operation of supported living units, a network of complementary units is necessary, which will forward to high supported units elderly patients who face serious health problems, or are not up to the everyday activities of the unit they live in.

Behavioral and psychological symptoms of dementia (BPSD) are common during the course of dementia and are associated with poor outcome for patients. There are some clinical data indicating that SSRI antidepressants have a positive influence on BPSD. Escitalopram has an excellent side-effect profile and might be a suitable treatment for BPSD in older demented patients.

An open-label observation of inpatients aged 65 to 90 years with a clinical diagnosis of probable AD and an MMSE score of 6 to 20 points and NPI total score ≥20 points treated with escitalopram for 8 weeks. The evaluation of improvement/worsening counted as ±10% change from baseline score in NPI and CMAI short. The results expressed in numbers of improved, unchanged and worsened patients.

13 patients, 12 women and 2 men. The average age was 79.3 years, the average MMSE was 12.8 points. Three patients discontinued due to AEs (bronchopneumonia, progressive worsening of dementia, transfer to another institution). The other AEs were mild and not related to study medication.

Most patients exhibited a reduction of BPSD, half of them with a very substantial reduction. Patients exhibited very good tolerance of the medication.

There is a growing appreciation that depression may be a presenting syndrome of dementia.

This study intends to show that the presence of cognitive impairment in a depressive episode in older people may have important prognostic implications in developing dementia.

In this study a first group of 17 depressed patients with mild cognitive impairment (MMSE over 26) was compared with a second group of 18 depressed patients with mild to moderate cognitive impairment (MMSE bellow 26). The mean age for both groups was 68. The depression was measured using the MADRS scale. All the patients included were severely depressed at the inclusion. Both groups showed important improvement of the depressive episode, following the treatment with antidepressants (escitalopramum, sertralinum, venlafaxinum).

Both groups were followed for 2 years after the depression resolution.

In the first group of patients the MMSE was 26 at baseline and 26 or over at discharge.

In the second group of patients the score of MMSE had a value of minimum 17 at baseline and a maximum of 26 at discharge.

Five patients (three in the first group and two into second group) did not complete the 2 years follow up period.

Over the period of 2 years, 37% of patients from the second group developed a dementia, comparing with only 14% of the patients from the first group.

After 2 years, the patients with depression and significant cognitive impairment had twice the risk of developing dementia as those who had only depression.

To explore autobiographical life review therapy as a therapeutic intervention in enhancing the stroke patients’ and caregivers’ state hope, life satisfaction, life mastery level as well as in reducing their loneliness.

20 Korean-American aged stroke patients (mean age=73.6) and 20 female Korean-American caregivers (wives) (mean age=67.5) were selected for autobiographical life review therapy. 20 male stroke patients out of 46 stroke patients were screened, by using the Hastean-Reitan Neuropsychological Test battery. During pretreatment testing sessions, the subjects completed state hope scale, life satisfaction scale, life mastery scale, and loneliness scale. At the end of total 10 sessions of autobiographical life review therapy interventions, the subjects completed these scales again. Pretreatment and posttreatment assessments of the selected scales were administered for both the stroke patients and their caregivers.

Between pretreatment and posttreatment, there were significant increases in the subjects’ assessments of state hope (male: p< .01 and female: p< .001), life satisfaction (male: p< .01 and female: p< .01) and of life mastery (male: p< .05 and female: p< .01) as well as significant reduction of their loneliness scale (male: p< .001 and female: p< .01).

The research results demonstrated the effectiveness of autobiographical life therapy interventions as an aid in improving the stroke patients’ and caregivers’ quality of life.

Doing there is no consensus for a multidimensional definition of Quality of Life (QoL) in dementia, and that informant- and self-perceptions of QoL differed substantially, lately it has been proposed to analyze Overall QoL using a simple item. Our objective was to investigate Overall QoL and how this perception among people with Cognitive Impairment and Dementia is associated with other variables. Thus, obtained predictor variables of QoL will act as confirmatory indexes to corroborate the self-reported QoL in clinical setting.

We conducted a cross-sectional survey where 106 participants with Cognitive Impairment (CI) and Dementia completed a face to face interview including diagnosis of dementia (DSM-III-R / DSM-IV), sociodemographic information, health perception and a list of chronic medical conditions, depressive symptoms (GDS-15) and functional ability (Barthel Index). Quality of life was measured with the self-assessment of overall QoL item from WHOQOL-BREF.

