Background: Many older patients have difficulty in swallowing their tablets and capsules. Dose form modification, by crushing tablets or opening capsules, is often used by nurses to administer such medication.

Methods: Electronic searches of five literature databases on tablet crushing and capsule opening were carried out. A review of medication incident reports involving tablet crushing from the U.K. National Reporting and Learning System (NRLS) was also undertaken. An observational study of medication administration on two long-stay wards for older mentally ill inpatients was carried out in a large psychiatric hospital.

Results: Only 17 incidents involving tablet crushing were reported to NRLS in 13 months. In the observational study, the administration of 1257 oral doses of medication at 36 medication rounds was observed. Tablets were crushed or capsules opened for 25.5% (266/1045) of solid oral doses. For 44.0% (117/266) of these doses the tablet crushing had not been authorized by the prescriber. For 4.5% (12/266) of doses crushing was specifically contra-indicated by the manufacturer. In 57.5% (153/266) of doses, tablet crushing was avoidable by the correct use of more suitable preparations. Crushing caused contamination, spillage and hygiene problems.

Conclusions: Although tablet crushing and capsule opening are common practices, they are rarely reported as causing patient harm. Tablet crushing can often be avoided by the use of more suitable preparations. Crushing tablets and opening capsules are contra-indicated for some preparations. Older patients' medication may benefit from review by a pharmacist in order to optimize safe medication administration. Where tablet crushing is unavoidable, attention to cleanliness, contamination and spillage are necessary.

This study examined the quality of emotional responsivity in mid-to late-stage dementia patients. Eighty-two nursing home patients with a DSM-III-R diagnosis of primary degenerative dementia of the Alzheimer type served as subjects. Patients were staged using the Global Deterioration Scale. The level and type of patient affectivity were assessed by family reports, aide reports, and direct observation and coding of patient facial expressions during a family visit. All three measures indicated that patients with Alzheimer's disease expressed a range of affective signals. Some showed an intact and functional emotion system even during the last stage of the disease; one third of end-stage dementia patients expressed sadness at the departure of their relatives as coded by an objective facial affect coding system.

Objective: To determine the attitudes of patients with mild dementia and their carers towards the disclosure of diagnoses of cancer and dementia and whether there are differences between these groups. To determine whether any major adverse events occurred following disclosure of diagnosis of dementia. Design: A prospective study followed by a retrospective case-note study after 1 year. Participants and Setting: Fifty patients with mild dementia and their carers were recruited from a memory clinic in Nottingham, UK, and an old-age psychiatrist, using a semistructured questionnaire, separately interviewed them. Measures: Questions related to whether patients and their carers wished to be told diagnoses of cancer and dementia; the reasons for this; whether they would want treatment and make use of predictive testing if available were included. At 1-year follow-up whether antidepressants had been prescribed and whether any catastrophic reaction had occurred following disclosure of diagnosis. Results: An overwhelming majority of patients with mild dementia wished to be informed of their diagnosis (92%); even more (98%) of the same patient sample reported wanting disclosure of a hypothetical diagnosis of cancer. A higher proportion (98%) of carers would wish to be told if they were to develop either dementia or cancer. All patients and carers would like access to treatment for dementia. A total of 88% of patients and 86% of carers would make use of a predictive test of Alzheimer's disease. Before receiving a diagnosis of mild dementia, only 28% of patients had insight that they may have dementia. Only a quarter (26%) of carers did not want the doctor to disclose the diagnosis of dementia to the patient. After 1 year, 6% of the original sample had developed a depressive illness requiring antidepressant treatment and no major incidents had occurred following disclosure of diagnosis. Conclusions: There has been a growing debate on whether patients with dementia should be informed of their diagnosis. Until recently, little was known about the views of patients themselves. This study shows that the vast majority of patients with mild dementia wish to be fully informed. Despite increasing awareness, a quarter of carers still do not wish their relative to be informed, though wish to be informed if they themselves were to develop the illness. This is significantly lower, however, than previously reported, suggesting a shift in attitudes. This study adds support to the weight of evidence that disclosure of a diagnosis of dementia does not cause depression or any irreversible harm to the patient.

Background: Although social network relationships are linked to mental health in late life, it is still unclear whether it is the structure of social networks or their perceived quality that matters.

Methods: The current study regressed a dichotomous 8-item version of the Center for Epidemiological Studies Depression Scale (CESD-8) score on measures of social network relationships among Americans, aged 65–85 years, from the first wave of the National Social Life, Health and Aging Project. The network indicators included a structural variable – social network type – and a series of relationship quality indicators: perceived positive and negative ties with family, friends and spouse/ partner. Multivariate logistic regression analyses controlled for age, gender, education, income, race/ethnicity, religious affiliation, functional health and physical health.

