Over half of the world's population lives in Asia. With the Asian population aging, it is predicted that there will be a concomitant rapid rise in the number of people with dementia. Unfortunately, most countries in this region are still not well prepared to provide quality services for people with dementia.

This issue of International Psychogeriatrics sees the introduction of what I hope will become a regular journal feature: a “for debate” section. Several other journals have a policy of airing two opposing points of view on controversial topics, sometimes followed by a commentary. Although there are some things upon which all (or nearly all!) health professionals working in the field of psychogeriatrics can agree, it is also true that there are a number of issues on which available evidence is too thin, the balance of benefit and cost (or even harm) too delicately poised, or ethical viewpoints too diverse, to allow consensus to emerge. It also seems likely that some of the things that we do as routine or believe as gospel today, may one day turn out to be viewed quite differently (e.g. insulin coma therapy), so I think it is healthy that we should identify such areas of disagreement and rehearse in print the cases for and against certain practices or points of view. The aim is not to make everybody agree, nor solely to entertain our readership with the spectacle of two irreconcilable sides of an argument slogging away at each other until both succumb to a technical knockout (rather like the TV program, Monty Python's Flying Circus, which proposed a show called A Brick Wall in which two people of utterly opposed views would throw bricks at one another in front of a studio audience!), but rather, by outlining what is known and how it can be viewed, to assist us all in better understanding some of the difficult issues faced by our discipline, and to further comprehension and respect of divergent points of view.

Over 90% of people with dementia develop behavioral problems or psychiatric symptoms at some point during their illness (Ballard et al., 2002). These symptoms are clearly important, but that does not legitimize widespread use of dangerous treatments.

Behavioral and psychological signs and symptoms of dementia (BPSD) include disorders of behavior, mood, thought content and perception (Burns et al., 1990a, b, c, d; Foli and Shah, 2000). BPSD are common (Foli and Shah, 2000) and can cause distress to patients, informal carers and professionals, and lead to institutionalization and over-medication (Shah, 1999). Both non-pharmacological and pharmacological treatment strategies have been utilized to improve BPSD. Despite the recent controversy surrounding the use of olanzapine and risperidone for BPSD, a case for judicious use of these drugs is rehearsed below.

Ballard and Cream, henceforth referred to as the “noes”, and Shah and Suh (the “ayes”), express differing views on the matter of prescribing atypical antipsychotics to patients with dementia. They provide new and useful information which demonstrates that the psychogeriatric community is striving conscientiously to improve the management of BPSD. Despite some strong words, the “noes” ultimately admit that “long-term treatment with neuroleptics should (only) be considered in extreme circumstances and with the informed consent of next of kin”. Although this conflicts with their assertion that “there is clearly no rational reason for prescribing…(neuroleptics),” it suggests that the debate is really about defining where the threshold for prescribing neuroleptics to people with dementia should lie, rather than whether we should or shouldn't use the drugs at all. The “ayes” proffer the liberal opinion that clinicians should offer details about efficacy and side-effects to patients and carers in order that they might “weigh up carefully the risks and benefits” of treatment. It is not said in what proportion of cases with BPSD this avenue should be taken, nor is it clear how the final decision will be reached. This is too simplistic a solution. We cannot deal with this issue just by passing the buck to the patient and carer.

Background: Patients with dementia often receive poor end-of-life care, with inadequate pain control and without access to the palliative care services that patients with cancer are offered. This has been identified as an area of need in recent U.K. Government reports and by the Alzheimer's Society (U.K.). Our objective was to perform a systematic review of the scientific literature regarding the efficacy of a palliative care model in patients with dementia.

Methods: A systematic review was carried out to identify controlled trials that investigated the efficacy of palliative care in patients with dementia. Data sources included were Medline, EMBASE, PsycINFO, CINAHL, British Nursing Index, AMED, Cochrane Database of Systematic Reviews, Web of Science, Cochrane Central Register of Controlled Trials, International Standard Randomised Controlled Trial register, the NHS Economic Evaluation Database and the System for Information on Grey Literature in Europe. Other data was sourced from hand searches of papers identified on electronic databases and review articles.

Results: The search identified 30 review articles, but only four papers were eligible for full appraisal and only two of these met the full criteria for inclusion. These papers gave equivocal evidence of the efficacy for a palliative model of care in dementia.

Conclusion: Despite the increased interest in palliative care for patients with dementia there is currently little evidence on which to base such an approach. This may in part be due to the ethical difficulties surrounding such research, prognostic uncertainty in clinicians and the lack of clear outcome measures for patients who are unable to express their needs or wishes. Further systematic research is urgently needed to educate an important and developing area of clinical practice.

