Background: The majority of people in the early and middle stages of dementia are cared for at home by non-paid caregivers, the majority of whom will be family members. Two factors which could have an impact on the quality of care provided to the care-recipient are the caregiver's motivations for providing care and the meaning s/he finds in caregiving. The aim of this review is to explore the potential impact of both meaning and motivation on the wellbeing of caregivers of people with dementia. The review also explores individual differences in motivations to provide care.

Methods: This was a systematic review of peer-reviewed empirical studies exploring motivations and meanings in informal caregivers of people with dementia. Four studies were identified which examined the caregiver's motivations to provide care. Six studies were identified which examined the meaning that caregivers found in dementia caregiving.

Results: Caregivers' wellbeing could be influenced by the nature of their motivations to care. In addition, cultural norms and caregivers’ kin-relationship to the care-recipient impacted on motivations to provide care. Finding meaning had a positive impact on caregiver wellbeing.

Conclusions: The limited evidence currently available indicates that both the caregiver's motivations to provide care and the meaning s/he finds in caregiving can have implications for the caregiver's wellbeing. More research is needed to explore the role of motivations and meaning in dementia caregiving.

This article reports the findings of a 3-year epidemiological survey for dementia in an urban community-resident population in Mumbai (Bombay), India, wherein the prevalence of all types of dementia was determined. Method: The study was conducted in three stages. Stage 1: From a potential pool of 30,000 subjects aged 40 years or more, 24,488 (male = 11,875; female = 12,613) persons completed self-report or interviewer-rated protocols based on the Sandoz Clinical Assessment Geriatric Scale, but 5,512 (18.37%) persons refused to participate. Scores on the protocol had a possible range from 0 through 34. Stage 2: Persons with a score +2SD above the mean were selected in this stage where the persons were screened for cognitive functioning using a modified and translated version of the Mini-Mental State Examination. Individuals who scored below the 5th percentile were included in Stage 3 and underwent a detailed neurological, psychiatric, and neuropsychological evaluation as well as hematological, radiological, electrocardiographic, and electroencephalographic investigations. Diagnoses were made jointly by a neurologist, psychiatrist, and psychologist using the DSM-IV diagnostic criteria. Subjects were also rated on the Clinical Dementia Rating (CDR) scale and assessed for activities of daily living. Results: One hundred five subjects with dementia (CDR ≥ 0.5) were identified in this population of 24,488 persons. The prevalence rate for dementia in those aged 40 years and more was 0.43% and for persons aged 65 and above was 2.44%. Seventy-eight individuals had a CDR of ≥ 1 yielding an overall prevalence rate of 0.32%, and a prevalence rate of 1.81% for those aged 65 years and older. The overall prevalence rate for Alzheimer's disease (AD) in the population was 0.25%, and 1.5% for those aged 65 years and above. AD (n = 62;65%) was the most common cause of dementia followed by vascular dementia (n = 23;22%). There were more women (n = 38) than men (n = 24) in the AD group. Increasing age was associated with a higher prevalence of the dementia syndrome in general as well as AD specifically. Conclusion: In the population surveyed, the prevalence of AD and other dementias is less than that reported from developed countries but similar to results of other studies in India. Prevalence of the dementia syndrome increased with age and was not related to gender. AD was the most common dementia and the prevalence was higher in women than in men. Results are discussed with respect to shorter life expectancy, relocation of affected persons, and differences in the risk factors as compared to developed countries.

Background: This study aims to develop and validate a Chinese translation of the 6-item De Jong Gierveld Loneliness Scale – a widely used instrument to measure loneliness – specifically determining its psychometric properties in community-dwelling Chinese elders in Hong Kong. The relationships between loneliness and several clinical variables are also assessed.

Method: The English version was translated into Chinese. Content validity was established by group discussion and Delphi panel. The questionnaire was administered to 103 Hong Kong Chinese community-dwelling elders. Statistical analysis was performed to test the reliability and validity of the scale.