Results: The perceived social network quality variables were unrelated to the presence of a high level of depressive symptoms, but social network type maintained an association with this mental health outcome even after controlling for confounders. Respondents embedded in resourceful social network types in terms of social capital – “diverse,” “friend” and “congregant” networks – reported less presence of depressive symptoms, to varying degrees.

Conclusions: The results show that the structure of the network seems to matter more than the perceived quality of the ties as an indicator of depressive symptoms. Moreover, the composite network type variable stands out in capturing the differences in mental state. The construct of network type should be incorporated in mental health screening among older people who reside in the community. One's social network type can be an important initial indicator that one is at risk.

Background: Neuropsychiatric symptoms in dementia patients are common and are often treated with psychotropic drugs. The aim of this study was to determine the prevalence and correlates of psychotropic drug use in Dutch nursing home patients with dementia.

Methods: Psychotropic drug use of 1322 patients on 59 dementia special care units (SCUs) in 25 nursing homes was registered. Drugs were categorized according to the Anatomical Therapeutical Chemical classification (ATC). The influence of age, gender, dementia stage measured by the Global Deterioration Scale (GDS), and type of neuropsychiatric symptoms on psychotropic drug use was analyzed using binomial logistic regression analysis.

Results: 63% of the patients used at least one psychotropic drug. Psychotropics in general and antipsychotics in particular were most frequently prescribed in GDS stage 6, and in patients aged between 65 and 75 years. Psychotropics in general were positively associated with depression, night-time behavior and agitation. Antipsychotic drug use was positively associated with psychosis, agitation and night-time behavior and was negatively associated with apathy. Anxiolytics were associated with age, psychosis, agitation and night-time behavior. Antidepressants were most frequently prescribed in GDS stage 6 and associated with female gender, agitation and depression. Sedatives were only associated with night-time behavior.

Conclusion: Nursing home patients with dementia have a high prevalence of psychotropic drug use. In particular, the association with neuropsychiatric symptoms raises questions of efficacy of these drugs and the risk of chronic use.

Background: Behavioral and psychological symptoms of dementia (BPSD) are a source of distress and burden for caregivers. This study attempts to determine the neuropsychiatric symptoms, demographic characteristics, and referral patterns of outpatients with dementia compared with patients admitted to the acute psychogeriatric wards of Woodbridge Hospital. We also assessed the impact of neuropsychiatric symptoms on distress in family and professional caregivers.

Method: Eighty-five consecutive patients with a first-time diagnosis of dementia were recruited. They were assessed using the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D). The professional caregiver distress questions were rephrased to assess the “occupational disruptiveness” of behaviors in the nursing home version (NPI-NH).

Results: Neuropsychiatric symptoms were common and were positively correlated with caregiver distress. Family caregivers were significantly more distressed than professional caregivers over the delusion, agitation, depression and aberrant motor domains, although the severity of the behavioral disturbances reported was not higher in the sample. The median NPI scores for the agitation and disinhibition domains were significantly higher in the inpatient group, contrasting with a higher score for the depression domain among the outpatient group.

Conclusions: This study highlights the prevalence of neuropsychiatric symptoms in dementia and illustrates the strong correlation between the severity of behavioral disturbances and caregiver distress.

Background: Increasingly more attention has been paid to non-pharmacological interventions as treatment of agitated behaviors that accompany dementia. The aim of the current study is to test if personalized one-to-one interaction activities based on Montessori principles will improve agitation, affect, and engagement more than a relevant control condition.

Methods: We conducted a randomized crossover trial in nine residential facilities in metropolitan Melbourne, Australia (n = 44). Personalized one-to-one activities that were delivered using Montessori principles were compared with a non-personalized activity to control for the non-specific benefits of one-to-one interaction. Participants were observed 30 minutes before, during, and after the sessions. The presence or absence of a selected physically non-aggressive behavior was noted in every minute, together with the predominant type of affect and engagement.

Results: Behavior counts fell considerably during both the Montessori and control sessions relative to beforehand. During Montessori activities, the amount of time spend actively engaged was double compared to during the control condition and participants displayed more positive affect and interest as well. Participants with no fluency in English (all from non-English speaking backgrounds) showed a significantly larger reduction in agitation during the Montessori than control sessions.

