To open volume 22 of International Psychogeriatrics we take great pleasure in publishing the papers submitted by the three recipients of the 2009 International Psychogeriatric Association (IPA) Junior Research Awards in Psychogeriatrics. As you can see from our new 2010 front cover, all of them accepted their prizes in person on Tuesday 1 September 2009, at the opening session of the IPA 14th International Congress in Montreal, Canada, where they were congratulated by George Grossberg (chair of the 2009 IPA Junior Research Awards committee) and Serge Gauthier (chair of the 2009 IPA 14th Congress). One of the highlights of the Congress was the plenary session on the afternoon of Thursday 3 September, which I was privileged to chair, at which the three prize recipients presented their research findings to a large and appreciative audience.

The frequency of late life depression is estimated to be low relative to the frequency in young adulthood and middle age, as documented in many community-based epidemiological studies from Western populations. We first reported such a low-frequency in 1980 (though we did not compare the frequency of late life depression with that earlier in life) (Blazer and Williams, 1980). Since that time, many community-based studies have documented this lower frequency (Blazer et al., 1994; Kessler et al., 2003; Hasin et al., 2005). Yet a review of the origins of late life depression at first glance may suggest that older persons are at significant increased risk compared to adults in young adulthood and mid-life (Blazer, 2003; Blazer and Hybels, 2005).

The past eighteen months have seen a number of new developments for this journal. These include the conclusion of a new contract between the journal's owner, the International Psychogeriatric Association (IPA), and our publisher, Cambridge University Press (CUP); the appointment of a new editor-elect to take over from me as editor-in-chief next year; the addition of three new deputy editors to bring the total of such appointees, who assist the editor in chief, to four; and the development and implementation of an online submission and review system to speed the processing of submissions.

The high prevalence of mental disorders among residents of long-term care (LTC) homes is highlighted in the paper by Seitz et al. in this special issue of International Psychogeriatrics. The International Psychogeriatric Association's Task Force on Mental Health Services in LTC Homes was formed in 2005 with two goals: (1) to gather information and share views from diverse countries and settings about how best to restore or ensure good mental health in LTC settings; and (2) to support and strengthen mental health services in the LTC sector. Since its formation, groups of members of the Task Force have visited residential facilities in Stockholm, Lisbon, Istanbul, Osaka, Dublin, Montreal and the Netherlands. Members have also reported on visits to LTC homes in the U.S.A., U.K., Korea, Thailand, South Africa and Nigeria. Further visits have been arranged during the IPA's meeting in Spain in September 2010. Information has also been provided by members in discussion groups and in response to a Task Force survey about facilities in various other countries.

Although there is a great emphasis on memory in the diagnosis of dementia and in the measurement of treatment response, disorders of language are an important, but sometimes neglected, feature of many dementias.

Recent years have seen much debate about both the prevalence and the nature of anxiety and depression in older adults. On the one hand, some authors have suggested that older populations are characterized by surprisingly high levels of well-being and resilience, despite increasing losses and functional impairment (Staudinger and Fleeson, 1996) and that the prevalence of mental illness, with the exception of dementia, decreases in late life (Jorm, 2000). Others have suggested that this is a spurious finding resulting from the methodological problems in obtaining accurate data for older adults (Beekman et al., 1998, Krasucki et al., 1999; O'Connor, 2006), with categorical diagnostic systems, such as the DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Organization, 1992) frequently cited as aggravating these difficulties (Palmer et al., 1997).

In September 2009, Montreal, Quebec hosted the International Psychogeriatric Association's 14th International Congress, in collaboration with the American Association for Geriatric Psychiatry, the Canadian Academy of Geriatric Psychiatry, the Canadian Coalition for Seniors' Mental Health, the Canadian Geriatrics Society, and the Société Québecoise de Psychogériatrie. The theme of the Congress was the “Pathway to Prevention”, and the presentations focused on progress made to date on the prevention of late-life mental disorders, barriers the field is still facing, and future achievements that will be needed for this goal to be achieved.

The need to train more health workers, and particularly mental health workers, in the care of older adults, has been highlighted by a variety of disciplines including psychiatry (Jeste et al., 1999), psychology (Knight et al., 1995), social work (Rosen et al., 2002) and nursing (Hirst et al., 1996). This rise in attention paid to geriatric health care is partly driven by demographics. Over the next 50 years, the global population of people aged 60 years and over is expected to triple to 2 billion by 2050 (U.N. Department of Economic and Social Affairs, Population Division, 2007). This same UN report states that the expected number of centenarians is set to increase globally by a factor of 20. Worldwide, the demographic trends in aging suggest that the number of people in the world aged 65 years and over will surpass the number aged 5 years or less in approximately 2017 (UN Department of Economic and Social Affairs, Population Division, 2005). The issues concerning who will care for older adults are faced by a growing number of nations throughout the world.