Mean age was 78.7 y.o. (SD: 7.1, range 55-91); 64.8% were female and 50% had primary school or more. Ordinal Logistic Regression analysis showed four factors correlated with a better QoL: (1) patients rating their health as good or more than good, (2) patients considering themselves healthy, (3) patients reporting not having depression, and (4) patients having less depressive symptoms (lower GDS scores).

A single-item global rating of patient QoL could prove useful in assessing QoL of most mild-to-moderate-stage CI and dementia patients. Affective states should be considered when assessing QoL in patients with CI and dementia; consistently, negative mood have a detrimental impact on QoL.

Increasing evidence suggests that training in complex reasoning skills may delay the onset of cognitive impairment. A key challenge is to develop cost effective brief interventions which lead to optimal performance.

Hence the major aims of this research were to examine the benefits of a brief intervention for elders, and to compare any improvements with those achieved after more training is provided.

A fully randomised controlled trial was conducted with 30 healthy older adults (M = 64 years) Participants completed measures of the WASI Matrix Reasoning subtest before and after the brief intervention, and again after the extended intervention. Those allocated to training were asked to complete a two week program of sudoku problems of increasing difficulty using tactics demonstrated in guidelines provided. This was followed by an advanced suduko program with harder problems and more sophisticated tactics.

A 2 × 3 (Training × Time) mixed ANOVA on WASI scores was conducted. This showed a significant interaction between Training and Time (F(2,56) = 4.18, p< .05, partial eta squared = .13). Further ANOVAs were conducted to examine this interaction. These showed that the training group improved over time but that the control group did not. Furthermore the training group improved significantly after the brief intervention, and improved more after the extended intervention.

A brief two week training program in suduko enhanced cognitive reasoning in older adults as assessed by the WASI reasoning subtest. A further two week advanced program in suduko further improved cognitive reasoning.

Mitochodrial Encephalopathy, Lactic Acidosis and Stroke like episodes, better known as MELAS continues to be rare and psychiatric literature on this disorder remains sparse. This maternally transmitted genetic disorder is progressive and fatal.

The neurological and neurophysiological symptoms of the disorder can be made out from the name MELAS which does not convey the plethora of psychiatric manifestations it can have. The psychiatric presentations can range from anxiety disorders, attention deficit, eating disorders, personality disorders and psychoses of the paranoid or affective types. Psychopathology can precede or appear during the course of neurological symptomatology leading to dementia. More knowledge about the possible psychiatric presentations is required to help detection and develop management guidelines.

Awareness of MELAS can result only from cohort studies. In the background of nearly fifteen years' follow up of a cohort with heavy genetic loading, the role of psychiatry in managing ongoing symptomatology with scope for futuristic interventions is discussed.

The fatality or the rarity of the disorder should not be a deterrant in charting out treatment guidelines for MELAS. Psychotropics, multidisciplinary care package and primary support net work maintain quality of life against progress of the disorder.

Understanding MELAS would help in maintaining and improving the quality of life of this patient group. MELAS requires further, in depth multidisciplinary studies. Comprehensive neuro-psychiatric, psychosocial and palliative models of management protocols need to be developed.

In the eldery population anti-epileptic drugs (AED) are used in epilepsy, neuralgiform pain, psychiatric disorders and behavioral problems in dementia. The prevalence of AED- treatment in the community is 1%; among nursing home residents 10%. A complex of adverse effects, known as Drug Reaction Eosinophilia and Systemic Symptoms (DRESS), is associated with several drugs, in particular AED. The incidence of DRESS syndrome is estimated between 1 in 1000 and 1 in 10000. DRESS syndrome has a high mortality rate (around 10%), primarily due to doctor's delay in recognition.

As AED-induced DRESS syndrome is rarely described in elderly patients, we describe two with dementia-related behavioural problems, treated with carbamazepine. Both patients developed severe rash, eosinophilia and fever after three weeks of administration. Patient 1 also developed anemia, diarrhoea and delirium; Patient 2 suffered from a severe edema of arms and face. Initially the clinical presentation of inflammatory and hypersensitivity symptoms was attributed to several diseases and/or medication other than carbamazepine. After recognition of DRESS by carbamazepine and stopping this drug, both patients fully recovered.

Recognition of DRESS syndrome induced by AED is difficult as the condition is rare, symptoms occur 1 to 8 weeks after start of treatment; there may be slow progression and similarity with infections and neoplastic disorders exists. Withdrawal of the offending drug is the primary treatment of the DRESS syndrome and patients relatives must be informed since the incidence of the DRESS syndrome is higher amongst first- degree relatives.

