The assessment of activities of daily living is a central procedure in the diagnosis of dementia. Few instruments in the field allow for early detection of functional decline because the items they use refer mainly to basic activities of daily living (BADL), which do not become compromised until later in the disease process. The Interview for Deterioration of Daily Living in Dementia (IDDD) may be a valuable tool for early detection of functional decline because it includes, apart from a BADL subscale, another subscale containing a variety of instrumental activities of daily living (IADL), which are the first to be affected in dementing processes. We present an adaptation and validation of the IDDD for Spanish-speaking communities (S-IDDD). A total of 254 control subjects (CONT), 86 patients with mild memory/cognitive impairment with no dementia (CIND), and 111 patients diagnosed with probable dementia of the Alzheimer type (DAT) participated in this project. IDDD total scores (mean and SD) were as follow: CONT: 33.1 (0.4); CIND: 35.2 (3.4); DAT: 54.3 (18.6). The present validation showed no sociodemographic effects on the IDDD total scores. The IDDD demonstrated great internal consistency (α = .985) and reproducibility (intraclass correlation coefficient = .94). Correlations were high (r = .81; p < .1) when they took into account the whole sample, but decreased significantly when the groups were separated by pathologic condition. The scale showed significant differences between DAT versus CIND and CONT. The IADL subscale differentiated all three groups, which makes it extremely valuable for early detection of functional decline. The present study shows that the S-IDDD is a reliable adaptation of the of the original IDDD scale and may be used successfully in Spanish populations for staging and follow-up of subjects with dementia.

Background: Cognitive stimulation, training or rehabilitation can achieve modest, skill-specific gains in cognitively healthy older adults. With regard to the limited efficacy of currently available anti-dementia drugs it is crucial to investigate whether such treatments also provide clinically meaningful benefits to cognitively impaired older individuals.

Methods: We conducted a systematic review of randomized controlled trials evaluating cognition-focused interventions in participants with mild cognitive impairment or dementia. Meta-analytic strategies were used to calculate effect sizes.

Results: Cognition-focused interventions confer small and inconsistent effects on trained cognitive skills which, according to some studies, translate into gains on general cognitive ability. Instruments measuring such effects such as the Mini-Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale, cognitive part (ADAS-Cog) show standardized mean differences of 0.20 and 0.30, respectively, which are comparable with those of current antidementia drug treatments. However, convincing evidence of clinical significance was only obtained from single trials in terms of delay of cognitive decline, improvement in activities of daily living, or enhanced attainment of personally relevant goals.

Conclusions: The potential of cognition-focused interventions has probably been obscured by the methodological inconsistencies and limitations of the clinical studies conducted thus far. Further randomized controlled trials on the efficacy of these treatment modalities are required using optimized and consistent methods. Emphasis should be placed on tailoring interventions to individual needs and resources while maintaining a high level of standardization, on implementing newly acquired skills and strategies in the everyday context, on appropriate treatment duration, and on including person-centered outcomes.

Background: Functional impairment is a core symptom of Alzheimer's disease (AD) often measured by loss of ability to perform activities of daily living (ADL). The objective is to describe the progressive loss of specific ADL functional capabilities expressed by AD patients’ cognitive ability.

Methods: Data are from ELN-AIP-901, an observational study of cognitive progression in participants aged 50–85 with AD (n = 196), mild cognitive impairment (n = 70), or cognitively normal (n = 75). Participants were evaluated using the Mini-Mental Status Exam (MMSE) and the Disability Assessment for Dementia (DAD) every six months for ≤2 years. Hierarchical regression was used to estimate annual change in DAD and MMSE; first, by individuals’ rate of change using linear regression, then controlling for baseline diagnosis.

Results: Over a two-year period, in AD participants, a 1-point change in MMSE was associated with a 3-point change in DAD (2.79, 95% CI: 1.97–3.63); DAD items within the finance, medication, and outings subdomains were impacted earlier than other subdomains; a hierarchy of functional impairment was observed, with instrumental ADL generally impaired prior to basic ADL.

