The elderly population size is increasing worldwide due to prolonged life expectancy and falling birth rates. Traditionally, suicide rates increase with age. For example, a recent cross-national study of 62 developing and developed countries reported an increase in suicide rates with aging in males and females in 25 and 27 countries respectively (Shah, 2007a). Thus, suicides in the elderly are an important public health concern. While much is known about proximal (individual level) risk and protective factors for elderly suicides (e.g. Conwell et al., 1991; Cattell and Jolley, 1995; Harwood et al., 2001), less is known about more distal (societal or population level) risk and protective factors (Rehkopf and Buka, 2006). Moreover, detailed knowledge of these distal factors may have greater public health relevance for the development of comprehensive prevention strategies (Knox et al., 2004).

Background: Frontotemporal lobar degeneration (FTLD) is a relatively rare disease compared to Alzheimer' disease (AD), but nevertheless causes higher burden and stress to caregivers. Only little is known about the problems and needs of the caregivers of patients with FTLD. Such information is crucial for the development of caregiver support interventions. The aim of the current study is to systematically review publications on (1) burden, problems, and needs of FTLD caregivers, and (2) the feasibility and efficacy of caregiver interventions in FTLD.

Methods: A systematic review was conducted. Medical, psychological, and social sciences databases were searched for publications on burden, problems, needs of FTLD caregivers, and support interventions.

Results: Very little published data are available on burden, problems, and needs of FTLD caregivers. Burden among FTLD caregivers is higher than among AD caregivers and correlated with neuropsychiatric symptoms. Specific problems include delayed diagnosis, young age of patients, behavioral disturbances, lack of information and suitable care facilities, caregivers' depression, social isolation, and neglect of personal needs. Hardly any literature is available on the actual needs of FTLD caregivers. Regarding interventions for caregivers, no randomized controlled trials exist. Eight publications could be identified that provide narrative reports on structured caregiver support groups or respite care in combination with caregiver support intervention or advanced practice nursing.

Conclusion: More research and funding are needed to elucidate the complex construct of burden of FTLD caregivers to identify and quantify their problems and needs in order to develop helpful interventions and services.

Background: Certain risk factors for cognitive decline appear modifiable. A potentially modifiable marker of inflammation, C-reactive protein may be associated with cognitive deficits, although not all studies have found a relationship between C-reactive protein and cognitive ability. Further, few research papers have examined whether gender may affect any association between C-reactive protein and cognitive deficit.

Methods: To better understand the association between C-reactive protein, cognitive deficit, and gender in elderly people, we meta-analyzed cross-sectional studies that reported cognitive ability assessed by the Mini-Mental State Examination or an equivalent measure, C-reactive protein concentrations, and gender.

Results: While we identified no studies containing only male subjects, the two identified studies containing both female and male subjects (n = 2,525) showed an effect size for cognition of −0.1809 (95% confidence interval, −0.2652 to −0.0967, p = 0.000025) between high and low C-reactive-protein groups. In contrast, the two identified studies containing only female subjects (n = 1,754) showed an effect size for cognition of 0.0345 (95% confidence interval, −0.0594 to 0.1285, not significant).

Conclusions: In the context of a small number of source studies and lack of an all-male group, these results suggest that any association between C-reactive protein and cognitive deficits may be stronger in elderly men than in elderly women.

Background: The study has a dual objective: (1) to investigate the extent to which, and how and to whom, elderly people gave warning (according to the definition of the term given by the American Association of Suicidology) prior to suicide; (2) to investigate how these warnings were perceived by the recipients of them, and what reactions the recipients had to the warnings.

Methods: This is a psychological autopsy study based on qualitative interviews. Sixty-three informants were interviewed about 23 suicides by individuals aged over 65 in Norway. The informants comprised relatives, general practitioners (GPs) and home-based care nurses. In general, the analysis of the interviews follows the systematic text condensation method.

