Long life expectancy is associated with a higher chance of experiencing cognitive impairment in a lifespan. It is well recognized that multiple factors play important roles in the maintenance of cognitive health when one gets older. While the mechanisms of neurodegeneration are complex, it is encouraging to note that simple healthy lifestyles maintained over time may modulate the rate of degeneration or buffer its effects when it becomes inevitable.

The last few years have seen considerable progress in revisions of clinical diagnostic criteria for dementia. In relation to Alzheimer's disease (AD), the focus of this particular debate, the original McKhann criteria were described in 1984 (McKhann et al., 1984) and represented a landmark in their field, allowing accurate categorisation of a type of dementia that was indeed shown subsequently by validation studies to largely represent AD. The criteria distinguished between “probable” AD, which despite its name was the highest level of clinical certainty available, “possible” AD, when there were variations in the course and presentation or the presence of another comorbidity that could be the cause of dementia, and “definite” AD for which autopsy validation was necessary. The impact of these criteria cannot be overestimated. Most of what we know regarding the natural history, and certainly the therapeutic response (and sadly non-response) of AD, is based upon cohorts diagnosed with these criteria, and most usually the probable Alzheimer type. Validation studies have shown reasonably good, and clinically applicable, sensitivity for the criteria of around 80%, but specificity has been lower, at around 70% (Knopman et al., 2001). This low specificity is an issue, largely because of the lack of any positive features for ruling AD in (they have largely, though somewhat unfairly, been labelled criteria of exclusion). In addition, the low specificity is in part because the criteria often also include conditions that were not well defined or even recognised in the 1980s as separate disorders. For example, dementia with Lewy bodies, subcortical ischaemic vascular dementia, and various subtypes of frontotemporal dementia, which have now been shown to have distinct clinical, pathological and, in some cases, genetic components.

Alzheimer's disease (AD) has traditionally been defined as a type of dementia, a concept reinforced by the publication of the National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer's Disease and Related Disorders (NINCDS–ADRDA) criteria in 1984 (Isaac et al., 2011). Three major tenets of these criteria were that (i) the clinical diagnosis of AD cannot be made with certainty and requires post-mortem confirmation; (ii) for that reason, the clinical diagnosis of AD can only be “probable”; and (iii) the diagnosis can be made only when the disease is advanced and reaches the threshold of dementia.

Impressive developments in the biomarker diagnosis of Alzheimer's disease (AD and pre-symptomatic states, using cerebrospinal fluid (CSF), positron emission tomography (PET), magnetic resonance imaging (MRI), and proteomics, have been at the forefront of research in the last decade. With the publication of the criteria of Dubois et al. (2007) and the revised National Institute on Aging and Alzheimer's Association (NIA–AA) criteria for the diagnosis of AD (Jack et al., 2011), this has further ignited the interest and enthusiasm for researchers and clinicians in the field. In some of the major conferences on dementia in recent years, the topic of the biomarker-driven diagnosis of AD has dominated the research agenda. But many questions arise as to how this research will translate into practice. Here, we would like to put forward our arguments against a biomarker-driven diagnosis of AD, and we would caution that very early diagnosis of AD may not result in better care of the subjects.

Dubois, Gauthier, and Cummings argue strongly and coherently for the need for revision of the Alzheimer's diagnostic accuracy and the many benefits to moving to a new diagnostic system. What they propose represents a fundamental paradigm shift in our field, moving Alzheimer's disease from a clinic-pathological to a clinic-biological entity, and separating the diagnosis of Alzheimer's disease from Alzheimer's dementia. In other words, recognising that people can have Alzheimer's disease for many years before they develop the global cognitive decline needed to fulfil current clinical criteria for dementia. The new diagnostic criteria are strongly supported by a very large body of research over the last 25 years and seek to advance the previous McKhann et al. (1984) criteria by, in particular, enhancing diagnostic specificity since, for the first time, CSF and imaging biomarkers are needed to “rule in” rather than simply rule out other disorders. The authors emphasise that these are research criteria and that they require validation and further investigation of clinical utility, whilst also pointing out that they have already been implemented in current Phase 2 clinical studies. Such a parallel introduction of criteria to our field whilst validation is ongoing is nothing new for psychiatry, or indeed dementia, and the same happened for the original Alzheimer's disease criteria as well. Dubois, Gauthier, and Cummings end with a stated aspiration to move the criteria from research to clinical settings, and by doing so hopefully increase the accuracy of the clinical diagnosis of Alzheimer's disease and ultimately improve patient care.

