The World Health Organization (2002) describes population aging as “one of humanity's greatest triumphs” as well as “one of our greatest challenges.” Growth in the number of older people as a proportion of the total population (described as the graying of the world's population) is a global phenomenon. With increasing age the causes of death and disease change: in early life communicable diseases, nutritional deficiencies and maternal/perinatal conditions are most important, but after midlife, chronic conditions assume increasing importance. Amongst the chronic conditions of later life, mental disorders feature prominently, the two most common being dementia and depression (Faculty of Old Age Psychiatry, 2006).

Psychogeriatrics is a specialty defined by its many contrasts and complexities. Over-reliance on biological models sometimes artificially narrows the breadth and content of psychogeriatric research, educational programs, service delivery and management models to the detriment of patient care. This guest editorial proposes a conceptual model that defines the scope of the field and provides a structure that overlays standard approaches to diagnosis and formulation. Five key defining elements of psychogeriatrics – the five “Cs” – are explored: complexity, chronicity, comorbidity, continuity and context.

Background: The study aim was to conduct a systematic review of the evidence from randomized, placebo controlled trials related to the efficacy of donepezil, rivastigmine and galantamine in the treatment of behavioral and psychological symptoms of Alzheimer's disease.

Methods: Electronic database searches of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were carried out using multiple search terms. Articles included were original publications of randomized, placebo-controlled trials of monotherapy of donepezil, rivastigmine or galantamine that reported a behavioral outcome measure.

Results: 14 studies were identified that matched inclusion criteria. Nine were of donepezil, three of galantamine and two of rivastigmine. Median study treatment length was 24 weeks (range 12–170). Most studies used the Neuropsychiatric Inventory as a behavioral outcome measure although three used specific scales for either agitation or apathy. Four studies were specifically designed to assess behavioral outcomes whilst in the majority of studies behavioral outcomes were only secondary measures. Three studies found statistically significant, albeit modest, differences in the change of NPI total score between drug and placebo. The interpretation of the results of many studies is limited by methodological considerations, including generally low NPI scores at baseline and the investigation of behavioral and psychological symptoms of dementia (BPSD) as secondary outcomes.

Conclusions: The evidence base regarding the efficacy of cholinesterase inhibitors in BPSD is limited, in part due to methodological considerations. In the absence of alternative safe and effective management options, the use of cholinesterase inhibitors is an appropriate pharmacological strategy for the management of BPSD in Alzheimer's disease.

Background: Advanced dementia is characterized by severe cognitive and functional impairments that lead to almost total dependency in self-care. Neuropsychiatric symptoms (NPS) are common in advanced dementia, diminishing quality of life and increasing the care burden. The challenge for health care providers is to find safe and effective treatments. Non-pharmacological interventions offer the potential for safer alternatives to pharmacotherapy, but little is known about their efficacy. This review evaluates the published literature on non-pharmacological interventions for treating NPS in advanced dementia.

Methods: A literature search was undertaken to find non-pharmacological intervention studies published between 1998 and 2008 that measured NPS outcomes in individuals diagnosed with advanced dementia. Strict inclusion criteria initially required that all study participants have severe or very severe dementia, but this range was later broadened to include moderately severe to very severe stages.

Results: Out of 215 intervention studies, 21 (9.8%) specifically focused on treatments for individuals with moderately severe to very severe dementia. The studies provide limited moderate to high quality evidence for the use of sensory-focused strategies, including aroma, preferred or live music, and multi-sensory stimulation. Emotion-oriented approaches, such as simulated presence may be more effective for individuals with preserved verbal interactive capacity.

Conclusions: Most studies of interventions for dementia-related NPS have focused on individuals with mild to moderate cognitive impairment. Individuals with severe cognitive impairment do not necessarily respond to NPS treatments in the same manner. Future studies should be specifically designed to further explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Areas of particular need for further research include movement-based therapies, hands-on (touch) therapies, and interventions that can be provided during personal care routines. Interventions appear to work best when they are tailored to balance individual arousal patterns.

