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.

Personality data gathered in a psychological autopsy study indicate that completed suicides obtain higher neuroticism scores than age- and gender-matched controls. Older suicide victims obtained lower openness to experience (OTE) scores than both younger suicide victims and normal controls. Although the role of neuroticism and negative affect in psychopathology has been discussed extensively, OTE has been accurded relatively little attention in the psychiatric literature. The apparent role of OTE in completed suicide warrants its closer examination. In this article, I offer the testable hypotheses that persons low in OTE are at risk for taking their own lives because their affective dampening, cognitive certainty, diminished behavioral repertoire, and rigidly defined self-concept have decreased their capacity to adapt to the expectable age-associated changes in role, health, and function that accumulate over time. Concrete thinking and excessive focus on proximal, low-level goals place them at risk for descending into states of suicidal meaninglessness in times of stress or crisis. This state of awareness increases the desirability of suicide as an action oriented solution to the stressors of aging. Other lines of investigation are suggested. These include research on OTE in attempted suicide; OTE and the neurobiology of suicidal behavior; OTE and gender differences in suicidal behavior; and clinical intervention designed to increase the degree to which one is open to experience.

Background: Ageism, a form of prejudice in which one relates negatively to people due to their age, exists throughout life. However, no attempt has been made to compare ageist attitudes across the life cycle, from young adulthood to old age. Consequently, the current study examined age and gender differences in ageism throughout adulthood.

Methods: 955 Israeli participants (age range: 18–98 years) were divided into three age-groups: young (18–39), middle-aged (40–67), and old (68–98), and were administered the Fraboni Scale of Ageism. Age and gender differences were examined both for the three groups and for subgroups within the older adult cohort.

Results: Multivariate analysis of variance revealed that middle-aged participants were significantly more ageist than younger and older groups. Across all age groups, men exhibited more avoidance and stereotypical attitudes toward older adults than women. Among the old age group, participants aged 81–98 held more ageist stereotypes and reported more avoidance of older adults than those aged 68–73. Within the older adult cohort, gender was a significant predictor for ageist attitudes among those aged 68–73 and 81–98, but not for people aged 74–80.

Conclusions: Ageism demonstrates a changing pattern across the life span. While gender differences remain stable, ageist attitudes toward growing old as we age ourselves are constantly changing. In order to gain a better understanding of ageism as a general and global phenomenon, we need to consider the role of such attitudes in different stages of life.

Background: There is no previous information about economic costs of Alzheimer's disease (AD) in South America. The objective of this study was to evaluate the costs of AD in Argentina.

Methods: Eighty community-dwelling patients, 20 institutionalized AD patients and their respective primary caregivers, and 25 healthy elderly subjects participated in this study. The cognitive and neuropsychiatric impairments and severity of dementia were assessed with the Mini-mental State Examination, Neuropsychiatric Inventory and Clinical Dementia Rating, respectively. A structured interview about health and health-care resources used during the past 3 months was administered to family caregivers. The time devoted by carers to looking after the patients and the caregiver burden (Zarit's Burden Interview) were recorded.

Results: The annual direct costs of the disease increased with cognitive deterioration from US$3420.40 in mild to US$9657.60 in severe AD, and with institutionalization (US$3189.20 outpatient vs. US$14 447.68 institutionalized). Most direct costs were paid for by the family.

Conclusions: With the projected increase in the number of persons at risk for developing AD in emerging countries, the family cost of the disease will be significant. Dementia costs should be a matter of analysis when health policies are being designed in developing countries.

Background: The goal of this study is to determine patterns of psychotropic drug use (PDU), the association with neuropsychiatric symptoms (NPS), and the variability across dementia types in nursing home residents with dementia. In addition, PDU was analyzed across multiple indications.

Methods: This was a prospective cohort study over a two-year period from 2006 to 2008, which involved 14 dementia special care units in nine nursing homes. A total of 117 residents with dementia participated in the study, of whom 35% had Alzheimer's dementia (AD) and 11% vascular dementia (VaD). PDU was classified according to anatomical therapeutic chemical-classification as either “present” or “absent”.

Results: The majority of residents had moderately severe to severe dementia. At all successive assessments, almost two-thirds of residents received any psychotropic drug (PD) and almost one-third continued to receive any PD. Of all PDs, antipsychotics (APs) were prescribed most frequently. Fewer residents started with antidepressants, but continued to receive antidepressants at higher percentages. Anxiolytics showed an intermittent course, but a subgroup of 9% showed two-year continuation. Once started on PDs at baseline, residents continued to use PDs at high percentages: three-quarters continued to receive APs for at least six months. Half of residents received at least one PD; one-fifth received at least two PDs simultaneously. Residents with AD received more hypnotics and antidementia drugs; residents with VaD received more antipsychotics, antidepressants, anxiolytics and anticonvulsants.