Conclusions: ADL are impacted in a progressive and hierarchical manner associated with cognitive decline, but substantial variability remains among individuals, as well as in the relative order of items affected.

Background:The possibility that low-dose antipsychotic treatment is associated with increased risk of cerebrovascular events (CVEs) in elderly patients with dementia has been raised. The objective was to determine whether risperidone is associated with an increased risk of CVEs relative to other commonly considered alternative treatments.

Methods:An analysis of Medicaid data from 1999 to 2002, representing approxi-mately 8 million enrollees from multiple states, was conducted. The primary outcome was the incidence of acute inpatient admission for a CVE within 3 months following initiation of treatment with atypical antipsychotics (risperidone, olanzapine, quetiapine, or ziprasidone), haloperidol, or benzo-diazepines.

Results:Descriptive analyses found similar rates of incident CVEs across evaluated agents. Multivariate analyses found no differences in comparisons of risperidone with olanzapine or quetiapine. Risperidone and other antipsychotics as a group were also not associated with a higher odds ratio (OR) of incident CVE than either haloperidol or benzodiazepines. With risperidone as the reference group: olanzapine, OR=1.05, 95% CI 0.63–1.73; quetiapine, OR=0.66, 95% CI 0.23–1.87; haloperidol, OR=1.91, 95% CI 1.02–3.60; benzodiazepines, OR=1.97, 95% CI 1.30–2.98. With benzodiazepines as the reference group, the OR of incident CVE for all antipsychotics as a class was 0.49, 95%CI 0.35–0.69.

Conclusions:This study found no significant difference in the incidence of CVEs between patients taking risperidone and those taking other atypical antipsychotics. Risperidone and all atypical antipsychotics were not associated with higher risk than two common treatment alternatives (haloperidol and benzodiazepines). These findings do not support the conclusion that risperidone is associated with a higher risk of CVE than other available treatment alternatives. The data also suggest that patient characteristics other than antipsychotic use are more significant predictors of CVEs. Given the relatively low rates of incident CVEs, a larger sample of patients with groups closely balanced on a wide spectrum of potential risk factors could provide a more precise assessment of risk.

Background: Eating disorders in the elderly are often overlooked. When they occur, significant morbidity and mortality result. In this study we review all existing literature on eating disorders in the elderly and provide practical guidelines for clinicians in recognizing and managing eating disorders in the elderly.

Methods: A literature search using Medline(R), PubMed(R), Web of Knowledge(R), and PsychINFO(R) revealed 48 published cases of eating disorders in people over the age of 50 years.

Results: The mean age was 68.6 years (range 50–94), and the majority (88%) of cases were females. The majority (81%) of cases had anorexia nervosa, and 10% had bulimia nervosa. Late onset eating disorders were more common (69%) than early onset. Comorbid psychiatric conditions existed in 60%, most commonly major depression. Management with a combination of behavioral and pharmacologic interventions was most successful, although only 42% were treated successfully. Mortality was high (21%) secondary to the eating disorder and its complications.

Conclusion: Eating disorders do occur in the elderly and should be included in the differential diagnosis of unexplained weight loss in the elderly.

Background: Knowledge about sleep complaints of caregivers of patients with Alzheimer's disease (AD) and Parkinson's disease (PD) is limited, and we lack information about the relationship between caregivers’ sleep problems and their quality of life (QoL).

Methods: We evaluated subjective sleep quality and its relationship to QoL in a group of 80 caregivers of patients with AD (ADCG, n = 40) and PD (PDCG, n = 40), and in 150 controls. Information about night-time complaints was collected using the Pittsburgh Sleep Quality Index (PSQI). QoL was measured using the McGill QoL Questionnaire.