Background: Medications are frequently prescribed for neuropsychiatric symptoms (NPS) associated with dementia, although information on the efficacy and safety of medications for NPS specifically in long-term care (LTC) settings is limited. The objective of this study was to provide a current review of the efficacy and safety of pharmacological treatments for NPS in LTC.

Methods: We searched MEDLINE, EMBASE, PsychINFO, and the Cochrane Library for randomized controlled trials comparing medications with either placebo or other interventions in LTC. Study quality was described using the Cochrane collaboration risk of bias tool. The efficacy of medications was evaluated using NPS symptom rating scales. Safety was evaluated through rates of trial withdrawals, trial withdrawals due to adverse events, and mortality.

Results: A total of 29 studies met inclusion criteria. The most common medications evaluated in studies were atypical antipsychotics (N = 15), typical antipsychotics (N = 7), anticonvulsants (N = 4), and cholinesterase inhibitors (N = 3). Statistically significant improvements in NPS were noted in some studies evaluating risperidone, olanzapine, and single studies of aripiprazole, carbamazepine, estrogen, cyproterone, propranolol, and prazosin. Study quality was difficult to rate in many cases due to incomplete reporting of details. Some studies reported higher rates of trial withdrawals, adverse events, and mortality associated with medications.

Conclusions: We conclude that there is limited evidence to support the use of some atypical antipsychotics and other medications for NPS in LTC populations. However, the generally modest efficacy and risks of adverse events highlight the need for the development of safe and effective pharmacological and non-pharmacological interventions for this population.

Background: Observational studies find that family carers of people with dementia who use more emotional support and acceptance-based coping, and less dysfunctional coping, are less depressed and anxious. We hypothesized that interventions effective in reducing psychological symptoms would increase emotional support and acceptance-based coping, or decrease dysfunctional coping.

Methods: We systematically reviewed randomized controlled trials published up to July 2011, of interventions for carers of people with dementia measuring coping and psychological morbidity. We rated study validity and reported findings. We conducted fixed-effect meta-analyses for interventions where possible.

Results: Eight of 433 papers identified by the search met inclusion criteria. All measured coping immediately after intervention. Two interventions significantly decreased depressive or anxiety symptoms: the smaller study found no change in dysfunctional coping. Neither measured emotional support and acceptance-based coping. Meta-analysis found that both group coping skills interventions alone (SMD = −0.39, 95% CI = −0.75 to −0.03, p = 0.04) and with behavioral activation (SMD = −0.26, 95% CI = −0.48 to −0.04, p = 0.02) significantly increased dysfunctional coping, while significantly reducing depressive symptoms. Positive coping (a mix of emotional and solution-focused strategies) increased (SMD = 0.28, 95% CI = 0.05–0.51, p = 0.02) with group coping skills interventions and behavioral activation.

Conclusions: Contrary to our hypothesis, dysfunctional coping increased when carer depressive symptoms improved. There was preliminary evidence that emotional support and acceptance-based coping increased, as positive coping increased although solution-focused coping alone did not. More research is needed to elucidate whether successful interventions work through changing coping strategies immediately and in the longer term.

Background: Globally, falls in older people are a leading cause of injury-related mortality and morbidity. Cognitive impairment is a well-known risk factor for falls in this population group. While there is now a large body of evidence to support effective interventions for falls reduction across care settings, very little is known about interventions in the vulnerable, but increasing population of cognitively impaired community-dwelling older people. Therefore, the purpose of this systematic review is to investigate interventions designed to reduce falls in community-dwelling, cognitively impaired older adults.

Methods: A literature search of databases was conducted to identify original research published in English, which met predefined inclusion and exclusion criteria for effective (non-pharmacological) falls prevention interventions in cognitively impaired community-dwelling people over 65 years of age. Data from the selected papers were extracted into data extraction tables and analyzed according to study characteristics, measures, results, and quality.

