Background: Vocally disruptive behavior (VDB) in the elderly is a common condition, especially in people with dementia, but difficult to treat. It may occur in as many as 40% of nursing home residents. This study is a review of the existing literature on this condition.

Method: The literature review was conducted using PubMed (particularly Medline and the Cochrane database) and reference lists from relevant publications in English, French, and German.

Results: Most studies are small and no conclusive prevalence data are available. Many biological and psychosocial treatments have been advocated, but most studies are little more than anecdotal case reports. It is evident that VDB can have deleterious consequences on others and the patients themselves, although no studies specifically examine the range or the pervasiveness of VDB. Etiopathogenic research on VDB is still in its infancy.

Conclusions: Most aspects surrounding VDB are insufficiently understood. The heterogeneity and multiple contributive factors regarding VDB suggest quite convincingly that a panoply of different interventions tailored to the individual's needs will be required to overcome VDB and the suffering related to it.

Background: Studies examining trends in elderly suicide rates over time reported a decline, an increase and no change. A cross-national study was undertaken to examine the current status of trends over time in elderly suicide rates because previous cross-national studies were well over a decade old.

Methods: Trends in suicide rates for males and females in the age-bands 65–74 years and 75+ years over a 10-year period were examined using data from the World Health Organization website for all the listed countries.

Results: The main findings were: (1) elderly suicide rates either declined or remained unchanged over the 10-year period in most countries; and, (2) suicide rates in both sexes in both the age-bands, over the 10-year period, declined in several European countries, and remained unchanged in several Central and South American countries, Eastern European countries and countries of the former Soviet Union.

Conclusions: Potential explanations for regional and cross-national variations in trends over time in elderly suicide rates include cross-national differences in trends over time in the prevalence of mental illness in the elderly, socioeconomic factors, cultural factors, the availability of appropriate healthcare services, and public health initiatives to improve the detection and treatment of mental illness, mental health and suicide prevention.

Background: Neurocognitive impairment is known to occur in euthymic bipolar patients, but language alterations have not been thoroughly investigated. The aim of this study is to examine the performance in language tests of a sample of elderly patients with bipolar disorder.

Methods: We studied 33 euthymic elderly patients with bipolar disorder but no dementia and 33 healthy individuals, matched for age and education, who were compared in terms of their CAMCOG global score and its subitems.

Results: The scores obtained in language-related abilities for patients and controls, respectively, were: language (total): 27.3 (1) and 28.5 (1), p < 0.0001; comprehension: 8.6 (0.5) and 8.9 (0.3), p = 0.006; production: 18.7 (1) and 19.6 (0.9), p = <0.0001; abstraction: 6.8 (1.1) and 7.3 (0.7), p = 0.016; verbal fluency: 16.3 (4.3) and 19.6 (4.1), p = 0.003.

Conclusion: A mild but significant impairment in language-related ability scores was detected when comparing patients and controls.

Background: Mild cognitive impairment (MCI) is proposed to describe the transitional stage between normal cognitive aging and dementia. It has had significant impact in the field of dementia research, but it remains controversial whether or not it should be used as a diagnostic category in clinical practice.

Methods: Semi-structured interviews were carried out with international experts (N = 37) in the field of dementia research and practice. These interviews explored the advantages and difficulties of using MCI as a clinical diagnosis.

Results: There is wide variation in the clinical use of MCI. This variation depends on institutional factors and two types of cultural factors: (a) clinical culture, and (b) the “evidential culture” – how research and guidelines figure in clinical practice.

Conclusion: The study shows the importance of combining values-based practice with evidence-based practice in the early diagnosis of dementia.

Background: Depressive symptoms are frequently observed in older adults with mild cognitive impairment (MCI). However, little is known regarding the cognitive characteristics of this important subgroup.

Methods: We examined executive functions (controlled inhibition) and verbal episodic memory in 33 healthy older adults (control group), 18 older adults with amnestic MCI plus subclinical depressive symptoms (a-MCI/D+ group), and 26 older adults with amnestic MCI but no depressive symptoms (a-MCI group).

Results: Compared to the a-MCI and control groups, patients with a-MCI/D+ showed poor controlled inhibition. Moreover, in verbal episodic memory these patients recalled fewer words than control participants on immediate free, delayed free, and delayed total (free plus cued) recall. Performance on immediate recall suggested a self-retrieval deficit, but delayed performance also revealed the existence of an encoding impairment. In the a-MCI group, participants exhibited normal performance on the executive task, but pervasive memory impairment; the memory deficit concerned free and total recall on both immediate and delayed tasks, suggesting the existence of encoding and self-retrieval disturbances.

