Professor Wahlund has made a convincing case that structural imaging is not useful as adjunct investigation for all cases of dementia in the primary care situation. In my opinion, no-one has ever suggested that it would or should be. Indeed, there would be insufficient resources to do so and it would be overkill, to say the least. Primary care is not the setting in which brain imaging should be performed and so I agree with Wahlund in this regard. However, following primary care evaluation of a patient with suspected dementia, a referral to a second line setting often occurs. This can happen for a number of reasons, including the need for treatment, and it is here that imaging should always be performed. The first approach then should always be a structural one, not only to exclude the odd case of a primary glioma or subdural hematoma, but to show evidence of medial temporal lobe atrophy, shown by the Swedish SBU to be of high diagnostic accuracy for AD (SBU, 2006). Additionally, vascular changes may be demonstrated, which may prompt the specific treatment of risk factors, or else focal atrophy suggestive of another specific neurodegenerative disorder may be seen (Scheltens et al., 2002; van der Flier and Scheltens, 2005). The recent surprising observation of a relatively high frequency of microbleeds in AD patients (18%) and VaD patients (65%), which may caution the clinician against the use of oral anticoagulation, again underlines the need to perform MRI in demented patients (Cordonnier et al., 2006). The only exception to this would be the sound judgment of the clinician that no nosological diagnosis is warranted in a specific case (usually because of high age, presence of severe dementia and/or extensive comorbidity). It is important to note that, in the case of medial temporal lobe atrophy, however it is measured, there is a tendency for reduced diagnostic utility (reduced specificity) at a higher age, making age specific norms a requirement (van de Pol et al., 2006).

Behavioral disturbances are a frequent feature of Alzheimer's disease (AD) and other dementing disorders. Although this observation has been noted since the beginning of this century, subsequent investigations into dementia have focused primarily on memory and cognitive impairments, with little attention to disturbances in behavior.

There is massive evidence that a healthy lifestyle, especially involvement in active exercise, reduces the risk of cardiovascular disease, diabetes type 2, and obesity (Taylor et al., 2004). There is less strong but nevertheless good evidence that it reduces the risk of depression in the older adult population (Strawbridge et al., 2002). The evidence that it reduces the risk of Alzheimer's disease is contestable (Rolland et al., 2008), but if it reduces vascular disease there can be no argument that it must reduce the risk of vascular dementia.

I am very pleased to be able to introduce the three research papers which have placed first, second and third in the 2011 International Psychogeriatric Association (IPA) Junior Research Awards in Psychogeriatrics. These papers represent the work of three promising young researchers in psychogeriatrics, and both IPA and International Psychogeriatrics are pleased to support such researchers by bringing their research findings to a wide audience.

It is believed that a better understanding of the methods used by older people for suicide may lead to the development of targeted preventative strategies, which are expected to meet the challenge of sustaining this observed decline in suicide rates among older people over time in England and Wales (Lindesay, 1991; Dennis and Lindesay, 1995).

There are various approaches to providing specialist care for patients with delirium in general hospitals. Those described in the literature include joint geriatric/psychiatric units and consultation–liaison (CL) psychiatry services. The Ferdinande Johanna Kanjilal Travelling Fellowship, from the Royal College of Psychiatrists, UK, provided an opportunity to more fully understand each model. This letter outlines observations of the Australian Fellow (AW) of different service structures in the care of hospitalized older people with delirium in the United Kingdom and Ireland.

The paper on predictors of repeat self-harm and suicide by Cheung et al. (2017), which has been chosen by the editorial team as paper of the month for this issue of International Psychogeriatrics, makes a very useful contribution to the study of self-harm and suicide in late life. Of 339 individuals presenting with an index episode of self-harm to one of seven Emergency Departments (EDs) in New Zealand, close to 15% harmed themselves again within one year and for nearly one in six of these 50 people, the repeat episode was fatal. Having alcohol in the blood and already being engaged with mental health services at the time of the index episode both had some utility in predicting the occurrence of a further self-harm episode. While it is encouraging that mental health services look to have been focusing on those who turned out to be at highest risk, clinicians may need to be particularly vigilant when following up individuals who had been drinking alcohol at the time of an initial self-harm presentation. This study also emphasizes the high risk of recurrent self-harm and completed suicide in those older adults who harm themselves and survive the initial episode. It deserves to be widely cited and gives some direction for future research on interventions designed to diminish the recurrence of self-harm in those of our patients who have presented to an ED with an initial self-harm episode.

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.

In his presentation, Dr. Burns discussed attributional style and emotional expressiveness as determinants of a caregiver's response to behavioral and psychological symptoms of dementia (BPSD). Dr. Hendrie asked whether attributional style reflected how caregivers felt not only about the patient's problems, but also about their own. Dr. Burns referred to ratings of relative causality, an indication of whether patients' relatives believed they may have contributed to symptoms in the patient or to their own symptoms, such as depression. However, Dr. Burns's studies did not specifically measure relative causality. Also, neither Dr. Burns nor others have studied attributional style and expressed emotion among paid caregivers, either those in private homes or in long-term care settings.

Concerns increasingly have been raised about the influence of pharmaceutical companies on doctors and their practice of medicine. The pharmaceutical industry has grown in profitability and influence over the past twenty years and is now second only to armaments in the U.S. economy (Public Citizen, 2002). Guidance is available from most Royal Colleges on the appropriateness of using finances/gifts and other benefits from pharmaceutical companies. A declaration of conflict of interest is required for most journals, and evidence shows that there are signs of a small but increasing proportion of articles declaring competing interests in some journals (Hussein and Smith, 2001). Concerns are probably greater in psychiatry, as psychiatric research is particularly susceptible to the influence of vested interests because of the subjective nature of diagnosis and outcome, the variable course of most psychiatric disorders, and the importance of placebo effects, including the context of participating in a research project (Moncrieff et al., 2005).