Results: The interviews contained four main themes regarding reactions to the warnings: “not taken seriously,” “helplessness,” “exhaustion,” and “acceptance.” A total of 14 of the 23 elderly people gave warning before the suicides occurred. The warnings were given to relatives (11), home-based care nurses (5), and GPs (2).

Conclusions: Even though more than half of the elderly people had given warning (most frequently to relatives) before the suicide, the warnings did not initiate preventive measures. Together with passive attitudes, the lack of recognition of both the risk of suicide and the opportunities for treatment prevented possible measures being implemented. The paper discusses the grounds for the reactions as well as how suicide warnings given by elderly people can be taken seriously.

Background: Few studies have examined suicidal ideation and behavior in hospitalized physically ill elderly patients, a group potentially at high risk. Our aim was to investigate the prevalence and risk factors for suicide ideation, and direct and indirect self-destructive behaviors among a sample of elderly inpatients.

Methods: A cross-sectional study was conducted in 2009; 650 inpatients aged 60 years and over were screened from various medical services in teaching hospitals affiliated to Shiraz University of Medical Sciences in Iran. Suicidal ideation and behavior were measured with the Beck Scale for Suicidal Ideation (BSSI) and the Harmful Behavior Scale (HBS). Depression was measured with the Geriatric Depression Scale (GDS), medical burden with the geriatric version of the Cumulative Illness Rating Scale (CIRS-G), life events with the Paykel Life Event Scale, and social support with the Perceived Social Support Scale.

Result: Of the 650 patients screened with a mean age of 70.5 years (SD ± 7.5), 570 met inclusion criteria and of these 123 (21.6%) reported suicidal ideation on the BSSI and 80 (14.4%) had at least one self-destructive behavior included in the HBS. There was a significant correlation between suicide ideation and harmful behaviors (r = 0.503, p = 0.001). In a regression analysis, depressive symptoms, increased burden of medical conditions, marital status, history of substance use, history of traumatic life events, lack of perceived social support, and poor education were associated with both suicide ideation and harmful behavior. From demographic variables, living without a spouse and unemployment were predictors of suicidal ideation and behavior.

Conclusion: Hospitalized, physically ill elderly patients have high rates of suicidal ideation and self-destructive behavior and these vary according to psychosocial and clinical factors. The general hospital is therefore a potential site for the recognition of suicidal individuals and implementation of proximal suicide prevention strategies.

Background: It is well documented that fall risk among elderly people is associated with poor health and depression. In this study, we set out to examine the combined effects of medical condition and depression status on fall incidents among community-dwelling elderly people.

Methods: A cross-sectional study was carried out to investigate the fall history of community-dwelling elders involving 360 participants. Those who had experienced at least two falls over the previous year, or one injurious fall, were defined as “fallers.” The Geriatric Depression Scale-15 was used as a screening instrument for depression status.

Results: Based on a multivariate logistic regression and stratification analysis, depression was found to interact with various medical conditions on fall risk. In comparison with the non-depressive reference group, a six-fold fall risk was discernible among depressed elders with polypharmacy, while a five-fold risk was found among depressive elders using ancillary devices, along with a four-fold risk among depressive elders with diabetes or cardiovascular disease. Finally, arthritis was found to produce a nine-fold risk of falls among such populations.

Conclusions: These findings suggest that greater emphasis should be placed on the integration of depression screening as an element of fall risk assessment in elderly people.

Background: In late life, falls are associated with disability, increased health service utilization and mortality. Physical and psychological risk factors of falls include falls history, grip strength, sedative use, stroke, cognitive impairment, and mental ill-health. Less understood is the role of positive psychological well-being components. This study investigated the protective effect of vitality on the likelihood of falls in comparison to mental and physical health.

Methods: Female participants were drawn from the Dynamic Analyses to Optimise Ageing (DYNOPTA) harmonization project. Participants (n = 11,340) were aged 55–95 years (Mean = 73.68; SD = 4.31) at baseline and observed on up to four occasions for up to 13 years (Mean = 5.30; SD = 2.53).