Conclusions: PDs have different utilization patterns, but overall, consistently high continuation rates were found. These results warrant scrutiny of continuous PDU.

Objective: To compare the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein Mini-mental State Examination (MMSE) for diagnosis of dementia in a multicultural cohort of elderly persons.

Methods: A total of 129 community-dwelling persons were selected at random from a database of referrals to an aged-care team. Subjects were stratified according to language background and cognitive diagnosis, and matched for age and gender. The RUDAS and the MMSE were administered to each subject in random order. Within several days, a geriatrician assessed each subject for dementia (DSM-IV criteria) and disease severity (Clinical Dementia Rating Scale). All assessments were carried out independent and blind. The geriatrician also administered the Modified Barthel Index and the Lawton Instrumental Activities of Daily Living Scale, and screened all participants for non-cognitive disorders that might affect instrument scores.

Results: The area under the receiver operating characteristic curve (AUC) for the RUDAS [0.92, 95% confidence interval (95%CI) 0.85–0.96] was similar to the AUC for the MMSE (0.91, 95%CI 0.84–0.95). At the published cut-points (RUDAS < 23/30, MMSE < 25/30), the positive and negative likelihood ratios for the RUDAS were 19.4 and 0.2, and for the MMSE 2.1 and 0.14, respectively. The MMSE, but not the RUDAS, scores were influenced by preferred language (p = 0.015), total years of education (p = 0.016) and gender (p = 0.044).

Conclusions: The RUDAS is at least as accurate as the MMSE, and does not appear to be influenced by language, education or gender. The high positive likelihood ratio for the RUDAS makes it particularly useful for ruling-in disease.

This study was made in an attempt to document the effects of early treatment of poststroke depression (including fluoxetine treatment) on neuropsychological rehabilitation (including cognitive function). Assessment measures used included the Schedule for Affective Disorders and Schizophrenia (SADS) and Research Diagnostic Criteria (RDC), as well as standard measures of severity of depression, functional ability, cognitive function, and neurological function. Thirty-seven patients with poststroke depression, treated with fluoxetine (n = 26) or nortriptyline (n = 11), were compared with 11 poststroke depressed patients who received no depression treatment and 82 poststroke nondepressed patients who received no depression treatment. Our findings about the prevalence of depression (37%), more frequent with anterior lesion (p = .009) and left hemisphere lesion (not statistically significant), tend to confirm previous reports. Early treatment (4th week poststroke) with either fluoxetine or nortriptyline significantly improved the depressed patients' mood, neurological function, functional ability, and cognitive ability. A close relationship between appropriate early treatment (including fluoxetine treatment) of poststroke depression and improved neuropsychological rehabilitation (including cognitive improvement) is suggested by our findings. This is the first report, to our knowledge, of the beneficial effects of early antidepressant treatment on the cognitive function of poststroke depressed patients.

Background: Delirium frequently accompanies acute illness. With treatment of the illness, some individuals recover from delirium while for others the symptoms persist. It is not understood why some individuals improve but others do not. The purpose of this paper is to review systematically what is known about the factors associated with the persistence of delirium.

Methods: A medical literature search was conducted using several bibliographic databases, supplemented by manual searches of the references. English or French studies were included if they compared two groups of delirious individuals in delirium duration or persistence up to six months after the onset of delirium, diagnosed prospectively with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (or a scale derived and validated against the DSM). Information was collected on the association between possible non-therapeutic prognostic variables and delirium persistence.

Results: Twenty-one observational studies were included, in various settings (e.g. mixed medical-surgical, medical or geriatric, surgical, psychiatric, cancer or palliative care units). Variables assessed included patient characteristics (e.g. age, dementia, medical comorbidity, functional status), delirium characteristics (e.g. presence of hypoactive symptoms, delirium severity) and illness characteristics (e.g. severity of illness, and underlying acute illness). Overall, studies suggested that delirium is often persistent at discharge or beyond. Persistence was associated with dementia, increasing numbers of medical conditions, increasing severity of delirium, hypoactive symptoms and hypoxic illnesses.

Conclusions: Preliminary findings suggest that some factors may identify those at risk for persistent delirium; however, more research is needed.

The aim of this study was to compare the performances on each item of the Mini-Mental State Examination (MMSE) of patients with Alzheimer's disease (AD) and multi-infarct dementia (MID). In order to identify the items that could better distinguish the two groups of patients, 70 AD and 31 MID patients matched for disease severity, age, and education were evaluated. The scores of the 101 patients on each of the MMSE items were entered into a principal component factor analysis using varimax rotation, and two main components were derived. Component 1 was probably representative of recently acquired information, whereas component 2 represented educational level. A score summing the items that loaded on component 1 and the recall item was calculated to generate a measure of episodic memory. Performing analysis of variance and covarying for age and education revealed that this score was statistically different in the two groups, with AD patients having lower values. The data suggest that the MMSE may demonstrate a pattern of impairment of memory that differs between AD and MID. Possible explanations of this finding should take into account the different neuroanatomical impairments and the different degrees of motivation, due to depression or attentional deficits, toward external stimuli.

