Background: There is a growing body of research exploring differences in behavioral and psychological symptoms of dementia (BPSD) between Alzheimer's disease (AD) and vascular dementia (VaD), yet these differences are inconsistent and it is uncertain whether this inconsistency might be due to the confounding effect of differing severities of dementia.

Methods: BPSD, measured with the Behavior Problems Check List (BPCL) and Revised Memory and Behavior Problems Check List (RMBPCL) and CDR-measured severity of dementia were examined using archival data of individuals with AD (N = 377) or VaD (including multi-infarct and other vascular causes; N = 74) presenting to a Sydney memory disorders clinic over a 20-year period.

Results: There was no significant difference in scores for AD and VaD patients on the BPCL or on the RMBPCL when controlling for sex and severity of dementia. However, severity of BPSD increased with increasing severity of dementia.

Conclusions: BPSD severity is no different in AD and VaD at the time of initial assessment in a memory disorders clinic population of mild to moderate dementia. However, BPSD increases with severity of dementia in this group.

Background: Only a few population-based studies on the epidemiology of post-traumatic stress disorders (PTSDs) are available to date. Most of the existing studies are from the U.S.A. Against the background of World War II, the extent and long-term effects of war-related traumatic experiences in the German elderly population are of special interest. Nevertheless, population-based data on this topic are lacking to date.

Methods: This study examines the occurrence of traumatic experiences and the prevalence rates of PTSD according to DSM-IV and of partial PTSD in a randomly selected sample of the German general population aged 60 years and over (N = 814) using self-rating instruments.

Results: PTSD is apparent in 3.4%; when partial post-traumatic stress syndromes are included, a total of 7.2% of the aged population are involved. The most common individual symptoms resulting from war-induced trauma are avoidance of thoughts and feelings, sleep disturbances, distressing dreams and intrusive thoughts. The most frequently mentioned traumatic experiences of the generation examined in this study were war-related trauma experienced as children or in early adulthood during World War II. As a person's age increases, so does the prevalence of war-related traumatic experiences. There are some gender differences in traumatic experiences, but not in post-traumatic symptoms.

Conclusion: The results emphasize the importance of war-related traumatic experiences from World War II in the German elderly population and their impact on the prevalence of PTSD more than 60 years later.

Background: Health care professionals are recommended to deliver patient-centered care in dementia; however, guidance and training on how to do this in practice is currently lacking. The aim of this study was to develop and evaluate pragmatically an educational intervention for old age psychiatrists to promote patient-centered care in their consultations with people with dementia and their carers.

Methods: We used a range of methods to (i) identify the theoretical components of patient-centered care (literature review) and (ii) observe actual practice (video recording of 53 consultations between old age psychiatrists and people with dementia and their family carers). We also interviewed participants from (ii) including 7 old age psychiatrists, 25 people with dementia and 44 carers. From this we developed a workshop for old age psychiatrists and piloted and evaluated it. Pre- and post-workshop questionnaires were completed; the latter included an assessment of planned and subsequent behavior change by participants.

Results: The educational workshop, attended by 41 old age psychiatrists, focused on how best to structure the consultation and the most effective communication skills to use in consultation with people with dementia. Three months after the workshop, 59% had made one or more changes to the structure of their consultations, 71% had used new communication skills and 56% had reflected further on their practice.

Conclusions: We developed an educational intervention with both a theoretical and empirical basis. The workshops resulted in many changes to self-reported practice; whether this was noticeable to patients and carers requires further study.

Background: Wandering and fecal smearing (scatolia) are among the problematic behaviors in dementia, and many caregivers are troubled by these behaviors. The purpose of this study was to clarify the clinical characteristics of patients with these symptoms.

Methods: We performed a questionnaire survey. The questionnaire items were the age, sex, living environment, diagnosis, cognitive function, and activities of daily living. Other clinical characteristics were evaluated using the quality of life (QOL) questionnaire for dementia.

Results: A total of 246 patients with dementia were rated. Wandering was observed frequently in 23%, sometimes in 12%, rarely in 14%, and never in 51% of the patients; scatolia was observed frequently in 2%, sometimes in 8%, rarely in 15%, and never in 75%. Wanderers were more frequent among those with severe dementia. They displayed more restlessness, positive affect and attachment to others with respect to QOL. The patients with scatolia tended to get lower scores in tests of cognitive function and displayed more negative affect/actions with respect to QOL. Both wanderers and patients with scatolia suffered from insomnia more frequently.