Results: A series of random intercept logistic regression models consistently identified vitality's protective effects on falls as a stronger effect in the reduction of the likelihood of falls than the effect of mental health. Vitality is a significant predictor of falls likelihood even after adjusting for physical health, although the size of effect is substantially explained by its covariance with mental and physical heath.

Conclusions: Vitality has significant protective effects on the likelihood of falls. In comparison with mental health, vitality reported much stronger protective effects on the likelihood to fall in comparison with the risk associated with poor mental health in a large sample of older female adults. Both physical health and mental health account for much of the variance in vitality, but vitality still reports a protective effect on the likelihood of falls.

Background: Frailty is a complex health state of increased vulnerability associated with adverse outcomes such as disability, falls, hospitalization, and death. Along with physical impairments, cognition and quality of life may be affected in frail older adults. Yet, evidence is still lacking. The aim of this study was to compare frail and non-frail older adults on physical, cognitive, and psychological dimensions.

Methods: Thirty-nine frail and 44 non-frail elders were compared on several measures of physical capacity, cognition, and quality of life. Frailty status was based on a geriatric examination and scored using the Modified Physical Performance Test.

Results: After controlling for demographic and medical characteristics, physical capacity measures (i.e. functional capacities, physical endurance, gait speed, and mobility) were significantly lower in frail participants. Frail participants showed reduced performances in specific cognitive measures of executive functions and processing speed. On the quality of life dimension, frail elders reported poor self-perceptions of physical capacity, cognition, affectivity, housekeeping efficacy, and physical health.

Conclusion: In addition to the reduced physical capacity, frailty might affect selective components of cognition and quality of life. These dimensions should be investigated in intervention programs designed for frail older adults.

Background: This study examined the prevalence and risk factors for intimate partner violence (IPV) among Chinese older couples in Hong Kong.

Methods: A population representative sample was surveyed.

Results: The prevalence of IPV in older adults was found to be quite high in the present study, with a lifetime prevalence ranging from 1.4% to 53.6%, and a past year prevalence ranging from 0.4% to 36.1% for various forms of aggression. Results of logistic regression analyses showed that older persons who were younger among this “older” group, who were not employed, who had a substance abuse problem, who had witnessed parental violence during their childhood, who had a criminal history, who had a low level of assertiveness, who had an anger management problem, who experienced a low level of social support and/or experienced stressful conditions, were all more likely to fall victims of IPV.

Conclusion: It is suggested that IPV in older couples is a complex phenomenon that is closely intertwined with other forms of domestic violence, including spousal violence, child abuse, in-law conflicts, and elderly adult abuse. Thus, before we have more definitive and concrete evidence that IPV in older couples should definitively come under the category of elder abuse or IPV, it is advisable to treat it under its own separate category of family violence.

Background: Elder abuse is often unreported, undetected, and underestimated by professionals. For the first time, we report the effectiveness of an educational elder abuse intervention over three months and its impact on professionals’ practice.

Methods: Forty trainee psychiatrists in two London National Health Service trusts completed the KAMA (Knowledge and Management of Elder Abuse) and CSQ (Caregiver Scenario Questionnaire) measuring knowledge about managing and detecting elder abuse, before and immediately after a brief group education session. We asked how often they considered, asked about, detected, and managed elder abuse and their confidence in doing so, at baseline and three months post-intervention.

Results: Compared with baseline, participants scored higher on the KAMA (paired t = 3.4, p = 0.002), and identified more definitely abusive (t = 3.0, p = 0.003) and possibly abusive (t = 2.1, p = 0.043) items immediately post-intervention. At three-month follow up, 24 (60%) participants reported higher confidence in managing abuse (Wilcoxon signed ranks test z = 3.7, p < 0.001) and considered it more frequently (z = 2.8, p = 0.006), but did not ask older people and their carers about abuse more frequently (z = 1.2, p = 0.24). Two (5%, 95% confidence interval 2%–17%) participants detected abuse in the three months before the intervention, compared with 2 (8%, 2%–26%) in the same period afterward.