Conclusions: This study reveals differences between the pattern of cognitive impairment for a-MCI/D+ and a-MCI subgroups particularly at the level of executive capacities. In terms of memory functioning, the differences between the subgroups were more subtle; more studies are needed in order to better characterize the memory impairment of a-MCI/D+ and a-MCI patients.

Background: This research concerns the prevalence and course of depression in newly admitted nursing home residents. We attempted to recruit consecutive admissions into the study, irrespective of cognitive status, enabling a comparison of the prevalence and course of depression experienced by cognitively intact residents and those exhibiting all levels of cognitive impairment.

Method: Depression was assessed at one month, three months and six months post-admission. The assessment of mood in this study entailed the conduct of a semi-structured clinical interview, which encompassed DSM-IV criteria and Cornell Scale for Depression in Dementia (CSDD) items.

Results: Recruitment difficulties resulted in a sample of 51 newly admitted residents, drawn from six nursing homes located in Victoria, Australia. Of particular interest, throughout the duration of the study, only the cognitively impaired were diagnosed with major depression (MD). One month post-admission, 24% of the sample were diagnosed with MD, and a further 20% evidenced a non-major depressive disorder. At the second and third assessments, MD was observed in 14% and 15% of residents, respectively. For residents who completed all three assessments, there was no appreciable change in the proportion diagnosed with a depressive disorder, nor was there a change in the levels of depressive symptomatology.

Conclusion: Although subject to limitations, the current study indicated that clinical depression in nursing home facilities most often occurs in residents who also exhibit pronounced cognitive impairment. These depressions are unlikely to remit spontaneously. Accordingly, care staff and general practitioners must be trained in the identification of depression in dementia, and any interventions implemented in these facilities should be tailored to meet the unique needs of this group.

Background: This longitudinal study aims to describe the prevalence and characteristics associated with persistent risk of depression in a group of older, hospitalized patients.

Methods: We examined patients at two time-points: baseline and one month post-discharge from hospital. Patients in this study comprised those who had been admitted to the cardiology unit, with no cognitive impairment, aged 60 years and over, and those who were followed up at both time points (N = 155). Questionnaires administered included risk of depression (Geriatric Depression Scale-15; GDS-15), cognitive impairment (Mini-mental State Examination), social support (7-Item Subjective Social Support Index), co-morbidity (Charlson's Comorbidity Index), sociodemographic variables, physical functioning (Modified Barthel's Index) and clinical variables.

Results: The prevalence of risk of depression (GDS-15 score ≥ 5) among older inpatients at baseline was 34%. At one month post-discharge this had fallen to 17% and this group was identified as those at persistent risk of depression. Factors associated with a risk of persistent depression were: hospitalization within the last six months; length of stay of four days or more; discharge diagnosis of angina; and impaired Subjective Social Support Score.

Conclusion: Depression occurs commonly among older hospitalized patients and may resolve spontaneously. The identification of factors associated with persistent risk of depression can be helpful when looking at which patients may benefit most from screening and treatment for depression after discharge.

Background: No specialized geriatric psychiatry consultation services are available for elderly people in the institutional care system in Turkey. Our aim was to evaluate psychiatric consultations among the residents of three homes for the elderly in a country with a rapidly aging population, and to investigate possible problems regarding psychiatric consultations.

Methods: The residents of three homes for the elderly, which served partially as “care and rehabilitation centers” (equivalent to nursing homes), were chosen for the study. Data on the use of psychiatric services (mainly patient consultations with a visiting psychiatrist) were collected and analyzed.

Results: The percentage of patients in the three homes for the elderly who had psychiatric consultations between 2005 and 2007 was 31.8% (172/540). The main reasons for referral were forgetfulness (61%), depressive symptoms (37.7%), agitation and disruptive behavior (29.6%), and psychotic symptoms (27.9%). Of these patients, 46.5% were diagnosed with dementia, 20.9% with depression, 20.5% with behavioral and psychotic symptoms of dementia, and 18.6 % with primary psychotic disorders such as schizophrenia.

Conclusion: Homes for the elderly in Turkey are not adequate in terms of consultations for psychiatric problems. Integration of these institutions with hospitals and organizing routine consultation visits from the psychiatry units would enhance the mental health of the elderly. Supporting the staff, maintaining good cooperation between them, and organizing educational programs in the field of mental health of the elderly are also required.

Background: Clinical experience suggests that the work characteristics of staff in residential care may influence the well-being of residents with dementia. However, few studies have explored those anecdotal experiences. The aim of this study was to investigate associations between work characteristics of nursing staff and prevalence of behavioral symptoms among people with dementia in residential care settings.

Methods: The self-report job strain assessment scale was used to measure staff perceptions of their working environment, and the Multi Dimensional Dementia Assessment Scale to measure the occurrence of behavioral symptoms among residents in 40 residential care units for people with dementia.