Results: The content validity was high as shown by the results of the Delphi panel. Cronbach's α of the 6-item scale was 0.76. For the inter-rater reliability of the six items, the intra-class correlation coefficients ranged from 0.98 to 1.00. The emotional loneliness subscale significantly correlated with the social loneliness subscale (ρ = 0.37; p < 0.001). In using a direct question to measure loneliness, 21 participants (20%) reported that they were lonely. The overall loneliness scale score significantly correlated with the answers on the direct question of loneliness (rpb = 0.71; p < 0.001). The overall loneliness score showed significant correlation with Cornell Scale for Depression in Dementia (ρ = 0.29; p = 0.003), current smoking status (rpb = 0.24; p = 0.014), and some objective social characteristics.

Conclusion: The Chinese version of the 6-item De Jong Gierveld Loneliness Scale is a reliable and valid measure of loneliness in Chinese elders.

The purpose of this study was to examine the Geriatric Depression Scale (GDS) translated into Turkish for its reliability, discriminant validity, and factor structure in a sample of 276 community-dwelling elderly and 30 patients with major depression. One item (Item 5) was discovered to have conceptual difficulty for Turkish elderly and was transformed to negative form. Item 2 was transformed to positive form to keep the number of positive and negative items equal to that in the original GDS. A reasonable time stability with 1-week interval (r:.74) and a high level of internal consistency (α = .91) were observed. Student's t test resulted in a significant discriminant validity for the scale total score. Factor study with principal component analysis and varimax rotation gave rise to a structure with seven factors. Results of the same analysis with two factors were found to be easier to interpret. The first factor was composed of 19 items reflecting “depressive affect and thought content.” The other 11 items representing “decrease in motivation and cognitive functions” loaded in the second factor. In conclusion, the Turkish GDS was found to have reasonable time reliability, high internal consistency, and discriminant validity for Turkish elderly. Its two-factor structure can be used as an informative instrument for epidemiological studies, reflecting two main dimensions of depression in the elderly.

Background: Suicide rates generally increase with age. With the emergence of studies from several countries without an increase in suicides rates with aging, a cross-national study examining the relationship between suicide rates and age was undertaken.

Methods: The relationship between suicide rates and age was examined by ascertaining suicide rates in both sexes in seven age-bands 16–24 years, 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years and 75+ years, from the World Health Organization website for all the listed countries (N = 62).

Results: The main findings were: (i) there was a significant increase in suicide rates with increasing age in males and females in 25 and 27 countries respectively; (ii) there was no significant increase in suicide rates with increasing age in males and females in 31 and 29 countries respectively; (iii) suicide rates were the highest in the younger age-bands in countries without a significant increase in male suicides rates with increasing age; (iv) countries without a significant increase in the suicide rate with increasing age in both sexes, females only and males only demonstrated regional clustering; and, (v) in a small number of countries suicide rates declined with increasing age.

Conclusions: Potential explanations for regional and cross-national variations in the relationship between suicide rates and age require further study.

Background: We reviewed studies of in-service interventions for caregivers of persons with dementia in nursing homes published between 1990 and 2004. The aim was to obtain an overview of the evaluated interventions and to characterize their methodological quality.

Methods: A thorough literature search was conducted, including searching electronic databases for selected intervention studies and previous reviews. Selected studies were summarized and compared along certain categories, and methodological quality was assessed.

Results: A total of 21 studies were identified, mostly published in the United States. Most were of poor methodological quality. Although nearly all reported positive effects, their results must be interpreted cautiously due to methodological weaknesses. Extensive interventions with ongoing support successfully demonstrated sustained implementation of new knowledge. Owing to methodological weaknesses and a lack of follow-up evaluations, little or no evidence existed for the efficacy or, particularly, the transfer of knowledge in simpler interventions when reinforcing and enabling factors were not present.