Results: The review identified 11 studies providing data from 1,928 participants. Interventions included exercise, health assessment and management of risk, multi-component and cognitive behavioral programs, and hip protectors as falls risk reduction strategies. Seven of the selected studies showed an intervention effect in decreasing falls risk; however, only two of these showed a significant improvement in physical performance measures specifically in a cognitively impaired group.

Conclusions: The diversity of interventions, study designs, populations, and quality of the studies, which met inclusion criteria, resulted in conflicting evidence and inconclusive results for falls prevention interventions in this highly complex population.

Background: Neuropsychiatric symptoms (NPS) affect the majority of patients who have dementia. Neuropsychiatric sub-syndromes with symptoms that occur together and have common neurobiological correlates have been identified. There are scarce data regarding the comparison of the pattern of the neuropsychiatric sub-syndromes in distinct ethnical and cultural populations. We aim at comparing the pattern of the NPS, and the factor analysis of the Neuropsychiatric Inventory (NPI-10) in two samples of outpatients with dementia living in Brazil and Norway.

Methods: This is a cross-sectional study. The sample consists of 168 Brazilian and 155 Norwegian demented patients from psychogeriatric facilities and community-based educational programs. Brazilian patients were diagnosed with Alzheimer's disease (63.7%), vascular dementia (15.5%), or mixed dementia (20.8%), whereas the diagnoses of Norwegian patients were Alzheimer's disease (97.4%) and mixed dementia (2.6%). Principal component analysis with the Varimax rotation was used for factor analysis of the NPI-10.

Results: Apathy (80.4 %), agitation/aggression (45.8%), and aberrant motor behavior (45.8%) were the most common symptoms in the Brazilian sample. Apathy (72.3%), dysphoria (61.9%), and anxiety (52.3%) were the most frequent symptoms in the Norwegian sample. Factor analysis of the NPI-10 revealed three syndromes for the Brazilian (Psychosis, Mood, Psychomotor) and Norwegian (Psychosis, Mood, Frontal) groups.

Conclusions: The frequency of individual NPS may differ among distinct populations. However, Psychosis and Depression are common sub-syndromes in diverse ethnical and cultural patients with dementia. Our findings support the syndromic approach for the clinical assessment of the patients with dementia.

Background: To clarify physicians’ actual practice in treating agitation in the nursing home and to elucidate the relationship between background factors, familiarity with interventions, and practice.

Methods: A survey of actual practice for agitation in persons with dementia was administered to 67 physicians aged 31–70+ working in nursing homes in Israel. Questionnaires were administered by personal interview, self-completed, or a combination of the two.

Results: Psychotropic medications are prescribed by 92.5% of physicians for treating agitation, most notably, Haloperidol (39%). Non-pharmacological treatment was also reported to be common, though to a lesser extent, with environmental change being the most prevalent non-pharmacological intervention. Generally, physicians showed low familiarity levels with non-pharmacological interventions, with higher levels noted for physicians with a specialty in geriatrics compared to those who were non-specialized. Physicians who were non-Israeli and younger also reported higher familiarity levels compared to their respective counterparts (i.e. Israeli and older) but this difference did not reach significance.

Conclusion: The findings indicate that, despite current guidelines, psychotropic medications are the treatment of choice among nursing home physicians in Israel. While rates of use of non-pharmacological interventions are substantial, their in-practice application may be hindered by lack of familiarity as well as system barriers. The results have implications for system and education changes.

Background: Dementia is a major public health problem in aging populations. The Clinical Dementia Rating (CDR) classifies the severity of dementia and identifies borderline cases that supposedly have higher rates of conversion to dementia. This study aims to verify the dementia conversion rate (CR) in a subsample of an elderly cohort (70+ free of the disease), and to identify risk factors, determining whether CDR is able to predict which individuals have high likelihood of converting.

Methods: A subsample of 156 participants was clinically evaluated for dementia at baseline in which 80 patients without dementia were reassessed after 2.6 years on average to verify the conversion. The CR was analyzed according to demographic, health variables, and CDR classification at baseline, using the Poisson regression method in univariate and multivariate analyses, with exposure time as an offset variable (person-years).