Background: Neuroimaging studies have revealed structural and functional changes in brain regions associated with major depressive disorder (MDD). These abnormalities appear to be more common and extensive in patients with late-life depression than in younger patients. It has therefore been hypothesized that different morphometric and pathological changes may be associated with MDD, depending on age.

Methods: This review stratifies the findings of the various studies on cell morphology in MDD according to age and assesses any possible differences in neuronal and glial cell changes in younger and older age groups.

Results: Recent morphological studies in postmortem tissue have revealed alterations in neuron and glial cell populations in the frontal and subcortical circuitry associated with depression. These may differ by age, with glial reduction consistently reported in younger groups in cortical areas and neuronal changes identified in studies with older subjects.

Conclusions: Apparent differences in the morphological changes between younger and elderly patients may suggest a differing pathological basis in MDD, dependent on age.

We were delighted, but surprised, by the publication success of our first pilot trial on the efficacy of repetitive transcranial magnetic stimulation (rTMS) to treat late life depression (LLD) (Manes et al., 2001). This preliminary study had major limitations – for example, the small sample size and the use of both a non-therapeutic dose of rTMS and a defective method of sham stimulation. However, it addressed an important clinical problem for which we still do not have a satisfactory solution: how do we treat LLD that has been resistant to the usual therapeutic approaches in a safe and efficient way?

Background: We aimed to investigate factors enabling older people with cognitive impairment to age successfully.

Methods: We used the 12-item Short Form Health Survey to measure health-related quality of life (HR-QoL) in 2,007 people aged ≥60 in the 2000 British National Psychiatric Morbidity Survey. We tested the hypothesis that affective symptoms and social support mediated the relationship between cognitive functioning and poorer HR-QoL.

Results: The mean age of the participants was 66.2 (66.0–66.4). The majority of people with suspected dementia reported high mental health-related quality of life, suggesting they may not be distressed by, or aware of, cognitive and mental impairment, and the majority are aging “successfully.” The relationship between cognitive impairment and mental HR-QoL was mediated by affective symptoms, but not by social support. After considering mediators and confounders, HR-QoL was no longer associated with cognitive impairment.

Conclusions: The lower quality of life previously reported by people with cognitive impairment is due to the greater physical and mental health problems in this population, rather than to cognitive impairment per se. Active management of mental and physical health may improve the HR-QoL of those with cognitive impairment who are not ageing successfully.

Background: Attrition from mortality is common in longitudinal studies of the elderly. Ignoring the resulting non-response or missing data can bias study results.

Methods: 1260 elderly participants underwent biennial follow-up assessments over 10 years. Many missed one or more assessments over this period. We compared three statistical models to evaluate the impact of missing data on an analysis of depressive symptoms over time. The first analytic model (generalized mixed model) treated non-response as data missing at random. The other two models used shared parameter methods; each had different specifications for dropout but both jointly modeled both outcome and dropout through a common random effect.

Results: The presence of depressive symptoms was associated with being female, having less education, functional impairment, using more prescription drugs, and taking antidepressant drugs. In all three models, the same variables were significantly associated with depression and in the same direction. However, the strength of the associations differed widely between the generalized mixed model and the shared parameter models. Although the two shared parameter models had different assumptions about the dropout process, they yielded similar estimates for the outcome. One model fitted the data better, and the other was computationally faster.

Conclusions: Dropout does not occur randomly in longitudinal studies of the elderly. Thus, simply ignoring it can yield biased results. Shared parameter models are a powerful, flexible, and easily implemented tool for analyzing longitudinal data while minimizing bias due to nonrandom attrition.

Background: Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A.

Methods: The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview – Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition.

Results: When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19%. Prevalence was similar for men (10.19%) and women (11.44%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression.

Conclusions: The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.

Background: Critical study of attempted suicides may allow greater understanding of completed suicides because of the considerable overlap between attempted and completed suicides in the elderly.

Methods: Age-associated rates (60–74 years versus 75+ years), trends over time and methods of attempted suicide in the elderly in England were examined using recently collected national data for a nine-year period.