Conclusions: This brief educational intervention increased trainee psychiatrists’ knowledge and vigilance for abuse immediately and after three months. They remained reluctant to ask about abuse for reasons including fear of causing offence or harming the therapeutic relationship and being unsure how to ask people with dementia. We postulate that changing doctors’ behavior may require a more complex intervention, focusing on communication skills.

Background: The risks of financial exploitation and abuse of people with dementia remain under-researched. Little is known of the views of those responsible for local adult safeguarding systems about prevention and redress. We explore current repertoires of responses of such persons and consider barriers and facilitators to minimizing risks of financial abuse for people with dementia.

Methods: Fifteen qualitative interviews were undertaken with a purposively sampled group of Adult Safeguarding Co-ordinators in England in 2011. Framework analysis delineated themes in the transcripts; these were included in an iteratively developed coding framework.

Results: Five themes were explored: (1) incidence of financial abuse; (2) impact of dementia on safeguarding responses; (3) warning signs of financial abuse, including neglect, unpaid bills, limited money for provisions; (4) encouraging preventive measures like direct debit to pay for bills, advance care plans, appointing Lasting Power of Attorney; and (5) barriers and facilitators in safeguarding, including the practice of financial agencies, cultural barriers, other systemic failures and facilitators. Not all systems of financial proxies are viewed as optimally effective but provisions of the Mental Capacity Act 2005 were welcomed and seen as workable.

Conclusions: Healthcare professionals may need to be more alert to the signs and risks of financial abuse in patients with dementia both at early and later stages. Engaging with safeguarding practitioners may facilitate prevention of abuse and effective response to those with substantial assets, but the monitoring of people with dementia needs to be sustained. In addition, professionals need to be alert to new risks from electronic crime. Researchers should consider including financial abuse in studies of elder abuse and neglect.

Background: The aim of this study was to investigate the clustering of symptoms on the Neuropsychiatric Inventory (NPI) and the relative prevalence of symptom clusters in mild and moderate Alzheimer's disease (AD).

Methods: Confirmatory factor analysis (CFA) was performed on the polychoric correlation matrix of 12 NPI items (scored yes or no) using the weighted least squares with mean and variance adjustment (WLSMV) estimator in Mplus (N = 224 community-dwelling Chinese persons with mild/moderate AD). Severity of AD was determined by Clinical Dementia Rating scores. The relative model fit of three competing measurement models (also known as factor structures) was tested using a modified χ2 difference test. Prevalence rates across mild and moderate stages were compared using χ2 tests. Furthermore, the measurement model of choice was cross-validated in an independent sample of 181 community-dwelling persons with dementia.

Results: CFA supported a four-factor model, namely behavioral problems (agitation/aggressiveness, disinhibition, irritability, and aberrant motor behavior), psychosis (delusions and hallucinations), mood disturbance (depression, anxiety, sleep, appetite, and apathy), and euphoria (a stand-alone item that is equivalent to the factor). The most prevalent symptom clusters were behavioral (72%) and mood (69%) disturbances, followed by psychosis (45%). Euphoria was rare (6%). All syndromes were more prevalent in moderate than in mild stage, except for euphoria. In addition, the four-factor model was replicated in the cross-validation sample.

Conclusions: The four syndromes provide a parsimonious conceptualization of neuropsychiatric symptoms corresponding to clinical observations and neurochemical changes of the disease. The independent replication in the second sample supports generalization of the four-factor model in Chinese persons with AD.

Background: White matter hyperintensities (WMH) have frequently been associated with lower executive function performance. Little is known, however, about the effects of hippocampal atrophy on executive control in Alzheimer's disease (AD). The present study focused on the association of hippocampal atrophy with executive function in AD patients and examined whether a threshold effect is present, indicating that a certain amount of brain damage must be present before cognitive function becomes impaired. Finally, we examined the combined effect of hippocampal atrophy and WMH on cognitive task performance.