Results: Eighteen ADCG (45%), 22 PDCG (55%), and 45 (30%) controls reported poor sleep quality. Mean global PSQI score of PDCG (6.25 ± 3.9) was not significantly different from that of ADCG (5.8 ± 3.5; p = 0.67). However, both PDCG and ADCG scored significantly higher than control group (4.3 ± 3.1; p < 0.01). ADCG frequently reported difficulties falling asleep (72.5%) and disturbed sleep (100%). PDCG reported reduced subjective sleep quality (80%) and increased sleep disturbances (100%). Poor sleep quality was associated with depressive symptoms and correlated with QoL in caregivers of both groups, particularly the psychological symptoms domain.

Conclusions: Among caregivers of patients with AD and PD, poor sleep quality is frequent and significantly linked to QoL and depressive symptoms. Identifying the nature of sleep disturbances not only in patients but also in their caregivers is important as appropriate treatment may lead to a better management of the needs of families coping with these patients.

Background: The aging population in prison is growing rapidly in the United Kingdom. This trend is also found in other countries worldwide. As this population increases prison authorities will need to adjust the custody process to accommodate increasing mental and physical frailty.

Methods: This study examined the prevalence of psychiatric disorders and physical disorders, including dementia, in prisoners aged 50 years and over from four prisons in and around Staffordshire to see whether detection and treatment rates have improved over the past decade during which there has been a dramatic increase in the number of older prisoners. Subjects were assessed using the Geriatric Mental State Examination, the Mini-Mental State Examination and Short Form 12 and their prison records.

Results: Sixty prisoners (50%) had a diagnosable mental disorder, with depression being most common, and 15 (12%) prisoners had signs of cognitive impairment. Only 18% of those with a psychiatric diagnosis were prescribed medication from the appropriate class. Physical problems were also common in this population with an average self-report of 2.26 problems per prisoner.

Conclusions: Mental disorders in older prisoners are common, but despite recent training initiatives they often go undetected and untreated. Prisoners themselves accurately self-report mental disorder, but the best way of detecting dementia in the prison population remains unclear. The psychological and physical health of this prison population was poorer than that of their community-based peers.

Dementia with Lewy bodies (DLB) is a common cause of the dementia syndrome. Symptomatic treatment of the fluctuating cognition, visual hallucinations, and sleep distrubance that characterize this condition is challenging; neuroleptics are relatively contraindicated. We describe eight patients fulfilling the consensus diagnostic criteria for probable DLB who were treated with rivastigmine. Clinical features rated were: cognition by the Modified Mini-Mental State Examination (3MS); and behavioral and psychiatric symptoms by the Neuropsychiatric Inventory (NPI). Additional information was obtained from family and nursing reports. Seven patients showed resolution or improvement in cognition and neuropsychiatric symptoms as demonstrated by improvement in their 3MS and NPI scores. They also became more independent in mobility and activities of daily living, and the majority returned to live in their own home. Of the seven patients with sleep disruption, six improved. One case had no improvement in his symptomatology and the rivastigmine was stopped. Outcomes in this case series suggest that rivastigmine is well tolerated in clinical practice.

Background: Unawareness of cognitive deficit in people with dementia (PwD) has wide clinical implications, impacting on help-seeking behavior, treatment compliance, and patient safety. Most studies on unawareness among PwD have been conducted in small clinical samples. This study investigated the frequency of unawareness of memory impairment in dementia, exploring regional differences and sociodemographic and health status correlates in large population-based surveys.

Methods: Community samples (total n = 15,022) from three world regions (Latin America, China, and India) were obtained using cross-sectional population-based surveys. Out of these, 897 (5.97%) PwD with memory impairment were identified using standardized interviews, diagnostic algorithms (DSM-IV or 10/66 criteria), and neuropsychological memory assessment. Unawareness of memory deficits was ascertained from the participants’ subjective report. The frequency of unawareness was calculated for each region and associations with demographic variables and health status were investigated using prevalence ratios and Poisson regressions.

