This is the 48th and final regular issue of International Psychogeriatrics to be produced by Springer Publishing since the first appearance of the journal in 1989. There have also been several popular supplements. It is time to say farewell and thank you to the publishing company that helped to inaugurate what I and my colleagues on the editorial panel hope is and will be the preeminent peer-reviewed journal devoted to the mental health of older people.

Background: We determined the incidence, probable risk factors, causes, and long-term survival of delirium in patients hospitalized in a medical specialty teaching hospital in Mexico City. Method: From June to December 1995, 667 elderly patients 60 years and older were hospitalized and assessed within 48 hours, excluding those with delirium at admission, those sedated, on respiratory support, or unable to speak. Results: Twelve percent of the population developed delirium, identified by means of the daily application of the Confusion Assessment Method; its appearance was attributed in 50% to two or more causes, in 10% to an insufficient control of pain, in 7.5% to a preceding surgical event, and in the rest to other causes. Each case was compared randomly with three nonpaired control patients of the same cohort who did not develop delirium. There was a significant increase in the number of cases of delirium in patients older than 75 years (p < .001), those with low schooling (p = .04), those with greater comorbidity (p < .001), those with a hematocrit lower than 30% (relative risk [RR] 2.1, confidence interval [CI] 1.2–4.1), and those with a glucose level greater than 140 mg/dl (RR 2.1, CI 1.2–3.6). Patients with delirium remained hospitalized longer than controls (p = .02). There was no significant difference in the intrahospital mortality of both groups, although during 5 years' follow-up, survivors demonstrated a significant increase in mortality (p = .03) in the group of individuals with delirium during the hospital stay when compared to controls. Conclusion: In this geratric polulation of Mexican patients, delirium incidence was similar to that previously reported in the worldwide literature. Its incidence is associated with longer hospital stay and greater mortality. Age, low level of schooling, greater comorbidity, high glucose levels, poor pain control, and hematocrit lower than 30% were independently associated with a greater incidence of delirium.

Objective: The purpose of this research was to identify environmental and personal factors that could be related to the variability in the age of onset of familial Alzheimer's disease (FAD) (36–62 years). Methods: A sample was taken of 49 subjects with FAD and with the mutation E280A in the presenilin-1 gene on chromosome 14; the sample was divided into two subgroups: 27 individuals with age of onset of the disease between 36 and 46 years (early onset) and 22 individuals whose disease began between 47 and 62 years (late onset). Information on environmental and personal factors was collected by means of a questionnaire answered by the patients if their clinical condition allowed it, or by their relatives; such information was organized in a categorical way. Comparisons between the two groups for each categorical variable were done by means of the chi-square test. Noncollinear variables that showed statistical significance were included as independent variables in a logistic regression analysis to predict their association with early onset of the disease. Results: Only 5 of the 140 studied variables were different between the two groups in univariate analysis: education, surgical history, type of stressful event, depression, and affective losses. The logistic regression model was constituted by education, depression, and affective losses. High-level education had approximately 15 times more probability of association with an early onset of the disease; both the history of affective losses and depressive symptoms had 4 times more probability of a similar association. Conclusions: The association of high-level education and early onset of the disease could be related to an earlier detection of symptoms, in turn determined by greater intellectual and environmental demands. The occurrence of depression and affective losses has been considered a prodromic manifestation of the disease. Our findings are evidence of high clinical heterogeneity even in a genetically homogeneous group.

Background: This study focused on the identification of risk profiles for institutionalization among older adults diagnosed with cognitive impairment-not dementia or dementia in 1991/92 and subsequent institutionalization in the following 5-year period. Methods: Data were from a sample of 123 individuals aged 65+ and their unpaid caregivers in Manitoba, Canada. Cluster analysis was conducted using baseline characteristics of age, cognition, disruptive behaviors, ADLs/IADLs, use of formal in-home services, and level of caregiver burden. Results: Three distinct groups emerged (high-risk [n = 12], medium risk [n = 40], and low risk [n = 71]). The high-risk group had the poorest cognitive scores, were the most likely to exhibit disruptive behaviors, were the most likely to need assistance with ADLs and IADLs, and had the highest level of burden among their caregivers. Follow-up of the groups validated the risk profiles; 75% of the high-risk group were institutionalized within the next 5 years, compared to 45% of the medium-risk group and 21% of the low-risk group. Discussion: The risk profiles highlight the diversity among individuals with cognitive impairment and the opportunity for differential targeting of services for the distinct needs of each group.

Objective: This study compared medical history and findings on initial clinical examination in Native Americans diagnosed with possible or probable Alzheimer's disease (AD) at Native American satellite clinics of the University of Texas (UT) Southwestern Medical Center's Alzheimer's Disease Center with those of Whites diagnosed with probable AD at the UT Southwestern Medical Center's Alzheimer's Disease Clinic. Methods: The information reviewed was contained in the database of the UT Southwestern Alzheimer's Disease Center. Results: In relation to Whites, Native Americans had slightly but significantly greater age at onset of symptoms (71.7 vs. 69.6 years, t = −2.08, p = .04) and equivalent cognitive scores at evaluation (Mini-Mental State Exam score = 17.4 vs. 18.5, t = 0.98, p = .33), despite significantly lower educational level (11.4 vs. 13.4 years, t = 5.63, p < .001). Native Americans were more frequently depressed on examination (22.8% vs. 9.5%, χ2 = 12, p = .001) and reported diabetes, hypertension, and heart disease significantly more often than did Whites (p < .01 for all), but their survival time after AD diagnosis was similar to that of Whites despite these comorbidities. Conclusions: With the exception of a greater prevalence of depression and cardiovascular risk factors in Native Americans than in Whites, Native Americans had a course of illness similar to that of Whites.