Results: The rate of attempted suicides in the 60–74 years age-band increased over the nine-year study period. Rates of intentional self-poisoning by and exposure to non-opiod analgesics, antipyretics and antirheumatics, intentional self-poisoning by and exposure to narcotics and psychodysleptics and intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system increased over the nine-year study period in both elderly age-bands. The rates and the frequency of intentional self-poisoning by and exposure to non-opiod analgesics, antipyretics and antirheumatics and intentional self-harm by sharp objects were higher in the 75+ years age-band compared to the 60–74 years age-band. The rates and frequency of intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system, intentional self-poisoning by and exposure to alcohol and intentional self-harm by smoke, fire and flames were higher in the 60–74 year age-band compared to the 75+ years age-band.

Conclusions: There is a need to develop strategies to reduce access to targetted methods of attempted suicide in elderly that are most prevalent and increasing over time.

Background: Prior studies have inadequately explored the relationship between late-life suicidal behavior and subclinical/clinical symptoms. This study aimed to assess the risk associated with subclinical symptoms, mild cognitive impairment and clinical factors among late-life suicide attempters.

Method: Forty-three elderly patients aged 60 years and older who sought emergency services in a university-affiliated general hospital for attempting suicide and 43 comparison subjects participated in this study between March 2005 and December 2006. The comparison group was recruited by advertising in the community around the hospital. DSM-IV based diagnostic interview and screening instruments including the GDS, MMSE, BSRS-5 and APGAR were applied. Adjusted odds ratios were measured in the final multiple logistic regression model.

Results: Suicide attempters were more likely to meet a diagnosis of depressive disorder, after adjustments for BSRS-5 score and drinking habit. The adjusted odds of suicide among people with a BSRS-5 score of more than 5 points was 17.8 times higher than those with the BSRS score less than or equal to 5 points.

Conclusions: Our findings support the significant impact on late-life suicidal behavior from the assessment of subclinical symptoms, including anxiety, depression, hostility, sleep condition and interpersonal symptoms. The assessment of subclinical symptoms by the BSRS-5 may help in the future prevention of late-life suicidal behavior in primary care settings.

Background: Suicidal behavior among the elderly is a research field in which qualitative and quantitative methods can and should supplement each other. The objective of this qualitative study is to investigate whether the descriptions of elderly people who committed suicide, given by those who knew them, can provide common features that create recognizable patterns, and if so whether these patterns can help to shed light on the suicidal process.

Method: This is a psychological autopsy study based on qualitative interviews with 63 informants concerning 23 suicides committed by persons aged over 65 in Norway. The informants were relatives, their family doctors, and home-based care nurses. In general, the analysis of the interviews follows the systematic text condensation method.

Results: The descriptions have three main topics: life histories, personality traits and relationships. “Life histories” includes the sub-topics ability to survive and action-oriented achievers. They describe people who came through difficult circumstances when growing up and who were action-oriented in life in general and in crises. “Personality traits” includes the sub-topics obstinacy and controlling others. The informants saw the elderly people as strong-willed, obstinate and possessing a considerable ability to control themselves and those around them. “Relationships” includes the sub-topics I didn't know him and He showed no ability to meet us halfway, and describes the informants’ experience of emotionally closed persons who kept a distance in their relationships.

Conclusions: On the basis of the descriptions of the elderly people given in this study, we argue that these individuals will find difficulty in accepting and adapting to age-related loss of function since their self-esteem is so strongly associated with being productive and in control. Loss of control reveals their vulnerability – and this they cannot tolerate.

Background: This study examines the psychometric properties of the Dysfunctional Thoughts about Caregiving Questionnaire (DTCQ).

Methods: DTCQ was administered to 227 dementia family caregivers.

Results: Principal components analyses resulted in a two-factor solution: Perception of Sole Responsibility and Perfectionism. The DTCQ has a strong internal consistency and an adequate temporal stability. The DTCQ score differentiated between depressed and non-depressed caregivers, although only in the female group. Construct validity was also supported by significant relationships between DTCQ scores and global dysfunctional attitudes, social support, seeking social support and number of hours per day engaged in caring. The dysfunctional thoughts about caregiving specify rigid and inappropriate contingencies to guide and assess behavior while acting as cognitive barriers that make healthy care difficult.

