Cognitive decline has commonly been considered an inevitable result of brain aging and has been of clinical interest principally because of related difficulties with everyday functioning. Since the 1990s the “normality” of age-related cognitive decline has been called into question, being commonly attributed to a number of underlying disorders. Numerous concepts have been proposed which link subclinical cognitive change to pathological states (mild cognitive disorder, mild neurocognitive disorder, mild cognitive impairment). Of these, mild cognitive impairment (MCI) has become the most popular, driven on the one hand by industrial interests seeking to extend new dementia treatments for a more prevalent subclinical syndrome, and on the other by researchers attempting to identify at-risk populations. MCI has been both criticized for “medicalizing” behavior still within normal limits (Stephan et al., 2008; Moreira et al., 2008) and welcomed in that it suggests cognitive decline with aging may not be inevitable, but rather due to abnormalities which could ultimately be treated. Recently, in both Europe (DuBois et al., 2007) and the USA (Albert et al., 2011), panels of experts have scrutinized the concept of MCI and more broadly the pre-dementia stages of neurodegenerative diseases and offered new research diagnostic criteria. These proposed criteria have highlighted the (potential) value of biomarkers in assisting diagnosis, although some have considered the elevation of biomarkers to this level of importance in diagnosing disease before dementia develops to be premature given both the extent and quality of diagnostic biomarker data currently available (McShane et al., 2011a; 2011b).

Background: The course of delirium in patients with dementia who are undergoing management of delirium with antipsychotics has not previously been studied. In order to investigate the treatment characteristics of patients with delirium superimposed on dementia in contrast to delirium in the absence of dementia we performed a secondary analysis of our delirium database.

Methods: We collected sociodemographic data and medical variables in addition to using the systematic rating scales of the Memorial Delirium Assessment Scale (MDAS) and Karnofsky Scale of Performance Status (KPS). These data were recorded in the delirium database. For this analysis we extracted all data pertaining to patients with delirium and dementia (DD) and compared them to those with delirium without dementia (i.e. non-demented with delirium; NDD).

Results: Out of 111 cases with a diagnosis of delirium we acquired 22 cases with a diagnosis of DD and 89 cases with NDD. The mean age was significantly different with 77.1 years for DD and 62.7 years for NDD. The MDAS scores at baseline were significantly higher in DD (21.1) compared to NDD (17.6). Over the course of treatment, MDAS scores were significantly higher in DD with 11.7 at T3 compared with 7.0 in NDD. After three days of management, delirium resolution rates were significantly lower in DD with 18.2% compared to 53.9% in NDD, and at seven days delirium resolution rates were 50% and 83% respectively. At the endpoint of the observation period, DD had a significantly more pronounced disturbance of consciousness and impairment in the cognitive domain. KPS scores were not significantly different between DD and NDD.

Conclusion: In our sample of patients with delirium superimposed on dementia the delirium resolution rates were lower than in patients without dementia at one week of treatment. The data suggest that when delirium is superimposed on dementia the delirium may resolve at a slower rate.

Background: Hospitalized frail older patients are usually assessed for their ability to perform some daily living activities in a clinical setting prior to discharge. However, assessments that take place in this unfamiliar environment might not be as representative of their functional performance as assessments at home. This may be related to a decline in some cognitive components, such as executive functions (EF), which enable one to cope with new environments. This study thus aims to compare cooking task performance in familiar and unfamiliar settings in a population of frail older adults with poor and preserved EF.

Methods: Thirty-seven frail older adults were assigned to one of two groups: poor EF or preserved EF. Participants performed two cooking tasks in familiar and unfamiliar settings, using a counterbalanced design. Their performance was assessed with a reliable tool based on observation of motor and process skills (Assessment of Motor and Process Skills).

Results: Thirty-three participants were retained for analysis. They demonstrated significantly better motor skills (F = 5.536; p = 0.025) and process skills (F = 8.149; p = 0.008) in the familiar setting. The difference between settings was particularly marked for process skills in participants with poor EF (F = 16.920; p < 0.001).

Conclusions: This study suggests that a home setting may be preferable for a more accurate assessment of cooking task performance in frail older adults, especially those with poor EF. These findings highlight the risk of underestimating frail older adults’ performance when assessed in an unfamiliar setting (e.g. hospital), which could lead to inefficient allocation of home care services.