Conclusion: On an international and, particularly, on a national level a lack of evaluated in-service training programs for caregivers in homes for people with dementia is apparent. Methodological weakness is common. This study highlights the need for well-defined methodologically improved studies, providing conclusive evidence of the effects of intervention types to help improve the quality of dementia care.

Depression in the geriatric population is a frequents, serious, and potentially reversible disorder, yet relatively few blinded, controlled, antidepressant trial have been reported. A number of age-related issues complicate safe and effective pharmacotherapy. In a 6-week, double-blind trial in moderately to severely depressed (nonpsychotic) outpatients over age 60, fluoxetine (N = 335) was statistically significantly more efficacious than placebo (N = 336) in overall response (43.9% vs. 31.6%, p = .002) and remission (31.6% vs. 18.6%, p < .001) rates. Analyses of early discontinuations because of an adverse drug event revealed no statistically significantly greater rate with fluoxetine (n = 39; 11.6%) than was seen with placebo (n = 29; 8.6%). These results corroborate that major depression in an older population is responsive to antidepressant pharmacotherapy. Specifically, fluoxetine, at a conventional 20-mg dose, was both safe and effective relative to placebo in this special population.

Background: The aim of this study was to determine levels, rates and progression of apathy in healthy older persons and to investigate factors associated with its progression.

Methods: Seventy-six healthy elderly subjects, aged 58–85 years (mean 69.9), who were recruited by general advertisement and through local community groups, participated as a control group for a longitudinal study of stroke patients. Data were collected on demographic, psychological, neuropsychological and neuroimaging (MRI) variables and apathy was rated by informants on the Apathy Evaluation Scale (AES).

Results: Apathy scores and rates increased over 5 years, especially in men. Change of apathy was associated with informant ratings of cognitive decline in the years prior to baseline assessment but not to subsequent neuropsychological, neuroimaging or functional changes.

Conclusions: Apathy increases with age in otherwise healthy community-dwelling individuals, particularly in men.

Background: A recent Cochrane report concluded that more and better quality research is required to investigate the effectiveness of music therapy in reducing problems in behavioral, social, emotional and cognitive domains in patients with dementia. This randomized placebo-controlled trial with blinded observer rater aimed to explore whether music, live or pre-recorded, is effective in the treatment of apathy in subjects with moderate to severe dementia.

Methods: Thirty-two subjects meeting ICD-10 diagnostic criteria for moderate to severe dementia and fulfilling diagnostic criteria for apathy were exposed to live interactive music, passive pre-recorded music or silence for 30 minutes. Each subject was randomized to 30-minute music or silent periods and was video recorded and the muted recording analyzed every 3 minutes using dementia care mapping to assess the quality of engagement to the blinded music intervention.

Results: Compared to low baseline levels of positive engagement (12.5%) in the silent placebo period, the majority of subjects (69%), regardless of dementia severity, showed a significant and positive engagement to live music. Engagement to pre-recorded music was non-significant, with just 25% of all subjects showing positive engagement. No subjects showed any evidence of experiencing a state of ill-being during either the live or pre-recorded music sessions.

Conclusions: During the intervention, live interactive music has immediate and positive engagement effects in dementia subjects with apathy, regardless of the severity of their dementia. Pre-recorded music is non-harmful but less clearly beneficial.

Background: There is a paucity of past research concerning longitudinal changes in loneliness in old age and in the factors that correlate with loneliness in older persons. This study examines (a) whether loneliness increases with age, (b) characteristics of the lonely older population, and (c) predictors of becoming lonely in old age.

Methods: Data are from the Cross-Sectional and Longitudinal Aging Study, a national longitudinal study on the health, mental, and social status of people aged 75 and older living in Israel. Loneliness was measured as the frequency at which participants had felt lonely during the last month (range: 0–3). The analysis included two waves of data, with an average gap of 3.5 years between them, with 1147 participants at wave 1 and 588 participants at wave 2.