Results: From those re-evaluated, 50% had CDR = 0 and a CR of 38.1/1,000 person-years and the other 50%, CDR = 0.5 (70% with sum of boxes scores ≤1, CR = 145.4/1,000 person-years and 30% > 1, CR = 216.8/1,000 person-years). CR was 91.3/1,000 person-years on average. In the multivariate analysis, when compared with those with CDR = 0, the hazard ratio of those with CDR = 0.5 was 3.82; and for those with CDR = 0.5 and sum of boxes scores >1, 5.69.

Conclusions: Conversion rate to dementia was significantly higher among those with CDR = 0.5 and even higher for those whose sum of boxes scores was >1. Therefore, CDR was able to predict which individuals had a higher likelihood of converting to dementia.

Background: The objectives of this study were to examine the factors modifying the relationship between cortisol level and prevalent/incident cognitive impairment in older adults and to verify whether these relationships were non-linear.

Methods: Data were collected from 1,226 individuals aged 65 and older by two in-home interviews separated by 12 months. Cortisol level was measured using saliva samples taken at the beginning of the baseline interview before cognitive, mental, and physical health evaluations. Prevalent and incident cognitive impairment were defined using the Mini-Mental State Examination scores according to normative data for age, education level, and sex.

Results: High morning cortisol level increased the risk of incident cognitive impairment in participants with anxiety or depressive episode while low cortisol level increased the risk in participants without anxiety or depressive episode. In high educated participants, but not in low educated participants, high morning cortisol level was associated with prevalent cognitive impairment and high afternoon cortisol level increased the risk of incident cognitive impairment. The results also suggested that lower morning cortisol values could increase the risk of incident cognitive impairment in individuals with few chronic diseases. A curvilinear relationship was observed between morning cortisol and the probability of incident cognitive impairment, but further analyses suggested that it was likely explained by anxiety and depressive episode.

Conclusions: These results suggest that cognitive impairment in older adults is linked to higher or lower cortisol level depending on characteristics such as anxiety, depressive episode, education level, and physical health.

Background: Qualitative research has suggested that spousal carers of someone with dementia differ in terms of whether they perceive their relationship with that person as continuous with the premorbid relationship or as radically different, and that a perception of continuity may be associated with more person-centered care and the experience of fewer of the negative emotions associated with caring. The aim of the study was to develop and evaluate a quantitative measure of the extent to which spousal carers perceive the relationship to be continuous.

Methods: An initial pool of 42 questionnaire items was generated on the basis of the qualitative research about relationship continuity. These were completed by 51 spousal carers and item analysis was used to reduce the pool to 23 items. The retained items, comprising five subscales, were then administered to a second sample of 84 spousal carers, and the questionnaire's reliability, discriminative power, and validity were evaluated.

Results: The questionnaire showed good reliability: Cronbach's α for the full scale was 0.947, and test–retest reliability was 0.932. Ferguson's δ was 0.987, indicating good discriminative power. Evidence of construct validity was provided by predicted patterns of subscale correlations with the Closeness and Conflict Scale and the Marwit–Meuser Caregiver Grief Inventory.

Conclusion: Initial psychometric evaluation of the measure was encouraging. The measure provides a quantitative means of investigating ideas from qualitative research about the role of relationship continuity in influencing how spousal carers provide care and how they react emotionally to their caring role.

Background: The present study examined the prospective relationships between subjective fatigue, cognitive function, and everyday functioning.

Methods: A cohort study with secondary data analysis was conducted using data from 2,781 community-dwelling older adults without dementia who were enrolled to participate in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized intervention trial. Measures included demographic and health information at baseline, and annual assessments of subjective fatigue, cognitive function (i.e. speed of processing, memory, and reasoning), and everyday functioning (i.e. everyday speed and everyday problem-solving) over five years.

Results: Four distinct classes of subjective fatigue were identified using growth mixture modeling: one group complaining fatigue “some of the time” at baseline but “most of the time” at five-year follow-up (increased fatigue), one complaining fatigue “a good bit of the time” constantly over time (persistent fatigue), one complaining fatigue “most of the time” at baseline but “some of the time” at five-year follow-up (decreased fatigue), and the fourth complaining fatigue “some of the time” constantly over time (persistent energy). All domains of cognitive function and everyday functioning declined significantly over five years; and the decline rates, but not the baseline levels, differed by the latent class of subjective fatigue. Except for the decreased fatigue class, there were different degrees of significant associations between the decline rates of subjective fatigue and all domains of cognitive function and everyday functioning in other classes of subjective fatigue.