Results: Regional differences in frequency of unawareness were found, from 63% in China to 81% in India. Unawareness was associated with depression in China and Latin America, dementia severity in India and Latin America, and education and socioeconomic level in Latin America.

Conclusions: Unawareness of memory impairment in PwD varies across international regions. Our data support the notion that unawareness should be seen not only as a common neurobiological feature of dementia, increasing with severity of dementia, but also as a phenomenon influenced by social and cultural factors.

Background: The aim of the study was to determine the amount of trauma impact, post-traumatic stress symptoms and current psychopathological distress in a sample of former German children of World War II.

Methods: 93 participants were recruited through the local press, and assessed using the modified Post-traumatic Diagnostic Scale (PDS) and the Symptom Checklist (SCL-90-R).

Results: Subjects reported a high qualitative and quantitative degree of trauma exposure. 13.8% reported PTSD-related symptoms after the war, and 10.8% reported current symptoms. PTSD symptoms after World War II were significantly correlated with current psychopathological distress.

Conclusions: In line with other studies, our data document a high degree of trauma exposure during warchildhood. In comparison with other studies on PTSD in warchildren, there is a persisting high prevalence of war-associated PTSD symptoms in this sample. Despite some methodological limitations, our data underline the urgent need for further studies on the ageing group of former children of World War II.

Neuroplasticity, the ability of synapses to undergo structural adaptations in response to functional demand or dysfunctions is increasingly impaired in aging and Alzheimer's disease. EGb761® has been shown in several preclinical reports to increase nearly all aspects of impaired neuroplasticity (long-term potentiation, spine density, neuritogenesis, neurogenesis). While all three fractions of constituents (ginkgolides, flavonoids, bilobalide) seem to be active, the flavonoids and specifically the aglycone isorhamnetin seem to be most relevant.

The aim of this study was to identify factors associated with vocally disruptive behavior (VDB) in nursing home patients referred to aged care services for treatment, using a case-control methodology. Characteristics of the VDB, reasons for referral, perceived causal factors, and psychotropic use were noted. Twenty-five subjects and controls were examined with the Screaming Behavior Mapping Instrument, the Cornell Scale for Depression in Dementia, the Dementia Behavior Disturbance Scale, and measures of cognition, functional capacity, social activities, and emotional reactions of nursing staff. VDB was associated with other disturbed behaviors, depression, anxiety, severe dementia, functional impairment, communication difficulties, use of psychotropic medication, social isolation, and emotional distress in the nursing staff. Reasons for referral may relate more to the stress experienced by nursing home staff in managing VDB than to specific attributes of the VDB itself.

Background: Admission to a nursing home might challenge the way in which individuals experience their own sexuality, but it does not automatically diminish their need and desire for sexual fulfillment. Despite the fact that sexuality proves to be an intrinsic part of human existence, the sexual expression of geriatric residents remains a sensitive subject for many caregivers and family members. It evokes a variety of ethical issues and concerns, especially when dementia patients are involved. The overall objective of this review was to examine the ethical arguments and concepts about the debate on sexuality within a nursing home environment.

Methods: We conducted a systematic search for argument-based ethics literature focusing on sexuality in institutionalized elderly people. Twenty-five appropriate studies were identified.

Results: A thematic analysis of the included literature led us to distinguish two major groups of ethical arguments: (i) principles and (ii) care. Ethics arguments on sexuality in institutionalized elderly are particularly guided by the principle of respect for autonomy and the concomitant notion of informed consent. Arguments related to care were also apparent within the research literature although they received considerably less attention than the arguments related to the principles of respect for autonomy, beneficence, nonmaleficence and justice.

Conclusions: The lack of clarity in the conceptualization of the arguments referred to in the research literature indicates that there is a pressing need for a better defined, more fundamental philosophical-ethical analysis of the values at stake.