Results: Data showed an increase in the mean level of loneliness over time, rising from 0.62 to 0.80, p<0.001. The strongest correlate of being lonely at wave 1 was unmarried status. Different variables predicted loneliness in the married and the unmarried. Among the married, lonelier persons tended to have experienced more traumatic events, had more doctor's visits, and manifested less cognitive vitality. In contrast, among the unmarried, loneliness was higher in those with financial difficulties, poor health, and less social network support. The longitudinal transition to becoming lonely was more likely in women, those with insufficient financial resources, and people with poorer health.

Conclusions: Results highlight the following implications for the development of preventive programs: (a) helping older persons maintain and develop social networks for preventing increased loneliness, (b) taking demographic factors, health factors, and previous trauma into account when designing interventions, and (c) targeting unmarried women for interventions.

This article presents the epidemiology of suicide with a special focus on suicides among the elderly, and discusses the known risk factors for suicide within a framework designed to encourage a systematic approach to theory testing and prevention. Throughout the world, suicide rates are highest among the elderly. The risk factors for suicide can be classified as distal or proximal, and, within these broad categories, as sociodemographic, psychiatric, biological, familial, and situational. Mental and addictive disorders are the major risk factors for suicide in all age groups. Other risk factors include male gender, disrupted marital status, prior suicide attempt, reduced brain stem serotonergic activity, family history of psychiatric disorder or suicide, a firearm in the home, and a recent, severely stressful life event. Since risk factors for suicide rarely occur in isolation, prevention efforts are more likely to succeed if multiple risk factors are targeted.

Depression is the most prevalent mental health problem among the elderly, including Chinese-American elderly. A Chinese-language version of the popular Geriatric Depression Scale Long Form (GDS-LF) and Short Form (GDS-SF) was developed. Based on the responses of 50 elderly Chinese immigrants to the U.S. (25 women and 25 men), the GDS-LF evidenced high internal consistency but the GDS-SF did not. Factor analysis was then used to develop a new version of the GDS-SF, which was internally consistent. The revised GDS-SF is an important and easy-to-administer tool for community screening of depression among elderly Chinese immigrants.

While all delirious patients have clouding of consciousness (alteration of attention) and cognitive dysfunction, the level of alertness of different patients may range from stuporous to hyperalert. We, therefore, developed an analog scale to rate the alertness of delirious patients, and a separate scale to rate the severity of their clouding of consciousness. Based on these scales, patients were categorized overall as relatively “activated” (relatively alert despite clouding of consciousness), or “somnolent” (relatively stuporous along with clouding of consciousness). Cognitive function was estimated using the Mini-Mental Status Exam. Separate ratings were made of hallucinations, delusions, illusions, and agitated behavior. Activated and somnolent patients had similar ages, overall severity of delirium, and Mini-Mental Status Exam scores. Activated patients, however, were more likely to have hallucinations, delusions, and illusions than somnolent patients, and were more likely to have agitated behavior. Patients with hepatic encephalopathy were more likely to have somnolent delirium, while patients with alcohol withdrawal appeared more likely to have activated delirium. These data indicate that phenomenologic subtypes of delirium can be defined on the basis of level of alertness. These subtypes are validated in part by their differing associations with symptoms unrelated to alertness. These subtypes may have different pathophysiology, and thus, potentially different treatments.

Background: This paper provides a systematic review of selected experimental studies of the effectiveness of psychosocial treatments in reducing psychological symptoms in dementia (e.g. anxiety, depression, irritability and social withdrawal).

Method: English language reports published or in press by February 2008 were identified by means of database searches and checks of previous reviews. Reports were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

Results: Only 12 of 48 relevant papers met every specification. Treatments proved more effective in reducing psychological symptoms than an attention control condition or another treatment in only six of the 12 selected studies. Interventions with moderate effect sizes included music and recreation therapy.