Conclusion: Future interventions should address subjective fatigue when managing cognitive and functional abilities in community-dwelling older adults.

Background: Mild cognitive impairment (MCI) may represent a transitional stage between normal functioning and dementia. Following the initial criteria developed by Petersen et al. in 1999, which focused on memory deficit in the context of otherwise normal cognition and general functioning, the concept has evolved with the introduction of subtypes of MCI and improved understanding of etiology. Our aim was to investigate current practice as well as familiarity with and attitudes toward the concept of MCI amongst UK old age psychiatrists.

Method: We sent an anonymized postal survey to all clinicians on the Royal College of Psychiatrists Old Age Psychiatry register. Questions covered attitudes toward the concept of MCI in addition to diagnostic criteria and assessment tools used.

Results: The response rate was 39% (453 of 1,154 questionnaires returned completed). The majority of respondents were consultants (83%) and 91% diagnosed MCI. Only 4.4% of the respondents thought that the concept of MCI was not useful and 79% of them required a memory complaint from either the patient or an informant for a diagnosis, but the majority did not have a specific cut-off on cognitive testing. Eighty-two percent reported that they required no or minimal impairment in activities of daily living for a diagnosis of MCI. The two most frequently used tools for assessment were the Mini-Mental State Examination and the Addenbrooke's Cognitive Examination–Revised.

Conclusions: Our survey shows that in the United Kingdom, the term MCI has become part of everyday clinical practice in psychiatry, suggesting that clinicians find it a useful term to conceptualize the transitional stage between normal aging and dementia. However, there is variability in diagnostic practice.

Background: Depression in old age is common. Only few studies examined the association of depressive symptoms and direct costs in the elderly in a cross-sectional way. This study aims to investigate prospectively health service use and direct costs over a course of 4.5 years considering also different courses of depressive symptomatology.

Methods: 305 primary care patients aged 75+ were assessed face-to-face regarding depressive symptoms (Geriatric Depression Scale), and service use and costs at baseline and 4.5 years later. Resource utilization was monetarily valued using 2004/2005 prices. The association of baseline factors and direct costs after 4.5 years was analyzed by multivariate linear regression.

Results: Mean annual direct costs of depressed individuals at baseline and follow-up were almost one-third higher than of non-depressed, and highest for individuals with chronic depressive symptoms. Most relevant cost drivers were costs for inpatient care, pharmaceuticals, and home care. Costs for home care increased at most in individuals with chronic depressive symptoms. Baseline variables that were associated with direct costs after 4.5 years were number of medications as a measure of comorbidity, age, gender, and depressive symptoms.

Conclusions: Presence and persistence of depressive symptoms in old age seems to be associated with future direct costs even after adjustment for comorbidity. The findings deign a look to the potential economic consequences of depressive symptoms in the elderly for the healthcare system in the future.

Background: Findings from studies investigating depression in adults in late life are mixed due to a lack of large longitudinal studies with the power necessary to yield reliable estimates of stability or change. We examined the long-term stability of probable depression and depressive symptomology over a 13-year period in the Dynamic Analyses to Optimize Ageing (DYNOPTA) project.

Methods: Community-living participants (N = 35,200) were aged 45–103 at baseline, predominantly female (79%), partnered (73%), and educated to secondary school only (61%) and followed for up to 13 years.

Results: At baseline, increased age was associated with lower prevalence of probable depression and depressive symptomology. Over time, prevalence of probable depression was stable while levels of depressive symptomology reported a small decline. However, this finding was not consistent for all age groups; there was evidence for increasing levels of depressive symptomology, but not probable depression, as individuals aged. This effect was particularly notable among males aged 70 plus years.

Conclusions: These results answer important questions relating to the longitudinal prevalence of probable depression and depressive symptomology in a sample of older Australians. These findings have policy implications for mental health service provision for older adults.