Objective: In this study, we examined 204 older depressed individuals for up to 64 months to determine factors related to depression outcome. We hypothesized that both presence of vascular brain lesions seen on baseline magnetic resonance imaging (MRI) scans and lower baseline social support measures would be related to worse depression outcome.

Method: At study entry, all subjects were at least 59 years old, had a diagnosis of major depression, and were free of other major psychiatric illness and primary neurological illness, including dementia and stroke. Depression was diagnosed via structured interview and clinical assessment by a geriatric psychiatrist who completed a Montgomery Asberg Depression Rating Scale (MADRS) to determine severity of depression. Subjects provided self-report data on social support variables and ability to perform basic and instrumental activities of daily living (ADL, IADL). All subjects agreed to have a baseline standardized MRI brain scan. Ratings of severity of hyperintensities were determined for the periventricular white matter, deep white matter, and subcortical gray matter by two readers who decided by consensus. Treatment was provided by geropsychiatrists following clinical guidelines. Using mixed models to analyze the data, we determined the effect of a variety of demographic, social and imaging variables on the trajectory of MADRS score, the outcome variable of interest.

Results: MADRS scores decreased steadily over time. In a final HLM model, in which time since entry, a baseline time indicator, age, gender, education and Mini-mental State Examination score were controlled, subjective social support, instrumental ADL impairment, subcortical gray matter severity, and the interactions of time with social network and with subcortical gray matter lesions remained significantly associated with MADRS score.

Conclusions: Both social and biological factors at baseline are associated with longitudinal depression severity in geriatric depression.

Background: Frontotemporal dementia (FTD) is difficult to diagnose in the early stages and may be misdiagnosed as Alzheimer's disease (AD) or as a psychiatric disorder. This study aimed to investigate neuropsychological function in FTD of mild severity and compare it to that of mild AD and healthy control participants.

Methods: The study comprised 11 individuals with FTD, 29 with AD and 27 healthy controls. Participants completed a comprehensive neuropsychological assessment in which each area of cognitive function was examined with several widely used clinical tests. Test scores were converted to age-corrected scaled scores and combined to form indices for six areas of cognitive function. These indices were attention, psychomotor speed, memory acquisition, memory recall, executive function and constructional ability.

Results: The FTD group performed below the level of the controls in all areas except constructional ability. FTD and AD groups showed distinct patterns of neuropsychological performance. The FTD group showed predominantly executive dysfunction with less impaired memory function, while the AD group showed the opposite pattern. The capacity of the tests to discriminate between groups was good overall, with 90% of the total sample correctly classified. Predictive success for the FTD group was 64%, given a base rate of 16%.

Conclusion: Administration of a comprehensive neuropsychological protocol including several tests of executive function allows increased certainty about accurate clinical diagnosis of mild FTD.

Background: The present study aims to develop and validate a Chinese version of the Dementia Rating Scale (DRS) for use with Chinese populations in psychogeriatric settings.

Methods: The DRS was translated into Chinese and its content validity was evaluated by an 11-member expert panel. To assess reliability and concurrent validity, 52 subjects with dementia were recruited from medical and psycho-geriatric settings using purposive sampling.

Results: With percentage of agreement as an indicator, 28 out of 36 items (78%) had satisfactory content validity. Items with a percentage of agreement below 70% were reviewed and modified, based on the comments of the experts. The CDRS had excellent test-retest and inter-rater reliability, with intraclass correlation coefficient (ICC) at 0.94 and 0.93 respectively. Intraclass correlation coefficients ranged between 0.75 and 0.89 for the subscales. The internal consistency of the CDRS subscale, as measured by Cronbach's α, ranged from 0.57 to 0.82. The CDRS had high correlations with the Chinese Mini-mental State Examination (r=0.80 for total score, r=0.58 to 0.84 for subscales.

Conclusions: The CDRS is a valid instrument for the assessment of dementia in Chinese–speaking subjects.

Background: Instrumental activities of daily living (IADL) depend on executive planning and procedural memory mediated by the frontal lobes. Planning and judgment are involved in clock drawing. Neuropsychiatric symptoms are also mediated by frontal lobes, and a relationship between ADL, clock drawing and neuropsychiatric symptoms was hypothesized.

Objective: To investigate the relationship between behavioral disturbances, ADL, and executive function.

Methods: Seventy-three Thai patients with Alzheimer's disease (AD) were evaluated. Neuropsychiatric symptoms and behaviors were assessed with the Nevropsychiatric Inventory (NPI). The Thai version of the Mini-mental State Examination (TMSE) was utilized as a global cognitive assessment. A clock-drawing test (CDT) and both category (animals) and letter (ko, so in Thai) verbal fluency were used as executive measures. Thai ADL scale, Barthel Index (BI), and Functional Assessment Questionnaire (FAQ) were ADL measures used in this study.