Results: The findings show that in settings where staff reported high job strain, the prevalence of behavioral symptoms was significantly higher compared to settings where staff reported low job strain. Furthermore, settings characterized by staff having a more positive caring climate had significantly less prevalence of escape, restless and wandering behaviors compared to settings having a less positive caring climate. There was no statistically significant association between staff members' self-reported knowledge in caring for people with dementia and prevalence of behavioral symptoms.

Conclusions: This study provides evidence for the oft-cited clinical experience that the well-being of nursing staff is associated with the well-being of people with dementia in residential care settings.

Background: Many people with dementia exhibit some behavioral or psychological symptoms, e.g. aggressive or aberrant motor behavior, depression or hallucinations, at some time during the course of the disorder. The aim of the present study was to describe the probability of the occurrence of these symptoms of dementia in relation to the level of cognitive impairment.

Methods: 3404 people with cognitive impairment were selected from two large cross-sectional surveys of those in geriatric care settings, conducted in 1982 and 2000 in the county of Västerbotten, Sweden. Symptoms were assessed using the Multi-Dimensional Dementia Assessment Scale (MDDAS), subsumed with a rotated factor analysis, and investigated in relation to level of cognitive impairment, measured using the Gottfries cognitive scale.

Results: The passiveness factor had an almost linear correlation to the level of cognitive impairment (r2 = 0.237). Non-linear correlations, with highest prevalences in middle-stage cognitive impairment, were found for aggressive behavior (r2 = 0.057), wandering behavior (r2 = 0.065), restless behavior (r2 = 0.143), verbally disruptive/attention-seeking behavior (r2 = 0.099), regressive/inappropriate behavior (r2 = 0.058), hallucinatory symptoms (r2 = 0.021) and depressive symptoms (r2 = 0.029).

Conclusion: The relations between the behavioral and psychological symptoms of dementia and level of cognitive impairment were non-linear, with higher prevalence rates in the middle stages of dementia, apart from the symptom of passiveness, which increased almost linearly with the severity of cognitive impairment.

Background: Antipsychotics are widely used for the treatment of behavioral and psychological symptoms of dementia (BPSD). In the light of the increased risk of cerebrovascular events, many countries have issued guidelines concerning their use in treating BPSD.

Methods: We carried out an audit of antipsychotic prescribing practice for inpatients with BPSD at a tertiary referral centre using standards derived from two U.K. dementia guidelines. We collated case note and prescription data and interviewed consultant psychiatrists.

Results: Of the 60 patients with dementia 50 (83%) had BPSD; of these, 28 (56%) were receiving antipsychotics. Those prescribed antipsychotics were more likely to have severe BPSD and to be aggressive and/or agitated. Audit of the 28 patients receiving antipsychotics for BPSD showed generally satisfactory results but there was room for improvement in case note documentation of off-label usage, screening for risk factors of cerebrovascular disease, consultation with relatives and use of an appropriate starting dose and slow titration of the antipsychotic.

Conclusion: Audit of the use of antipsychotics for BPSD is important given the increased mortality associated with their use. Simple audit tools as used in this study can inform clinical practice. Even at a tertiary referral centre prescribing practice could be improved.

Background: Maintaining continuous pharmacological treatment of patients with dementia is often difficult. In the current study we surveyed the discontinuation of donepezil, a cholinesterase inhibitor, for the treatment of Alzheimer's disease in a Japanese geriatric outpatient clinic in a university hospital.

Methods: Using a retrospective chart review from 1 July 2003 to 30 June 2005, prescriptions of donepezil and the reasons for discontinuing the prescription in a university hospital were determined. The severity of dementia was evaluated by the clinical dementia rating (CDR).

Results: Out of 264 patients, 140 (53.1%) discontinued taking donepezil during the two-year observation period. The mean age of the continued group and the discontinued group did not differ significantly (79.5 ± 6.7, 79.8 ± 6.4, respectively). Kaplan-Meier analysis showed that the patients with more severe cognitive impairment (CDR score = 3) discontinued donepezil earlier and more frequently. The reasons for discontinuation were a change in the doctors treating the patients (n = 71), ineffectiveness (n = 16), gastrointestinal side-effects (n = 11), and others (n = 41). In patients with CDR = 1 or 2, changes of doctors were the most frequent reason for discontinuation. However, in patients with CDR = 3, ineffectiveness of the medication was the major reason for discontinuation.

Conclusion: Donepezil was frequently discontinued, and the rate of discontinuation was higher in patients with advanced dementia.

Background: Brief cognitive tests represent a first step in the assessment of elderly people referred to outpatient clinics because of cognitive impairment. The aim of this study is to determine sensitivity, specificity and likelihood ratio for a positive result (LR+) for the brief cognitive tests Seven Minute Screen (7MS) and Syndrom Kurztest (SKT) in an outpatient sample of elderly patients with no dementia or mild dementia.