Conclusions: These results suggest that both wandering and scatolia are behavioral symptoms intimately associated with cognitive dysfunction and insomnia.

Background: Delirium is common in the elderly and is associated with high mortality and negative health outcomes. Reduced activity in the cholinergic system has been implicated in the pathogenesis of delirium. Cholinesterase inhibitors, which increase cholinergic activity, may therefore be beneficial in the treatment of delirium.

Methods: This is a double-blind, placebo-controlled randomized pilot study of the treatment of delirium with a cholinesterase inhibitor of patients admitted to hospital medical wards. Patients over the age of 65 years were identified as having delirium by the Confusion Assessment Method (CAM). Patients with delirium were randomized to receive rivastigmine 1.5 mg once a day increasing to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days).

Results: Fifteen patients entered the trial; eight received rivastigmine and seven received placebo. All of the rivastigmine group, but only three of the placebo group, were negative for delirium on the CAM when they left the study and eventually discharged home. There was no significant difference in the duration of delirium between the two groups (rivastigmine group 6.3 days versus placebo group 9.9 days, p = 0.5, 95% confidence interval −15.6–8.4).

Conclusions: The numbers of patients who screened positive for delirium was very small and as a result the sample size was too small to make any meaningful inferences about treatment of delirium. Despite the small numbers included in the study, there are some indicators that rivastigmine may be safe and effective in treating delirium.

Background: National attitudes towards the elderly and their association with elderly suicide mortality in 26 European countries were assessed, and Eastern and Western European countries compared.

Methods: For each country, mean age-adjusted, gender-specific elderly suicide rates in the last five years for which data had been available were obtained from the WHO European Mortality Database. Questions about citizens’ attitudes towards the elderly were taken from the European Social Survey. Correlations between attitudes and suicide rates were analyzed using Pearson's test. Differences between mean scores for Western and Eastern European attitudes were calculated, and data on labor-market exit ages were obtained from the EUROSTAT database.

Results: Perception of the elderly as having higher status, recognition of their economic contribution and higher moral standards, and friendly feelings towards and admiration of them are inversely correlated with suicide mortality. Suicide rates are lower in countries where the elderly live with their families more often. Elderly suicide mortality and labor-market exit age are inversely correlated. In Eastern European countries, elderly people's status and economic contribution are seen as less important. Western Europeans regard the elderly with more admiration, consider them more friendly and more often have elderly relatives in the family. The data also show gender differences.

Conclusions: Society's attitudes influence elderly suicide mortality; attitudes towards the elderly are more favorable among Western European citizens; and extended labor-market inclusion of the elderly is a suicide-protective factor.

Background: Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages).

Methods: Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity.

Results: Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains.

Conclusion: Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

Background: Screaming is common among older persons living with dementia in nursing homes. Research on this population has not provided a useful basis for understanding such behavior that could help determine appropriate interventions. The purpose of this study was to explore the meanings of screams in older people living with dementia and their influencing factors.

Methods: Critical ethnography was selected as the research design. Seven triads, each composed of an older person living with dementia who screamed, a primary family caregiver, and one or two formal caregivers, were recruited in a nursing home. Various data collection methods and Spradley's (1979) ethnographic analysis were used.

Results: Screaming is related to vulnerability, suffering, and loss of meaning experienced by older persons. This singular behavior also expresses various final outcomes that can be differentiated through modulation criteria. The meanings of screams are influenced by stability and flexibility in the nursing care organization and reciprocal effects between older persons who scream and others in the nursing home environment. Each person's screams constitute a unique language that can be learned. Other influencing factors include respect for the older person's wishes, needs, and personality, shifts in power relations within the triad, and feelings of powerlessness and guilt in family and formal caregivers.

Conclusions: This study advances knowledge of the meanings of screams in older persons living with dementia. It has implications for and offers insight on culturally congruent care for older persons living with dementia and the people around them.

In 2007, the U.K.'s All-Party Parliamentary Group on Dementia (APPG) undertook an inquiry into the prescription of antipsychotics for people with dementia on account of concerns expressed by carers, patient organizations and academics about the appropriateness and safety of these drugs (All-Party Parliamentary Group on Dementia, 2008). It has been estimated that 32% of patients with dementia in care homes are prescribed antipsychotics (Alldred et al., 2007). Both typical and atypical antipsychotics are associated with QT prolongation, which can lead to arrhythmias and sudden death (Joint Formulary Committee, 2009). They are also associated with an increased risk of cerebrovascular events. Adverse effects in the elderly include excessive sedation and dizziness, which can lead to falls and therefore accelerated cognitive decline.