Conclusion: Our results show that even non-personalized social contact can assist in settling agitated residents. Tailoring activities to residents’ needs and capabilities elicit more positive interactions and are especially suitable for people who have lost fluency in the language spoken predominantly in their residential facility. Future studies could explore implementation by family members and volunteers to avoid demands on facilities’ resources.

Trial Registration: Australian New Zealand Clinical Trials Registry – ACTRN12609000564257.

Background: There is inadequate information regarding the neuropsychiatric aspect of Mild Cognitive Impairment (MCI).

Objective: To determine the neuropsychiatric profile of MCI, and compare this with normal controls and patients with mild Alzheimer's Disease (AD).

Design: Cross-sectional assessment of psychiatric symptoms in subjects that are enrolled in Mayo Clinic's longitudinal study of normal aging, MCI and dementia.

Methods and Participants: The Neuropsychiatric Inventory (NPI) was administered to normal control subjects, MCI subjects and patients with early AD. Individual NPI domain scores and total NPI scores were compared among the three groups after controlling for age, educational status, Dementia Rating Scale (DRS) and Mini-Mental State Examination (MMSE) scores. Statistical analysis was performed by utilizing ANOVA, χ2 and Fisher's exact test.

Results: Data were analyzed on 514 normal controls, 54 MCI subjects, and 87 subjects with mild AD (CDR of 0.5 or 1); females consisted of 60.3%, 53.7% and 57.5%; and, the average ages (SD) were 77.8 (1.95), 79 (4.6), 80.5 (14.6) respectively. ANOVA pair-wise comparison revealed that both MMSE and DRS differences among the three groups were significantly different at (p=0.05). The total NPI scores were significantly different (p=0.0001, F=107.93) among the three groups using ANOVA. Pair-wise comparison of individual behavioral domain of NPI showed statistically significant differences between MCI and normals; and MCI and AD (p=0.001). Group differences on NPI remained after controlling for age and education at p=0.0375 and p=0.0050 respectively.

Conclusion: The neuropsychiatric pattern is reminiscent of the clinical, neuroimaging and neuropsychological profile of MCI. It gives further credence to the view that MCI is indeed the gray zone, with overlap on both ends of the pole.

Objectives: To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of psychotropic medications to these patients.

Methods: 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient.

Results: Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used.

Conclusion: Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.

Background: This paper provides an overview of the findings from the dementia module of the 2010 Northern Ireland Life and Times (NILT) Survey: an annual survey recording public attitudes to major social policy issues. Northern Ireland, in line with many other developed countries, recently released a Dementia Strategy. The opportunity to explore the knowledge and attitudes of the general public to dementia at a national level in Northern Ireland is timely and valuable. This paper reports on an initial exploration of these attitudes, based on bivariate analysis across demographic groups.

Methods: Data were analyzed using SPSS (Version 19). Descriptive and summary statistics were produced. A series of categorical bivariate relationships were tested (chi-square) and tests of association (Cramer's V) were reported. We discuss both knowledge-related findings and attitudinal findings.

Results: We found that the general public in Northern Ireland have a reasonably good level of knowledge about dementia. However, attitudinal measures indicate the stereotyping and infantilization of people with dementia.

Conclusions: This NILT module provides a unique source of data on attitudes to, and knowledge of, dementia. A key strength is that it provides statistically representative data with national level coverage. This information can be used to target public health education policies more effectively and to inform delivery of health and social services. The success of the module leads us to believe that it stands as a blue-print for collecting information on dementia in other social surveys.

Background: The results of studies of the association between awareness and clinical correlates in patients with dementia are inconclusive. The aims of this study were to investigate whether awareness changed during the course of dementia and to determine whether awareness was associated with certain behavioral symptoms. Specifically, it was hypothesized that relatively intact awareness was related to affective disorders.

Methods: One hundred and ninety-nine patients with dementia were included in a prospective 18-month follow-up study. Behavioral problems were assessed with the Neuropsychiatric Inventory and the Cornell Scale for Depression in Dementia. Awareness was assessed by means of the Guidelines for the Rating of Awareness Deficits.

Results: Cross-sectional analyses showed awareness to be positively associated with age, gender, education and socioeconomic status, and negatively associated with psychosis, apathy, and overall behavioral disorders at baseline. After 1 year, a higher level of awareness was related to depression and anxiety. The level of awareness at baseline also predicted depression and anxiety after 1 year. Awareness decreased during the study.

Conclusions: A higher level of awareness is associated with subsyndromal depression and anxiety, whereas lack of awareness is associated with psychosis and apathy. The level of awareness decreases as dementia progresses. Clinicians should be more alert to changes in awareness in patients with dementia because psychosocial support might help to prevent the development of affective symptoms.