Conclusions: Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were generally modest with an unknown duration of action. This limited efficacy suggests that treatments will work best in specific, time-limited situations, tailored to individuals' requirements. There is no preferred method to rate psychological symptoms.

Considerable burden is reported by informal caregivers of older individuals with cognitive impairment. Significant progress in the understanding of determinants of this burden has been achieved. However, further progress could be attained if we considered important methodological issues that may have limited our understanding of caregiver burden. These issues include subgroups of care recipients and caregivers, measurement issues, research design, and statistical techniques. Fifty-three studies published between 1980 and 1997 (inclusive) that focused on caregiver burden were abstracted to determine the extent to which the methodological issues discussed above were considered. Overall, we found considerable variability among the studies surveyed. Further understanding of the caregiving process and reductions in caregiver burden will depend on the attention to methodological issues and understanding of burden across the whole caregiving career.

Background: Frailty is a complex health state of increased vulnerability associated with adverse outcomes such as disability, falls, hospitalization, and death. Along with physical impairments, cognition and quality of life may be affected in frail older adults. Yet, evidence is still lacking. The aim of this study was to compare frail and non-frail older adults on physical, cognitive, and psychological dimensions.

Methods: Thirty-nine frail and 44 non-frail elders were compared on several measures of physical capacity, cognition, and quality of life. Frailty status was based on a geriatric examination and scored using the Modified Physical Performance Test.

Results: After controlling for demographic and medical characteristics, physical capacity measures (i.e. functional capacities, physical endurance, gait speed, and mobility) were significantly lower in frail participants. Frail participants showed reduced performances in specific cognitive measures of executive functions and processing speed. On the quality of life dimension, frail elders reported poor self-perceptions of physical capacity, cognition, affectivity, housekeeping efficacy, and physical health.

Conclusion: In addition to the reduced physical capacity, frailty might affect selective components of cognition and quality of life. These dimensions should be investigated in intervention programs designed for frail older adults.

Patients with dementia with lewy bodies (DLB) have progressive deficits in cognition, parkinsonism, and neuropsychiatric symptoms. Cholinesterase inhibitors have been used to ameliorate cognitive decline and neuropsychiatric symptoms in short-term trials. In this study, patients with DLB were treated with rivastigmine up to 96 weeks. Improvement from baseline was seen in cognitive function as measured by the Mini-Mental State Examination (MMSE), and neuropsychiatric symptoms as measured by the Neuropsychiatric Inventory (NPI) over the first 24 weeks of treatment. By 96 weeks, neither the MMSE scores nor the NPI scores were significantly worse than at baseline.

Background: Consensus recommends early recognition of memory problems through multi-disciplinary assessment in memory clinics; however, little is known about the experiences of people accessing such services. The aim of this review was to synthesis empirical evidence on patient and carer experiences in the transition to dementia.

Methods: This review updates an earlier review (Bamford et al., 2004) on the topic of disclosure of the diagnosis of dementia. Key electronic databases were searched including OVID Medline, CINAHL, Web of Science, EMBASE, and Sociological Abstracts; this was supplemented by hand searching of reference lists and contact with experts in the field. Only papers published after 2003 were included.

Results: Of the 35 papers included in the review, only one study observed the process of disclosure and only two papers explored the effects on the person with dementia's health. The vast majority of people with dementia wished to know their diagnosis. The key challenges for the person with dementia were coming to terms with losses on multiple levels. Although there may be short-term distress, the majority of people with dementia do not appear to experience long-term negative effects on their psychological health. For family carers, becoming the main decision-maker and adjusting to increased responsibility were common concerns.

Conclusions: There is still little empirical research observing the process of diagnostic disclosure in dementia. Studies exploring the views of patients and their families suggest this should be an ongoing process with the provision of support and information tailored to individual needs. The term “Alzheimer's disease” appears to have more negative connotations than the word “dementia”.