Dementia is an acquired syndrome of organic nature, characterized by permanent impairment of memory and other intellectual functions, often associated with psychological and behavioral symptoms without impairment of consciousness. There are psychopathological manifestations.There are different subtypes of dementia. To determine a mild cognitive impairment, the average score of Minimental scale test must be between 21 and 26.

It has been shown that patients with cognitive impairment have a decreased activity of acetylcholine and increased activity of glutamate. Therefore there is a decline in cognitive ability with significant memory impairment and increased aurousal. There is an impairment of cognitive function to perceive, process and use information, which contributes, along with the intelligence, plan and solve problems, learn from the experience, plan tasks and predict results.

For this postulate two fundamental ways in the treatment by use of cholinesterase inhibitors using memantine that blocks NMDA receptors.

However in mild cognitive impairment there is no evidence that these treatments improve patient outcome. Therefore we start treatment with cholinesterase inhibitors when Minimental score between 14 and 24. We'll use cholinesterase inhibitors in combination with memantine when the Minimental score between 10 and 14. We will use only memantine when the score between 3-14. It has been shown that only 30% of mild cognitive impairment progress to dementia. It is important to consider the use of these treatments because it is'nt shown a clear benefit in mild cognitive impairment and have side effects.

The aim of the present study is to evaluate the effects of Pet Therapy intervention on cognitive function, mood and perceived quality of life on elderly subjects (mean age 84.7 years; 95.2% women) living in a nursing home.

Participants were 21 subjects affected by mental illness including dementia, depression and psychosis (diagnosis based on the International Statistical Classification of Disease - ICD-10). The Mini-Mental State Examination (MMSE) and the 15-items Geriatric Depression Scale (GDS) were administered to ten persons (pet-group) and eleven subjects (control-group) together with a self-perceived quality of life questionnaire. The pet-group underwent a dog-assisted educational intervention lasting 90 minutes, once a week for six weeks. MMSE and GDS mean scores were compared between and within groups by Student's t-test.

The mean age ± standard deviation of the overall sample was 84.7±9.9 years. Mean schooling level was 4.0±3.4 years. Dementia was the most frequent diagnosis (47.6%), followed by psychosis (33.3%) and depression (19.0%). Both pet-group and control-group improved on GDS and MMSE. Within the pet-group, GDS symptoms decreased by 50% (from 5.9 to 2.7, p=0.013), whereas mean MMSE score increased by 4.5 (p=0.060). The between group comparison showed positive effect of Pet intervention on GDS (p=0.070). Furthermore, most of the participants reported an improvement of their perceived quality of life.

According to the most recent literature, our findings suggest that Pet Therapy program can be efficient in improving depressive symptoms and cognitive function in residents of long-term care facilities with mental illness.

To report a clinical case on neurosyphilis.

Clinical history, neuroimaging and lab investigations, and neuropsychological assessments.

A 66-year-old married man was admitted to an Old Age psychiatric ward presenting with a two-year history of desinhibited behaviour, hetero-aggression and a gradual loss of his ability cope with activities of daily living. His Mini Mental State Examination (MMSE) score was 20/30 on admission. The symptoms described above raised the working diagnosis of a frontotemporal dementia. Computerized axial tomography was normal. Laboratory and additional examinations were performed. Serological tests for syphilis were positive for both the Venereal Disease Research Laboratory test (VDRL) and Treponema pallidum hemaglutination test (TPHA). Cerebrospinal fluid (CSF) revealed a positive VDRL (cytology: 2 erythrocytes/μl, 30 leucocytes/μl with 24 mononuclear cells/ μl). Additional tests including human immunodeficiency virus (HIV) test were negative. Based on these findings the patient was treated for neurosyphilis according to the IUSTI 2008 European Guidelines on the management of Syphilis: Benzyl penicillin 18 million units i.v. daily, as 3 million units every four hours during 21 days. Two months later, he scored 28/30 at the MMSE but showing only slight improvement at the executive function battery.

Neurosyphilis remains a differential diagnosis for a wide variety of psychiatric syndromes, including dementia. However, the incidence of neurosyphilis presenting initially with frontotemporal impairment is unclear. High-risk groups such as patients with neuropsychiatric diseases should be routinely screened with serological tests in order to prevent morbidity and help to eliminate syphilis.