This paper provides a review of research issues and findings on the epidemiology of delirium. Despite the fact that research on this important geriatric syndrome has been conducted for many decades, several methodological issues make it difficult to compare findings across studies. In this paper we first discuss broadly methodological issues related to diagnosis, case-finding, and populations studied. We next review data on the occurrence and consequences of the syndrome. A discussion of the design and preliminary results of the Commonwealth-Harvard Study of Delirium in Elderly Hospitalized Patients documents both how we responded to the methodological issues outlined and how these choices influenced our findings. We conclude with a discussion of the needs for further research on the epidemiology of delirium.

Background: People with dementia in care homes are at risk of having their views ignored and decisions are often made on their behalf by care home staff and family carers. The aim of this study was to compare the ratings of needs of older people with dementia living in care homes, as assessed by the older person themselves, a family caregiver, and the staff of the care home.

Method: The Camberwell Assessment of Need for the Elderly (CANE) was completed for 238 residents with dementia by care staff. In addition, 149 users and 81 family caregivers also completed the assessment of the person's met and unmet needs.

Results: Many users were able to report their met and unmet needs despite having moderately severe dementia. The views of the person with dementia were commonly in agreement with the staff and family carers' views. However, user and carer pairs had the lowest average percentage agreement of 63% compared to that of 77% between user and staff pairs. In particular, users reported relatively higher unmet needs for psychological distress, company and information, and high unmet needs for daytime activities and eyesight/hearing problems.

Conclusions: Users' views on their needs should be sought even when the person has dementia and lives in a care home. Reliance solely on assessment by staff or carers may lead to under recognition of unmet needs.

Background/literature review: The prevalence of agitated behaviors in different populations with dementia is between 24% and 98%. Although agitated behaviors are potentially disruptive, little research attention has been focused on the effects of these behaviors upon nursing staff. The objectives of this study of demented patients in long-term-care beds at an acute care community hospital were to determine the frequency and disruptiveness of agitated behaviors; to investigate the associations of patient characteristics and interventions with the level of agitation; and to explore the burden of these agitated behaviors on nursing staff. Method: The study sample comprised 56 demented patients in the long-term-care unit during the study period. Twenty-seven staff who cared for these patients during three shifts over a 2-week period were interviewed to rate the frequency and disruptiveness of agitated behaviors using the Cohen-Mansfield Agitation Inventory, and the burden of care using a modified version of the Zarit Burden Interview. Data on patient characteristics and interventions extracted from the hospital chart included scores on the Barthel Index and Mini-Mental State Examination, the use of psychotropic medication, and the use of physical restraints. Results: Ninety-five percent of the patients with dementia were reported to have at least one agitated behavior; 75% had at least one moderately disruptive behavior. A small group of six patients (11%) had 17 or more disruptive behaviors. The frequency of most behaviors did not vary significantly by shift. Length of stay on long-term care, Barthel Index score, and the use of psychotropic medications were significantly associated with the number of agitated behaviors. The number of behaviors, their mean frequency, and their mean disruptiveness were all significantly correlated with staff burden. Discussion: The prevalence of agitated behaviors in patients with dementia in long-term-care beds at an acute care hospital is similar to that reported in long-term-care facilities. These behaviors are associated with staff burden.

Background: Frailty in older adults is a multifactorial syndrome defined by low metabolic reserve, less resistance to stressors, and difficulty in maintaining organic homeostasis due to cumulative decline of multiple physiological systems. The relationship between frailty and cognition remains unclear and studies about Mini-Mental State Examination (MMSE) performance and frailty are scarce. The objective was to examine the association between frailty and cognitive functioning as assessed by the MMSE and its subdomains.

Methods: A cross-sectional population-based study (FIBRA) was carried out in Ermelino Matarazzo, a poor subdistrict of the city of São Paulo, Brazil. Participants were 384 community dwelling older adults, 65 years and older who completed the MMSE and a protocol to assess frailty criteria as described in the Cardiovascular Health Study (CHS).

Results: Frail older adults had significantly worse performance on the MMSE (p < 0.001 for total score). Linear regression analyses showed that the MMSE total score was influenced by age (p < 0.001), education (p < 0.001), family income (p < 0.001), and frailty status (p < 0.036). Being frail was associated more significantly with worse scores in Time Orientation (p < 0.004) and Immediate Memory (p < 0.001).

Conclusions: Our data suggest that being frail is associated with worse cognitive performance, as assessed by the MMSE. It is recommended that the assessment of frail older adults should include the investigation of their cognitive status.