Methods: Ninety-five patients aged 65 years or more from 10 Norwegian geriatric and psychogeriatric outpatient clinics were included in the study. All the subjects had a Mini-mental State Examination score of 22–30. A consensus diagnosis of dementia according to ICD-10 was established by an expert panel that considered data from a standardized assessment protocol blinded for 7MS and SKT results.

Results: Subjects were diagnosed with mild dementia (n = 69) or no dementia (n = 26). Sensitivity for 7MS was 71%, specificity 73% and LR+ was 2.6. Sensitivity for SKT was 65%, specificity 65% and LR+ was 1.9.

Conclusion: Sensitivity, specificity and LR+ for 7MS and SKT were unacceptably low in this outpatient sample.

Background: Gamma glutamyltransferase (GGT) plays a role in cellular glutathione uptake, which is an important element of antioxidant mechanisms. An increase in serum GGT is thought to be an early and sensitive marker of oxidative stress. Oxidative stress has a role in the pathogenesis of Alzheimer's disease (AD). The aim of this study was to investigate the GGT levels in AD.

Method: In this cross-sectional study, 132 patients with AD (mean age: 74.1 ± 7.4, female 62.9%) and 158 age- and gender-matched normal controls (mean age: 74.5 ± 6.3, female 67.1%) were evaluated. For cognitive assessment, MMSE and clock drawing tests were performed; DSM-IV and NINCDS-ADRDA criteria were used. Serum GGT, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase concentrations were determined.

Results: Median (min-max) GGT levels were 18 (9–70) in AD group and 17 (5–32) in normal controls. Mann-Whitney U test showed that GGT levels were significantly higher in AD patients (p = 0.012). Linear regression analysis revealed AD was an independent correlate of elevated GGT levels. Hypertension, diabetes mellitus, total cholesterol, and low density lipoprotein cholesterol were not associated with GGT levels.

Conclusion: GGT levels were increased significantly in AD patients. To evaluate the role of GGT as a marker of oxidative stress in AD, further studies are needed.

Background: It has been anecdotally suggested that health care professionals have stigmatic beliefs about persons with Alzheimer's disease (AD). However, the nature and prevalence of those beliefs have yet to be elucidated. The aim of the present study is to examine stigma towards a person with AD among primary care physicians.

Methods: A nationally representative sample of 501 family physicians (54.1% female, mean age = 49, mean years in the profession = 21) were interviewed using a computer-assisted telephone interview and a structured questionnaire based on an expanded version of attribution theory.

Results: The findings showed that physicians' discriminatory behavior was especially high in the dimension of avoidance and coercion, but low in the dimension of segregation. Two central emotions (anger-fear and pity) were found to affect participants' tendency to discriminate, as were attributions of dangerousness.

Conclusions: Addressing these factors may require targeted education of health professionals as well as the enforcement of anti-discrimination policies.

Background: Paratonia is one of the associated movement disorders characteristic of dementia. The aim of this study was to develop an assessment tool (the Paratonia Assessment Instrument, PAI), based on the new consensus definition of paratonia. An additional aim was to investigate the reliability and validity of the PAI.

Methods: A three-phase cross-sectional survey was conducted. In the first two phases, the PAI was developed and validated. In the third phase, the inter-observer reliability and feasibility of the instrument was tested.

Results: The original PAI consisted of five criteria that all needed to be met in order to make the diagnosis. On the basis of a qualitative analysis, one criterion was reformulated and another was removed. Following this, inter-observer reliability between the two assessors resulted in an improvement of Cohen's κ from 0.532 in the initial phase to 0.677 in the second phase. This improvement was substantiated in the third phase by two independent assessors with Cohen's κ ranging from 0.625 to 1.

Conclusion: The PAI is a reliable and valid assessment tool for diagnosing paratonia in elderly people with dementia that can be applied easily in daily practice.

We note with interest the recently proposed new diagnostic framework published in Lancet Neurology entitled “Research criteria for the diagnosis of Alzheimer's disease: revising the NINCDS-ADRDA criteria” by Dubois et al. (2007).

There has been growing concern about the levels of violence on psychiatric wards in recent years, which has led to increased emphasis on the safe management of such behavior. Physical intervention (PI) is a form of “hands on restraint” to manage the aggressive patient. PI was originally introduced as control and restraint in high security special hospitals in the mid-1980s to enable nursing staff to manage aggressive behavior in a systematic manner. The use of PI is highly emotive and controversial, yet staff are trained in the techniques across all mental health services in the U.K. (Wright et al., 2005). To be legally and ethically justifiable, the form of PI employed must be an appropriate, proportionate and reasonable response to the risk posed and be terminated at the earliest possible opportunity (National Institute of Clinical Excellence, 2005).