Background: Home care for older adults is a common phenomenon worldwide because it allows older adults to remain in their home environment. Research has shown that depression is frequently found in older recipients of home care services. Nonetheless, it is often poorly recognized and treated. Untreated or poorly treated depression in older home care recipients has been associated with a variety of negative outcomes, including increased morbidity and mortality, greater likelihood of nursing home institutionalization and higher caregiver distress.

Methods: The present review outlines some of the challenges associated with appropriate recognition and treatment of depression in older home care recipients.

Results: Our review demonstrates that more aggressive management of depressive symptoms and the employment of an interdiciplinary team can result in beneficial outcomes.

Conclusions: Further research is needed, especially in the area of psychotherapeutic interventions as these should be flexible enough to meet the unique and evolving needs of this frail population of older adults.

Background: The population of older adults in long-term care (LTC) is expected to increase considerably in the near future. An understanding of the prevalence of psychiatric disorders in LTC will help in planning mental health services for this population. This study reviews the prevalence of common psychiatric disorders in LTC populations.

Methods: We searched electronic databases for studies on the prevalence of major psychiatric disorders in LTC using medical subject headings and key words. We only included studies using validated measures for diagnosing psychiatric disorders or psychiatric symptoms. Our review focused on the following psychiatric disorders: dementia, behavioral and psychological symptoms of dementia (BPSD), major depression, depressive symptoms, bipolar disorder, anxiety disorders, schizophrenia, and alcohol use disorders. We also determined the prevalence of psychiatric disorders in the U.S. LTC population using data from the 2004 National Nursing Home Survey (NNHS).

Results: A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including 30 studies on the prevalence of dementia, 9 studies on behavioral symptoms in dementia, and 26 studies on depression. Most studies involved few LTC facilities and were conducted in developed countries. Dementia had a median prevalence (58%) in studies while the prevalence of BPSD was 78% among individuals with dementia. The median prevalence of major depressive disorder was 10% while the median prevalence of depressive symptoms was 29% among LTC residents. There were few studies on other psychiatric disorders. Results from the 2004 NNHS were consistent with those in the published literature.

Conclusions: Dementia, depression and anxiety disorders are the most common psychiatric disorders among older adults in LTC. Many psychiatric disorders appear to be more prevalent in LTC settings when compared to those observed in community-dwelling older adults. Policy-makers and clinicians should be aware of the common psychiatric disorders in LTC and further research into effective prevention and treatments are required for this growing population.

Background: An increasing body of evidence suggests that health behaviors may protect against cognitive impairment and dementia. The purpose of this study was to summarize the current evidence on health behavioral factors predicting cognitive health through a systematic review of the published literature.

Methods: PubMed, Embase, and PsycINFO databases were searched for studies on community representative samples aged 65 and older, with prospective cohort design and multivariate analysis. The outcome – cognitive health – was defined as a continuum of cognitive function ranging from cognitive decline to impairment and dementia, and health behaviors included physical activity, smoking, alcohol drinking, body mass index, and diet and nutrition.

Results: Of 12,105 abstracts identified, 690 relevant full-texts were reviewed. The final yield amounted to 115 articles of which 37 studies were chosen that met the highest standards of quality. Leisure time physical activity, even of moderate level, showed protective effects against dementia, whereas smoking elevated the risk of Alzheimer's disease. Moderate alcohol consumption tended to be protective against cognitive decline and dementia, but nondrinkers and frequent drinkers exhibited a higher risk for dementia and cognitive impairment. Midlife obesity had an adverse effect on cognitive function in later life. Analysis showed vegetable and fish consumption to be of benefit, whereas, persons consuming a diet high in saturated fat had an increased dementia risk.

Conclusion: The review demonstrates accumulating evidence supporting health behavioral effects in reducing the risk of cognitive decline and dementia. Results indicate potential benefits of healthy lifestyles in protecting cognitive health in later life.

Background: Growing evidence suggests that participation in late-life leisure activity may have beneficial effects on cognitive function. The objective of the study was to evaluate the association between leisure activity participation and cognitive function in an elderly population of community-dwelling Hong Kong Chinese.

Methods: 512 participants were assessed in the follow-up study of a population-based community survey of the prevalence of cognitive impairment among Hong Kong Chinese aged 60 years and over. Leisure activities were classified into four categories (physical, intellectual, social and recreational). Information regarding leisure activity participation, cognitive function and other variables was collected. Multivariate linear regression analyses were performed to examine the association between leisure activity participation and cognitive function.

Results: A higher level of late-life leisure activity participation, particularly in intellectual activities, was significantly associated with better cognitive function in the elderly, as reflected by the results of the Cantonese Mini-mental State Examination (p = 0.007, 0.029 and 0.005), the Category Verbal Fluency Test (p = 0.027, 0.003 and 0.005) and digit backward span (p = 0.031, 0.002 and 0.009), as measured by the total frequency, total hours per week and total number of subtypes, respectively; the Chinese Alzheimer's Disease Assessment Scale-Cognitive Subscale (p = 0.045) and word list learning (p = 0.003), as measured by the total number of subtypes; and digit forward span (p = 0.007 and 0.015), as measured by the total hours per week and total number of subtypes, respectively.