Background: Long-term effects of World War II experiences affect psychological and physical health in aged adults. Forced displacement as a traumatic event is associated with increased psychological burden even after several decades. This study investigates the contribution of forced displacement as a predictor for mental health disorders and adds the aspect of health-related quality of life (QoL).

Method: A sample of 1,659 German older adults aged 60–85 years was drawn from a representative survey. Post-traumatic stress disorder (PTSD), somatoform symptoms, depressive syndromes, and health-related QoL were assessed as outcome variables. Chi-square and t-test statistics examined differences between displaced and non-displaced people. Logistic regression analyses were performed to examine the impact of forced displacement on mental health disorders and QoL.

Results: Displaced people reported higher levels of PTSD, depressive and somatoform symptoms, and lower levels of health-related QoL. Displacement significantly predicted PTSD and somatoform symptoms in late life, but not depressive disorders. Health-related QoL was predicted by forced displacement and socio-demographic variables.

Conclusion: Forced displacement is associated with an elevated risk for PTSD and somatoform symptoms and lowered health-related QoL in aged adults. Its unique impact declines after including socio-demographic variables. Long-term consequences of forced displacement need further investigations and should include positive aspects in terms of resilience and protective coping strategies.

Background: Casenote studies have characterized late onset schizophrenia (LOS) and related psychoses as somewhat different symptomatically from patients with an early onset schizophrenia (EOS). This study examined a range of phenomenological aspects of delusions and hallucinations as well as traditional symptom measures in both groups.

Methods: 34 LOS and 235 EOS completed the Positive and Negative Syndrome Scale, the Psychotic Symptom Rating Scales, and the Beck Depression and Anxiety inventories. Subgroups experiencing delusions were compared matching for chronological age and gender, and also when matched for chronicity and gender.

Results: Delusions were very common at over 80% in both groups. LOS participants with delusions exhibited greater suspiciousness/paranoia, greater belief-conviction, and reduced insight when compared with the EOS group. These findings remained when matching for chronicity of illness, but disappeared when matching for chronological age. Hallucinations were surprisingly rarer in LOS (35%) than EOS (57%), with half the LOS group reporting whispers rather than clearly audible sounds. In general, anxiety, depression, and distress were as marked in LOS and EOS.

Conclusions: Similarities between EOS and LOS far outweighed the differences across a range of symptoms and measures. Greater delusional conviction, paranoia, and poorer insight in LOS were associated with the later age of onset rather than relating to chronicity of illness. As belief-conviction in LOS was not associated with increased grandiosity, disorientation, or unusualness of thought content, as it was in EOS, delusional conviction may be determined somewhat differently later in life.

Background: We aimed to analyze the prevalence of prescription anxiolytics and antidepressants in elderly individuals in Spain between the years 2003 and 2009, and to identify those factors associated with the likelihood of consumption of these drugs during the study period.

Methods: We used individualized secondary data retrieved from the 2003 and 2006 Spanish National Health Surveys (SNHS) and the 2009 European Health Interview Survey (EHIS) for Spain to conduct a nationwide, descriptive, cross-sectional pharmacoepidemiology study on psychotropic medication in the population aged 65 years and over in Spain. A total of 12,228 interviews were analyzed (5,117 from 2003; 7,084 from 2006; and 5,144 from 2009). The dichotomous dependent variables chosen were the answers “yes” or “no” to the question “In the last two weeks have you taken the following medicines and were they prescribed for you by a doctor?” referring to intake of anxiolytics and antidepressants. Independent variables were sociodemographic, comorbidity, and healthcare resources.

Results: Multivariate analysis highlighted the association between increased psychoactive drug intake and female gender, depression, polypharmacy, and negative perception of health. We observed a significant increase in the consumption of prescription anxiolytics (AOR, 1.08 [95% CI, 1.06–1.10]) and antidepressants (AOR, 1.11 [95% CI, 1.08–1.14]) in individuals aged ≥65 years in Spain between the years 2003 and 2009.

Conclusions: The prevalence of anxiolytics and antidepressants consumption is higher in elderly women than men, and increases with negative perception of health. The Spanish elderly individuals taking antidepressants reported having problems to manage these medicines in their own homes.