Conclusion: The results of this study showed that such dysfunctional thoughts have a significant relationship to variables identified as mediators in caregiving stress models. The DTCQ has potential uses for both research and clinical purposes.

Background: The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales. The experience of clinicians working in Old Age Psychiatry, who are likely to have greater experience in the use of MCA, in the early implementation of the MCA was examined.

Methods: Case-notes of 37 patients in seven different Old Age Psychiatry services in two mental health trusts in west London, who had received at least one assessment of decision-making capacity (DMC) for a specific issue, were examined. A qualitative thematic analysis pertaining to the criteria used for the assessment of DMC, determination of best interests, least restrictive option and unwise decision was used for data analysis.

Results: The main findings were: the criteria used for the assessment of DMC and the determination of best interests were those described in the MCA and the accompanying Code of Practice; and clinicians were developing the concepts of least restrictive option and unwise decision with face validity despite the absence of their definitions in the MCA.

Conclusion: Caution should be exercised in extrapolating the findings of this study, which is confined to two Mental Health Trusts in one geographical area and the speciality of Old Age Psychiatry, to other localities and other specialties. Nevertheless, there was evidence that clinicians were following the basic principles of the MCA correctly.

Background: Although antipsychotic treatment of behavioral problems in dementia is common, studies investigating the course of these symptoms in nursing homes are scarce. Our primary objective is therefore to describe the course of behavioral problems during antipsychotic treatment in a large sample of elderly nursing home patients with dementia.

Methods: The course of behavioral problems during antipsychotic treatment was studied by comparing the characteristics of patients before, during and after antipsychotic treatment. The study was conducted using the VURAIDB, a database with over 40,000 assessments of over 10,000 nursing home residents in the Netherlands. We used the Challenging Behavior Profile (CBP) to measure an overall behavior score.

Results: In total, 556 patients starting with antipsychotics were studied. Of these, 101 (18.2%) improved and 260 (46.8%) deteriorated at three months on the behavior score, compared with their scores before therapy (z = −7.955; P<0.0001). Patients with severe challenging behavior showed improvement more often than patients with mild disturbances. The course of behavioral symptoms after withdrawal was evaluated in 520 patients. Of these patients, 352 (68%) remained stable or improved at 3 months compared with their scores before withdrawal (z = −0.697; p = 0.486), this figure was 58% at 6 months after withdrawal (z = −2.77; p = 0.006).

Conclusions: During treatment of nursing home residents with dementia with antipsychotics the severity of most behavioral problems continues to increase in most patients, with only one out of six patients showing improvement. After withdrawal of antipsychotics, behavioral problems remained stable or improved in 58% of patients.

Background: People with a dementia disorder often live in institutional care facilities, particularly when the dementia disorder becomes severe or complicated by various behavioral disturbances. The aim of the present study was to analyze and compare the one-week prevalence of various behavioral symptoms and psychotropic drug treatment among people with cognitive impairment living in institutional care, in two large, comparable samples from 1982 and 2000.

Methods: A comparison was made between two cross-sectional samples, collected in 1982 and 2000 respectively, comprising 3404 participants with cognitive impairment living in geriatric care units in the county of Västerbotten, Sweden. Behavioral symptoms were measured using the Multi-Dimensional Dementia Assessment Scale (MDDAS) and cognition was measured using Gottfries’ cognitive scale.

Results: Eight out of 25 behavioral symptoms had become less common, and six more common, after controlling for demographic changes. Regressive behavior, resistance to care and passiveness became less common, while certain aberrant motor behaviors showed an increased prevalence. Antidepressant drug use increased from 6.8% to 43.2%, antipsychotic drug use decreased from 38.0% to 26.2% and anxiolytics, hypnotic and sedative drug use increased from 12.7% to 38.5%.

Conclusion: One-week prevalence of regressive symptoms and resistance to care had decreased and there were signs of a generally increased activity level among old people with cognitive impairment living in institutional geriatric care in 2000 compared to 1982. These changes may be an effect of the extensive changes in pharmacological treatments and in the organization of institutional geriatric care.