Conclusion: Late-life intellectual activity participation was associated with better cognitive function among community-dwelling Hong Kong elderly Chinese.

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.

Background: In response to the global challenges of population aging in Portugal, it is crucial to improve research, education and clinical training in old age in order to meet the growing demands placed on psychogeriatric care services.

Methods: An overview is provided on the status of old age psychology and psychiatry as part of the multidisciplinary care delivery system for the elderly in Portugal. Available educational offerings and clinical training in geriatric mental health at both undergraduate and postgraduate level are described, as well as primary research associations and initiatives within Portugal.

Results: Important issues raised include the need for more educational and clinical training programs for specialists, a broader commitment to aging research and the need to increase interest in working with older adults among students across disciplines. The recent movement towards multidisciplinary work conducted by researchers, psychiatrists, psychologist and other health professionals in Portugal points to the urgent need for specialist education for all health professionals working in geriatrics. This educational initiative must focus not only on the transmission of knowledge on aging-related topics, but also on the training of specific skills and competencies. Improving geriatric mental health service delivery and connecting research with clinical practice constitute other significant steps forward.

Conclusions: An effective intervention in psychogeriatrics should involve a strategy with the participation of a multidimensional network that includes the commitment of researchers, educators, clinicians, health policy-makers and older adults. Several recommendations to improve late life mental health care are presented.

Alzheimer's disease (AD) is a complex progressive brain degenerative disorder that has effects on multiple cerebral systems. In addition to cognitive and functional decline, diverse behavioral changes manifest with increasing severity over time, presenting significant management challenges for caregivers and health care professionals. Almost all patients with AD are affected by neuropsychiatric symptoms at some point during their illness; in some cases, symptoms occur prior to diagnosis of the dementia syndrome. Further, behavioral factors have been identified, which may have their origins in particular neurobiological processes, and respond to particular management strategies. Improved clarification of causes, triggers, and presentation of neuropsychiatric symptoms will guide both research and clinical decision-making. Measurement of neuropsychiatric symptoms in AD is most commonly by means of the Neuropsychiatric Inventory; its utility and future development are discussed, as are the limitations and difficulties encountered when quantifying behavioral responses in clinical trials. Evidence from clinical trials of both non-pharmacological and pharmacological treatments, and from neurobiological studies, provides a range of management options that can be tailored to individual needs. We suggest that non-pharmacological interventions (including psychosocial/psychological counseling, interpersonal management and environmental management) should be attempted first, followed by the least harmful medication for the shortest time possible. Pharmacological treatment options, such as antipsychotics, antidepressants, anticonvulsants, cholinesterase inhibitors and memantine, need careful consideration of the benefits and limitations of each drug class.

Worldwide, lifespan is lengthening. Concomitantly, late-life dementias are increasingly common, challenging both personal and public health internationally. After age 65, rates of dementia tend to double every five years in developed countries and every seven in developing ones. The late-life dementias, particularly Alzheimer's disease, have profound effects on aging individuals and their caregivers. Multidisciplinary research has explored the potential for various approaches to prevent or delay the onset of late-life dementias. Outlining that research, including our team's Adult Changes in Thought and Kame studies, this review concludes that delaying the onset of these dementias appears feasible, although absolute prevention may not be. Today, the most promising methods appear to include controlling vascular risk factors like hypertension and engaging in physical exercise – and possibly mental exercise. If people can delay the onset of dementias, they can lead more fulfilling lives for longer, spending less time suffering from dementia and letting their families spend less time coping with the disease. It is possible that trends toward more knowledge-based societies, where cognitive health is so vital, may increasingly exert evolutionary pressure favoring larger and healthier brains – and a “compression of cognitive morbidity” – well into old age. Public health's great triumph, increased lifespan, should give more of the world's people the reward of many years of dementia-free life. Rather than the personal difficulties and public health burdens of many years of functional impairment, dependency, and suffering with dementia, some interventions may delay the onset of Alzheimer's disease and other dementias.

Background: Florida is a leader in requiring that all direct care staff employed in assisted living, nursing homes, hospice, adult day care and home health undergo Alzheimer's disease (AD) training. Legislative requirements prescribe the curricula components and require a review of curricular content and minimum standards for the training providers.

Methods: We describe Florida's AD training program review process, and report the results of our review of 445 curricula received over four and a half years.

Results: On initial submission, over 90% of curricula submitted did not include learning objectives, time formats or didactic approach. During a review of content we often found inaccurate information, language that was not person-centered, and missing required training components.

Conclusion: Form and content problems were prevalent across all curricular types. We propose the Florida credentialing program as a model to ensure that accurate and educationally sound curricula are used to train direct care workers.

The authors regret that they incorrectly cited the source of financial support in the original publication. The acknowledgment should have read: This study was supported by the Health Promotion Fund, Ministry for Health, Welfare and Family Affairs, Republic of Korea (08-23) and a grant of the Korea Healthcare Technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea (A050079).

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.

Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.