Results: There were statistically significant correlations between CDT and the frontally-mediated behaviors of agitation (r=−0.367), apathy (r=−0.273) and disinhibition (r=−0.247). Verbal fluency correlated with agitation (r=−0.341). There were significant correlations between Thai ADL scores and agitation (r=0.350), apathy (r=0.441), and disinhibition (r=0.417). FAQ correlated with the same three behaviors. After controlling for TMSE, a significant correlation remained between Thai ADL scores and agitation (r=0.291) and apathy (r=0.342).

Conclusions: We demonstrated correlations between ADL and behavioral changes in Thai elderly with AD. Our results emphasize the important relationships among behavioral changes and impaired ADL.

Background: Mounting evidence implicates diets high in fats and processed sugars with increased generation of free radicals in animals. It is still not clearly established whether such a diet alters antioxidant balance in dementia patients, where an oxidative stress status may already exist. The disruption to lipid metabolism by oxidative stress has been recently linked to neurodegeneration and clinical disease. The aim of this study is to assess the relationship between fat, sugar, carbohydrate and caloric intake levels, and antioxidant status in patients with mild to moderate dementia.

Methods: The levels of 3 essential endogenous antioxidants (superoxide dismutase, catalase, glutathione peroxidase) were measured in the blood of 26 dementia subjects and 26 cognitively unimpaired controls. Concurrently, the intake levels of relevant nutrients and dietary antioxidants were assessed in all subjects.

Results: A statistically significant positive association was observed in the dementia group between glutathione peroxidase activity and the intake of fats (r=0.44; p=0.023), carbohydrates (r=0.46; p=0.018), total sugars (r=0.51; p=0.007) and calories (r=0.47; p=0.14). The only significant association in the control group was observed between glutathione peroxidase and fat (r=0.47; p=0.015).

Conclusion: The higher glutathione peroxidase activity among subjects with greater intake of fats, carbohydrates and sugars may represent a compensatory response to the additional increase in oxidative stress in dementia. Our data shed light on the influence of dietary intake on the oxidant-antioxidant system in mild to moderate dementia patients.

Background: This study was carried out to determine why women caring for men report more burden than other caregivers, and to further examine the role of care-recipient problem behaviors as determinants of burden.

Method: A sample of 557 primary caregivers of community-dwelling individuals referred to a memory clinic was used. All care-recipients had a diagnosis of Alzheimer's disease (NINCDS-ADRDA). Data on care-recipient function, caregiver attributes, external supports and caregiver burden were obtained on the first visit. Hierarchical regression models were used to determine the contribution of gender, after controlling for care-recipient status, caregiver attributes, and external supports.

Results: This model explained 46% of the variability in caregiver “role burden”, with care-recipient problem behaviors and dependence in instrumental activities of daily living. The caregiver/care-recipient gender interaction explained an additional 4% of the variance (p=0.001); women caring for men scored 5.61 higher on the burden scale than other caregivers. Specific problem behaviors (e.g., anger) were more problematic for women caregivers than men.

Conclusion: These results indicate that the experience of men and women caregivers may be different despite seemingly identical circumstances, and highlight the need for interventions geared to the specific needs of women caregivers.

Background: In recent years, it has been claimed that learning potential (also called cognitive plasticity or rehabilitation potential) may be a good predictor of the course of cognitive impairment and the process of dementia. The basic objective of this research program is to test the extent to which the “Battery of Learning Potential for Assessing Dementia” (BEPAD) discriminates healthy people from those diagnosed with Mild Cognitive Impairment (MCI) and with Alzheimer's Disease (AD).

Methods: Two hundred people: 100 healthy elders (51 women, 49 men, mean age: 73.13), 50 diagnosed with MCI (30 women, 20 men, mean age: 74.89), and 50 diagnosed with mild AD (36 women, 14 men, mean age: 75.07). Learning potential was assessed through dynamic assessment (or testing-the-limits), using experimental test-training-post-test, a form of evaluation closely related to functional or stress testing in medicine. In several previous studies the BEPAD was developed, with four tasks: visuo-spatial, verbal recall (including delayed verbal recall), executive control and verbal fluency. For all of these tasks, training procedures were developed, converting them into learning potential tests.

Results and Conclusions: All “dynamic” or learning scores (post-test) discriminate better healthy, MCI and AD subjects than all static or pre-test scores. A total of 89% of cases are correctly classified by the BEPAD: 95.7% of the healthy subjects, 90.6% of AD patients, and 71.1% of the MCI individuals were correctly classified.