Methods: We retrospectively collected neuropsychological and neuroimaging data of 94 AD patients. These patients completed tasks of general cognitive function, executive function, memory, and processing speed. With magnetic resonance imaging (MRI), hippocampal atrophy was rated as medial temporal lobe atrophy (MTA) and cerebrovascular disease was rated as WMH using validated visual rating scales.

Results: Medial temporal lobe atrophy (MTA) was associated with lower executive function, general cognitive function, and episodic memory performance. A threshold effect was present, indicating that severe to very severe, but not moderate, MTA was associated with lower executive function. WMH were significantly associated with a single executive test only, whereas the interaction between WMH and MTA was not significantly related to any of the cognitive tasks.

Conclusions: Our findings suggest that AD neuropathology in itself may be responsible for executive dysfunction. Potential explanations for these findings are discussed, focusing on the role of the hippocampus in executive function tests and reduced frontal-posterior connectivity in this patient sample.

Background: Previous studies using diffusion tensor imaging (DTI) have observed microstructural abnormalities in white matter regions in both Alzheimer's disease and mild cognitive impairment (MCI). The aim of this work was to examine the abnormalities in white matter and subcortical regions of MCI and its subtypes in a large, community-dwelling older aged cohort

Methods: A community-based sample of 396 individuals without dementia underwent medical assessment, neuropsychiatric testing, and neuroimaging. Of these, 158 subjects were classified as MCI and 238 as cognitively normal (controls) based on international MCI consensus criteria. Regional fractional anisotropy (FA) and mean diffusivity (MD) measures were calculated from the DTI and compared between groups. The false discovery rate correction was applied for multiple testing.

Results: Subjects with MCI did not have significant differences in FA compared with controls after correction for multiple testing, but had increased MD in the right putamen, right anterior limb of the internal capsule, genu and splenium of the corpus callosum, right posterior cingulate gyrus, left superior frontal gyrus, and right and left corona radiata. When compared with controls, changes in left anterior cingulate, left superior frontal gyrus, and right corona radiata were associated with amnestic MCI (aMCI), whereas changes in the right putamen, right anterior limb of the internal capsule, and the right corona radiata were associated with non-amnestic MCI (naMCI). On logistic regression, the FA values in the left superior gyrus and MD values in the anterior cingulate distinguished aMCI from naMCI.

Conclusions: MCI is associated with changes in white matter and subcortical regions as seen on DTI. Changes in some anterior brain regions distinguish aMCI from naMCI.

Background: Early definitions of mild cognitive impairment (MCI) excluded the presence of functional impairment, with preservation of a person's ability to perform activities of daily living (ADL) as a diagnostic criterion. However, recent studies have reported varying degrees of functional impairment associated with MCI. Hence, we aimed to test the potential functional impairment associated with MCI and its predictors.

Methods: Sixty-nine healthy elderly subjects, 115 amnestic single-domain MCI subjects (a-MCI), and 111 amnestic multi-domain MCI subjects (md-MCI) were assessed using a battery of neuropsychological tests including measures of attention, memory, working memory, executive functions, language, and depression. Additionally, functional ability was assessed by both qualitative (WHO-DAS II) and quantitative (CHART) instruments. Cognitive and functional performance was compared between groups, and regression analyses were performed to identify predictors of functional ability.

Results: The md-MCI group was more impaired than the a-MCI group, and both were more impaired than healthy subjects in all cognitive measures, in total CHART score, CHART cognitive and mobility subscores, and WHO-DAS II communication and participation subscales. For the rest of the functional measures, the md-MCI group was more impaired than healthy controls. Prediction of functional ability by cognitive measures was limited to md-MCI subjects and was higher for the CHART than for the WHO-DAS II. The WHO-DAS II was largely influenced by depressive symptoms.

Conclusions: Functional impairment is a defining feature of MCI and is partially dependent on the degree of cognitive impairment. Quantitative measures of functional ability seem more sensitive to functional impairment in MCI than qualitative measures, which seem to be more related to depression.