Background: In most European countries the ethnic minority migrant populations are currently reaching an age where dementia becomes an increasingly important issue. There is no European consensus on good clinical practice with these patient groups, who often have special needs and expectations with regard to dementia services.

Methods: A survey was conducted in clinical dementia centers in 15 European countries. Questionnaires focusing on different points in the clinical assessment of dementia in ethnic minority patients were mailed to leading dementia experts of the European Alzheimer's Disease Consortium.

Results: Thirty-six centers from 15 countries responded to the survey. Ethnic minority patients were seen on a regular basis in 69% of these centers. The diagnostic evaluation was in accordance with evidence-based clinical guidelines in 84–100% of the centers, but most centers performed cognitive assessment with instruments that are only validated in Western cultures and frequently relied on family members for interpretation. Diagnostic evaluation of the patients was considered to be challenging in 64% of the centers, mainly because of communication problems and lack of adequate assessment tools. In general, there were few indicators of culturally sensitive dementia services in the centers.

Conclusions: Ethnic minority patients are seen on a regular basis in European dementia clinics. Assessment of such patients is difficult for a number of reasons. Results from this study show that the most challenging issues are communication problems and assessment of cognitive function where there is a need to develop specific tests for ethnic minority patients.

Background: Cerebrovascular disease may cause “vascular depression” (VaD). Calcium-channel blockers are presumed treatments for cerebrovascular disease and might be expected to improve depression and prevent recurrence.

Objective: To examine the efficacy and tolerability of the use of nimodipine as an augmentation of fluoxetine in the treatment of VaD.

Design: A double-blind, randomized clinical trial in which 101 patients with VaD (Alexopoulos criteria) were treated with fluoxetine at standard doses. Patients were randomized to placebo (n=51) or nimodipine (n=50). Treatment outcomes were assessed using the Hamilton Depression Rating Scale (HDRS) regularly up to 8 months after treatment initiation.

Results: Depression was reduced in 63% of patients, but those whose treatment was enhanced with nimodipine had greater improvements overall by repeated measures analysis of covariance (ANCOVA) (F(1.80)=9.76, p=0.001). In addition, a greater proportion of patients treated with fluoxetine–nimodipine (54% vs. 27%) exhibited full remission (χ2(d.f. 1)=7.3, p=0.006), with the number needed to treat (NNT) equal to 4 (95% CI 2–12). Of those experiencing full remission in the first 61 days, fewer patients on fluoxetine–nimodipine (3.7%) developed recurrence of major depression as compared to those on fluoxetine alone (35.7%) (χ2(d.f. 1)=7.56, p=0.006), NNT 3 (95% CI 2–9). Side-effects were noted in 33.3% of patients in the control group and 48% of the experimental group (χ2(d.f. 1)=2.25, p=0.133).

Conclusions: In treating VaD, augmentation of fluoxetine with nimodipine led to better treatment results and lower rates of recurrence. These findings support the argument that augmentation of antidepressant therapy might be helpful in the treatment of cerebrovascular disease, which is involved in the pathogenesis of this type of depression.

Alcohol use and use disorders in older people tend to be hidden and ignored by clinicians and scholars. Resulting misinformation about elderly alcohol problems can be found in such fundamental works as the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Yet, an extensive literature about the nature of geriatric alcohol problems has developed recently. This article reviews that literature, comments on current research at several North American centers, and offers some new information from the author's study of more than 300 older male alcoholics. Many findings remain to be replicated and further verified. Nonetheless, several coherent strands of information seem to be well substantiated: (a) problem drinking in the elderly constitutes a public health problem of moderate proportion, especially in men; (b) most signs predict increasing problem drinking in coming generations of elderly women and men; (c) many cases of geriatric alcoholism have late onset; (d) many geriatric cases are not properly identified; and (e) present screening and diagnostic methods for alcohol use disorders lack adequate validation for older persons.

Background: This paper reviews published literature on the pharmacological and non-pharmacological treatment of inappropriate sexual behavior in dementia.

Methods: A literature search of Psychinfo and Cochrane databases was performed and data from case reports and case series were analyzed.

Results: No randomized controlled trials exist for any treatment of sexual disinhibition in dementia and there are no trials comparing different pharmacological agents. Case reports and case series report a wide range of pharmacotherapies as efficacious in the treatment of inappropriate sexual behaviors in dementia. There is only one case report of non-pharmacological strategies to manage inappropriate sexual behavior.

Conclusions: Inappropriate sexual behaviors in dementia can be difficult to treat. Frequently, multiple psychoactive medications are used and many pharmacotherapies are trialed prior to finding an effective agent. More research is needed to clarify the usefulness of these medications and to identify non-pharmacological strategies to prevent unnecessary use of medications.