Background: The aging society will bring an increase in the number of people with dementia living in the community. This will mean a greater demand on care and welfare services to deliver efficient and customized care, which requires a thorough understanding of subjective and objective care needs. This study aims to assess the needs of community-dwelling people with dementia as reported by themselves and by their informal carers. The study also aims to give insight into the service use and gaps between needs and the availability of services.

Methods: 236 community-dwelling people with dementia and 322 informal carers were interviewed separately. (Un)met needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE).

Results: Most unmet needs were experienced in the domains of memory, information, company, psychological distress and daytime activities. People with dementia reported fewer (unmet) needs than their carers. Type and severity of dementia, living situation and informal carer characteristics were related to the number of reported needs.

Conclusions: This study showed a large number of unmet needs in dementia. Reasons for unmet needs are lack of knowledge about the existing service offer, a threshold to using services and insufficient services offer. These results provide a good starting point for improving community care for people with dementia.

Background: This study examined knowledge levels of Alzheimer's disease (AD) in a sample of Latin American seniors attending AD educational sessions in a Canadian city; and investigated the relationship between knowledge of AD, demographic variables, education level, acculturation level (years living in Canada), subjective memory complaint and objective memory impairment.

Methods: One hundred and twenty-five Spanish-speaking adults living independently in the Greater Toronto Area completed subjective and objective memory measures and completed a questionnaire on their knowledge of AD.

Results: Knowledge of AD was very weakly correlated with level of education and years living in Canada. In addition, there were no correlations between knowledge level and gender or subjective memory complaints.

Conclusions: The results suggest that Latin American seniors, in the Toronto community, are not knowledgeable about AD. In spite of showing subjective cognitive impairment the sample were not aware of the principal cause of their symptoms. Additional research is needed to develop better focused and specifically directed health promotion initiatives for the Latin American seniors living in the Toronto community.

Background: Little is known about how cognitive domains other than episodic memory are affected during the mild cognitive impairment (MCI) stage of Alzheimer's disease (AD). We attempted to clarify this issue in this study.

Methods: Fifty-seven Japanese subjects were divided into two groups: one comprising people in the MCI stage of AD (MCI group, n = 28) and the other of normal controls (NC group, n = 29). Cognitive functions were assessed using the Japanese version of the neurobehavioral cognitive status examination (J-COGNISTAT).

Results: The MCI group performed significantly worse than the NC group on subtests that assessed orientation, confrontational naming, constructive ability, episodic memory, and abstract thinking. Three-quarters of the MCI group had deficits in memory and other non-mnemonic domains, particularly constructive ability and abstract thinking. However, within-subject comparisons showed that the MCI group performed significantly worse on the memory subtest compared to any other subtest.

Conclusions: Besides episodic memory, multiple non-mnemonic cognitive domains, such as constructive ability and abstract thinking, are also impaired during the MCI stage of AD; however, these non-mnemonic deficits are smaller than episodic memory impairment.

Background: Alzheimer's disease (AD) is a neurodegenerative disease with a higher prevalence in women. Expression of estrogen receptor 1 (ESR1) gene has been identified throughout the brain. Owing to the putative neuroprotective effects of estrogen, estrogen receptor gene is a potential candidate modulating the development of AD. Preliminary associations between two polymorphisms of ESR1 (PvuII and XbaI) gene and AD have been reported.

Methods: In this study, 16 single nucleotide polymorphisms (SNPs) of the ESR1 gene (including four commonly studied ESR1 SNPs and 12 other tagging SNPs selected from the HapMap database) were investigated to further evaluate the association between ESR1 polymorphisms and the risk of AD in the Chinese population.

Results: A total of 233 Chinese AD patients and 245 age-matched elderly control subjects were recruited. Genetic associations were analyzed by chi-square test and interaction effect was analysed by logistic regression analysis. Five SNPs (clustered between intron 3 and intron 7) were associated with the risk of AD (p-value ranges from 0.001 to 0.035); another two SNPs (located on exon 2 and intron 2) were shown to modulate the age-at-onset (AAO) in AD (p-value = 0.036 and 0.011).

Conclusions: ESR1 gene polymorphisms may be associated with the AAO in AD. The present results provided information for possible associations between certain polymorphisms of ESR1 gene and the risk of AD.