Background: Dementia with Lewy bodies (DLB) is often associated with REM sleep behavior disorders (RBD) characterized, in contrast to the usual paralysis of REM sleep, by violent motor and verbal activity. Patients and Methods: The pharmacological management of RBD was investigated in three DLB patients treated with clonazepam, a benzodiazepine used as an antiepileptic, or donepezil, a cholinesterase inhibitor. Results: All three patients had marked improvement. The pharmacodynamic mechanisms underlying the efficacy of the two drugs might be due to facilitator effect on the pedunculopontine nucleus, a key structure in the physiology of REM sleep.

Background: Alzheimer's disease (AD) places a significant burden on health care systems worldwide. As new treatments are developed, their cost-effectiveness is often assessed to help health care professionals make informed decisions. In addition to the more common practice of assessing direct medical costs, indirect costs, including time spent in caregiving, should be evaluated. Methods: This study examined the potential effects of the dual cholinesterase inhibitor rivastigmine (Exelon) on caregivers of patients with AD. Results from two 26-week, placebo-controlled trials have demonstrated the clinically relevant and statistically significant efficacy of rivastigmine (6–12 mg/day) compared to placebo, on cognition, activities of daily living, and global functioning. By delaying progression of AD, significant savings in caregiver burden are anticipated, as measured by time spent caregiving and its related costs. Data collected in a prospective, observational study of AD patients and their caregivers were used to establish the relationship between disease severity (based on Mini-Mental State Examination [MMSE] score) and time spent caregiving (according to the 5-item Caregivers Activity Survery score). A significant correlation was observed between the two scores (N = 43, r = −.56, p < .0001), demonstrating that more time for supervision from caregivers is required as the disease progresses. This finding was used to estimate the reduced caregiver burden resulting from the delay in disease progression that was demonstrated with use of rivastigmine. Results: Over a 2-year period, the reduction in time spent in caregiving reached 691 hours for caregivers of patients with mild AD (MMSE score 21–30), resulting in a total savings of approximately $11,253. Treatment of patients with moderately severe AD was also evaluated. The trend was similar but the impact was less, suggesting an economic benefit to early therapy. Conclusion: Early diagnosis and a pharmacologic intervention that allows the patients to remain at home longer by delaying disease progression would have a beneficial impact on patients, caregivers, and payers, and should therefore be encouraged through initiatives designed to identify and treat patients early in the course of disease.

Background: The Neuropsychiatric Inventory (NPI) has been used to assess behavioral symptoms of dementia in the United States, Taiwan, Japan, and Italy. Method: This report evaluates the use of the NPI to assess behavioral symptoms of dementia in a population of Yoruba, Nigerians aged 65 years and older who are subjects in the Indianapolis-Ibadan Dementia Project. In this study, the NPI, Blessed Dementia Scale, and Mini-Mental State Examination (MMSE) were used to assess Nigerian subjects with dementia. For this study the NPI was translated, back translated, and harmonized into Yoruba. Results: The harmonized version of the NPI showed good interrater and test-retest reliability. The Cronbach alpha on 40 subjects was .80 for total severity score, .73 for frequency, and .73 for distress, indicating good internal consistency. The MMSE correlated with the NPI total score and severity scores of delusion, hallucination, and agitation, whereas the Blessed correlated with the NPI total score and severity scores of depression, anxiety, and nighttime behavior. Conclusions: The NPI was found to be a reliable tool to assess behavioral symptoms and caregiver distress of dementia in the Yoruba. Behavioral disturbances were as common in the Yoruba patients with dementia as in studies in other countries that have used the NPI, but the pattern of behavioral disturbances and caregiver response varied among the countries.

Background and Aim: Previous research suggested caregiver singing could influence persons with severe dementia to communicate with increased competence, to cease aggression, and to cease disruptive screaming, while at the same time they seemed to understand what was going on when being cared for during morning care sessions. The aim of this study was to illuminate the posture, body movements, and sensory awareness of patients with dementia during three types of morning care sessions with professional caregivers: (a) the usual morning care situation, (b) a caring session in which familiar background music was played, and (c) a caring session in which the caregiver sang to and/or with the patient throughout. Nine patients with late-stage dementia and 5 professional caregivers participated in this study, and 27 sessions were videotaped (9 patients x 3 caring situations). Data Collection and Method: Data collection was done by means of video recording and the data were analyzed using qualitative content analysis. Results: During the usual caring situation, patients demonstrated slumped posture, sluggish and asymmetric motion, listlessness, minimal awareness of both egocentric space and the physical environment, and a poor ability to perform to completion activities necessary for personal care. Both background music playing and caregiver singing had strong influences on the body and on sensory awareness. Patients had straightened posture, stronger and more symmetric movements, and a greatly increased awareness of themselves and their environment. Patients appeared to regain skills necessary for daily living, and demonstrated that they could perform tasks with intention, purpose, and competence. Caregiver singing, in particular, was very effective at drawing out capabilities that appeared to be lost in these patients. In addition, caregiver singing elicited a larger degree of mutuality in the interaction between patient and caregiver than was seen with background music. Discussion: These results provide further support for the use of caregiver singing in dementia care, and the findings on how caregiver singing can be used to help in dementia caring situations are discussed.