Electroencephalography is the only diagnostic instrument directly reflecting cortical neuronal functioning, and it remains an important clinical tool in the diagnosis and differential diagnosis of Alzheimer's disease (AD). Although a normal EEG is found in many patients with mild AD, a pathological EEG is an important finding, because such a result is not in line with differential diagnoses such as depression or pseudodementia within a dissociative disorder. The vast majority of patients with moderate to servere AD have a pathological EEG. A normal EEG in this patient group is more in line with subcortical dementia or frontal lobe degeneration than with AD. Compared to SPECT or routine structural brain imaging (cCT, MRT), EEG has a comparable diagnosis sensitivity and a higher specificity. For monitoring changes of brain function by serial recordings (e.g., during therapy with antidementia drugs), EEG is the best available method.

Background: Despite expansion of research on elder mistreatment, limited attention has been paid to the development of improved measurement instruments. This gap is particularly notable regarding measurement of mistreatment in long-term care facilities. This paper demonstrates the value of qualitative methods used in item development of a Resident-to-Resident Elder Mistreatment (R-REM) measure for use in nursing homes and other care facilities. It describes the development strategy and the modification and refinement of items using a variety of qualitative methods.

Methods: A combination of qualitative methods was used to develop close-ended items to measure R-REM, including review by a panel of experts, focus groups, and in-depth cognitive interviews.

Results: Information gathered from the multiple methods aided in flagging problematic items, helped to highlight the nature of the problems in measures, and provided suggestions for item modification and improvement.

Conclusions: The method employed is potentially useful for future attempts to develop better measures of elder mistreatment. The employment of previously established measurement items drawn from related fields, modified through an intensive qualitative research strategy, is an effective strategy to improve elder mistreatment measurement.

Early-life stress (ELS) has previously been identified as a risk factor for cognitive decline, but this work has predominantly focused on clinical groups and indexed traditional cognitive domains. It, therefore, remains unclear whether ELS is related to cognitive function in healthy community-dwelling older adults, as well as whether any effects of ELS also extend to social cognition. To test each of these questions, the Childhood Trauma Questionnaire (CTQ) was administered to 484 older adults along with a comprehensive neuropsychological test battery and a well-validated test of social cognitive function. The results revealed no differences in global cognition according to overall experiences of ELS. However, a closer examination into the different ELS subscales showed that global cognition was poorer in those who had experienced physical neglect (relative to those who had not). Social cognitive function did not differ according to experiences to ELS. These results indicate that the relationship between ELS and cognition in older age may be dependent on the nature of the trauma experienced.

Background: The Cognitive Abilities Screening Instrument (CASI) was designed for use in cross-cultural studies of Japanese and Japanese-American elderly in Japan and the U.S.A. The measurement equivalence in Japanese and English had not been confirmed in prior studies.

Methods: We analyzed the 40 CASI items for differential item functioning (DIF) related to test language, as well as self-reported proficiency with written Japanese, age, and educational attainment in two large epidemiologic studies of Japanese-American elderly: the Kame Project (n=1708) and the Honolulu-Asia Aging Study (HAAS; n = 3148). DIF was present if the demographic groups differed in the probability of success on an item, after controlling for their underlying cognitive functioning ability.

Results: While seven CASI items had DIF related to language of testing in Kame (registration of one item; recall of one item; similes; judgment; repeating a phrase; reading and performing a command; and following a three-step instruction), the impact of DIF on participants' scores was minimal. Mean scores for Japanese and English speakers in Kame changed by <0.1 SD after accounting for DIF related to test language. In HAAS, insufficient numbers of participants were tested in Japanese to assess DIF related to test language. In both studies, DIF related to written Japanese proficiency, age, and educational attainment had minimal impact.

Conclusions: To the extent that DIF could be assessed, the CASI appeared to meet the goal of measuring cognitive function equivalently in Japanese and English. Stratified data collection would be needed to confirm this conclusion. DIF assessment should be used in other studies with multiple language groups to confirm that measures function equivalently or, if not, form scores that account for DIF.

High-resolution single-photon emission computed tomography (SPECT) with brain-retained technetium-99m (99mTc)–labeled tracers may be used for 3-dimensional measurements of regional cerebral blood flow (rCBF). This article summarizes important findings in SPECT studies of Alzheimer's disease (AD). There are three distinct potential applications of SPECT in diagnosing AD: (a) as a diagnostic adjunct in patients with mild cognitive or behavioral symptoms, suggesting a possible dementia disorder; (b) as a diagnostic adjunct for demented patients in whom the history, physical examination, and laboratory studies are in agreement with a diagnosis of probable AD; and (c) for determining the relative contributions of degenerative and vascular pathology to the clinical picture in demented patients with mixed disease. A clinical diagnosis of probable AD is associated with focal perfusion deficits as measured by SPECT. Characteristically, hypoperfusion is observed in the frontal and temporoparietal association areas, whereas other brain regions are relatively spared. The changes are present in the early phases of AD. The topography of rCBF deficits displays a marked heterogeneity among patients and correlates with cognitive profiles. In patients with mild cognitive complaints, the presence of focal hypoperfusion on SPECT may increase the accuracy of the diagnosis by confirming the presence of brain disease. In patients with probable AD, the presence of temporoparietal rCBF deficits on SPECT increases the accuracy of the clinical diagnosis, in particular when associated with medial temporal lobe atrophy on cranial X-ray computed tomography (CT). The role of SPECT in diagnosing patients with mixed disease remains to be clarified.