Background: Subjective memory complaints are a requirement in the diagnosis of mild cognitive impairment (MCI) as they are thought to indicate a decline in objective memory performance. However, recent research suggests that the relationship between subjective memory complaint and objective memory impairment is less clear. Thus, it is possible that many people without subjective memory complaints who develop Alzheimer's disease are precluded from a diagnosis of MCI.

Methods: The present study examined the relationship between subjective memory complaint assessed using the Multifactorial Memory Questionnaire (MMQ) and objective memory impairment assessed using standard neuropsychological measures in cases of amnestic MCI (n = 48), non-amnestic MCI (n = 27), and unimpaired healthy participants (n = 64).

Results: Correlational and regression analyses indicated that subjective memory complaints displayed a poor relationship with objective memory performance. A subsequent discriminant function analysis indicated that subjective memory complaints failed to improve the diagnostic accuracy of MCI and resulted in increased rates of false negative and false positive diagnoses.

Conclusion: The results of the present study suggest that a diagnostic criterion of subjective memory complaint reduces the accuracy of MCI diagnosis, resulting in an elevated rate of false positive and false negative diagnoses. The results of this study in conjunction with recent research indicate that a criterion of subjective memory complaint should be discarded from emerging diagnostic criteria for MCI.

Background: Appropriate neuropsychological tests for cross-cultural assessment of dementia in elderly ethnic and linguistic minorities are generally lacking in Europe. The aim of this study was to investigate the cross-cultural applicability of the Recall of Pictures Test (RPT), Clock Reading Test (CRT), and supermarket fluency (SF) in samples of Turkish immigrants and Danish elderly.

Methods: Samples of Turkish immigrants and Danish elderly were recruited from the Greater Copenhagen area. All participants were screened for factors known to affect cognitive test performance. Those who were included in the study underwent an approximately two-hour assessment, where the RPT, CRT, and SF were applied as a part of a comprehensive battery of neuropsychological tests.

Results: A total of 109 elderly participants were included in the study: 73 Turkish and 36 Danish. Significant differences were found between the Turkish and Danish samples in CRT and SF performances, but not in any of the RPT measures. Age and acculturation level were the only demographic variables with significant impact on test performances. Performance data for the three tests are presented as percentiles.

Conclusions: Although small differences were observed between the Turkish and Danish samples on the CRT and SF, we consider the three tests to be important neuropsychological tests for assessment of dementia in elderly patients from ethnic minority migrant populations.

Background: Dementia is an important disease in older age. Existing studies on dementia mortality face limitations. For instance, they are based on prevalent, small, or geographically limited samples or do not include controls. We aimed to study survival after the first diagnosis of dementia compared with a control group.

Methods: We analyzed claims data of a German health insurance company, including 1,818 incident dementia cases and 7,235 age- and sex-matched non-dementia controls (53% male; mean age 78.8 years). The follow-up was five years. We assessed survival with the Kaplan–Meier curves and performed Cox proportional hazard regression, also including nursing care dependency and comorbidities.

Results: The cumulative five-year mortality was 53.5% in the dementia cases and 31.1% in the control group (hazard ratio: 2.1). Even after adjusting for comorbidities and nursing care, the mortality risk was 1.5 times higher for patients with incident dementia than for controls. Nursing care dependency showed high influence on mortality, likewise in dementia patients and controls.

Conclusions: Although some factors, such as education or the type and severity of dementia, could not be included in the analyses, our study shows a clear influence of dementia on mortality irrespective of age, sex, care dependency, and comorbidities. The strongest influence on mortality was found for dementia patients with nursing care dependency. Taking into account their mortality of around 70% in care level 1 and up to 80% in care levels 2 and 3, healthcare delivery to these patient groups should strongly consider elements of palliative care focusing on the quality of life.

Behavioral and psychological symptoms of dementia (BPSD) are common in Alzheimer's disease (AD) and can potentially contribute to disease burden among caregivers. In this letter, an attempt is reported to establish if disease burden was higher among those with BPSD compared to those without it.