Background: Alzheimer's disease (AD) is associated with dependence in activities of daily living (ADL). In addition to the cognitive impairment resulting from AD, the presence of psychotic symptoms may further increase this dependence. The objective of this study was to quantify the additional contribution of psychotic symptoms to dependence in ADL. Method: We analyzed data from 558 individuals with AD referred to a memory clinic. Information on ADL, psychotic symptoms, depression symptoms, and cognition was collected with standardized instruments. Results: The frequency of psychotic symptoms was correlated with dependence in ADL (r = −.44, p < .001). The independent contribution of psychotic symptoms to ADL (basic and instrumental) after consideration for cognitive impairment and depression symptoms was assessed with hierarchical regression models. Twenty-five percent of basic ADL variance was explained by cognition; psychotic symptoms accounted for an additional 7% of the variance (b = −0.12, p < .001). Cognitive impairment explained 31% of instrumental ADL variance; psychotic symptoms accounted for an additional 6% (b = −0.21, p < .001). Discussion: Psychotic symptoms are associated with dependence in ADL after controlling for cognitive impairment and depression symptoms. Future research should investigate possible causal linkages between psychotic symptoms and dependence in ADL. This may have implications regarding interventions to maintain independent living in people with AD.

Background: In many parts of the world the provision of psychogeriatric inpatient units (PGUs) remains limited. More units will be required over coming decades given rapid population aging.

Methods: Medline (1950–2010), psycINFO (1806–2009), EMBASE (1980–2009) and CINAHL (1982–2009) were searched for papers about PGU design. Selected non-peer reviewed literature such as government reports and unpublished academic dissertations were also reviewed. Data were also obtained from the literature related to general adult psychiatry inpatient units where there was limited information from studies of units designed for older people. Over 200 papers were reviewed and 130 were included.

Results: There are few good quality studies to guide the design of acute PGUs and much of the existing literature is based on opinion and anecdote or, at best, based on observational studies. Randomized controlled studies comparing different designs and assessing outcomes are virtually non-existent. Several studies have identified violence and trauma resulting from hospitalization as significant problems with current acute PGU care. Despite its limitations the available literature provides useful guidance on how PGU design can optimize patient and staff safety and improve clinical outcomes.

Conclusions: There are significant problems with current acute PGUs, and patient mix on existing units is an important issue. Future research should examine patient and staff perceptions of different PGU ward environments, the relationship between ward design and clinical outcomes, the effects of segregating patients with challenging behaviors in dementia and the benefits or otherwise of gender segregation.

Background: The concept of benign senescent forgetfulness (BSF) was introduced in 1958 by V. A. Kral, consultant neuropsychiatrist to the Montreal Hebrew Old People's and Sheltering Home (hereafter the Home). BSF was criticized and mild cognitive impairment (MCI) was adopted years later. In this paper I argue that a notion of MCI also originated with Kral.

Methods: A historical review was undertaken of the Canadian Jewish Congress archives in Montreal, Kral's biography and his publications, as well as relevant literature. A discussion was held with one of Kral's collaborators.

Results: In the mid-1950s the administration of the Home sought research-derived recommendations to improve residents’ conditions. In an initial survey, based on a meticulous neuropsychiatric examination, Kral departed from contemporaneous psychiatric nosology and suggested other criteria in order to classify the home's population. He classified one of the five groups, consisting of subjects with mild memory dysfunction, as having BSF. In his next survey, Kral included psychological tests in addition to clinical assessment and focused on the elderly people who were well preserved (good personal and social functioning). This sample was subdivided into four subgroups, including BSF and incipient amnestic syndrome (IAS). The findings revealed: well-preserved aged people; normal (dull) level of general intelligence; subnormal performance of specific memory and perceptual/organization tests; and no significant signs of malignant amnestic syndrome. This construct is very similar to that of MCI, which is widely used today.

Conclusions: The interaction between Kral and a particular home for the elderly at a particular moment in its history gave rise to the concept of BSF, and a notion of what we now call MCI emerged.

Background: The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).

Method: The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.

Results: An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.

Conclusion: There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.