Background: Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes.

Methods: The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design).

Results: 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 ± 8.3 vs. 15.0 ± 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001).

Conclusions: The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

Background: Several neuropsychiatric symptoms observed in elders with cognitive impairment no dementia (CIND) can be part of a major depressive episode (MDE) or a “subthreshold” depressive episode. Certain neuropsychiatric symptoms of CIND are essential symptoms of MDE (e.g. dysphoria, anhedonia), while other are non-essential symptoms (NESD; e.g. fatigue, insomnia, cognitive complaint). Contrary to essential symptoms, NESD are not specific to MDE and are present in other disorders. It is unknown whether NESD are linked to CIND in absence of MDE or subthreshold MDE. The present study examined the association between NESD and probable CIND in elders without essential MDE symptoms.

Methods: Participants were 2028 community-dwelling individuals aged 65–96 years who had not experienced dysphoria/anhedonia during the year preceding the interview. Semi-structured in-home interviews evaluated the following NESD: alteration of appetite, sleep disturbance, psychomotor alteration, fatigue/loss of energy, worthlessness/guilt, and cognitive complaints. Probable CIND cases were defined based on the Mini-mental State Examination cut-offs (15th percentile) stratified for age, education and sex.

Results: Symptoms of fatigue/loss of energy (OR: 2.41, 95% CI: 1.42–4.09), sleep disturbance (OR: 3.04 CI: 1.69–5.46) and cognitive complaints (OR: 2.86 CI: 1.71–4.77) were significantly associated with CIND. These associations were not modified after adjustments for potential confounders (age, education level, sex, benzodiazepine use, chronic diseases, and brain disorders).

Conclusion: A psychiatric symptomatology occurs in older adults with CIND in the absence of MDE or subthreshold MDE. NESD encountered in the absence of dysphoria/anhedonia should receive particular attention by clinicians since they can be linked to cognitive difficulties.

Background: Previous studies have shown that the verbal fluency test (VFT) is a sensitive measure of cognitive dysfunction in Alzheimer's disease (AD). However, other studies have shown that the performances were significantly influenced by education in the normal elderly population. In order to examine the utility of the VFT as a tool for screening for AD, it is necessary to study the effect of education not only in the cognitively intact population but also in the population of early AD patients.

Methods: Patients with AD (n = 345) and individuals with amnestic type of mild cognitive impairment (MCI) (n = 123) were asked to generate as many words as possible belonging to a category “animal” and beginning with “か [ka]” in syllabic Japanese “kana” script. In order to determine the education effect after adjusting for age and cognitive state on the VFT performance in early stage of AD, we performed multiple regression analysis with 396 individuals including both amnestic MCI and AD.

Results: After adjusting for patients’ age, sex, and cognitive state, the years of education were significantly related to category fluency test scores, but not significantly related to letter fluency test scores.

Conclusion: Our results demonstrated that a category fluency performance reflected not only AD-specific changes but also educational background. These results suggest the limitation of using the category fluency task for screening subjects at risk for developing AD without taking subjects' educational background into consideration.

Background: Sleep disturbance is common in caregivers of older adults with memory disorders. Little is known, however, about the implications of caregivers’ poor sleep with regard to their physical functioning.

Methods: In this cross-sectional study, we investigated the association between objectively measured sleep and self-reported physical functioning in 45 caregivers (mean age = 68.6 years) who completed the Beck Depression Inventory-II, the Medical Outcomes Study SF-36, and the Mini-mental State Examination, and wore an actigraph for at least three days. Our primary predictors were actigraphic sleep parameters, and our outcome was the SF-36 Physical Functioning subscale.

Results: In multivariate-adjusted linear regression analyses, each 30-minute increase in caregivers’ total sleep time was associated with a 2.2-point improvement in their Physical Functioning subscale scores (unstandardized regression coefficient (B) = 2.2, 95% confidence interval (CI) 1.0–3.4, p = 0.001). In addition, each 10-minute increase in time awake after initial sleep onset was associated with a 0.5-point decrease on the Physical Functioning subscale, although this was not statistically significant (B = −0.5, 95% CI −1.1, 0.1, p = 0.09).

Conclusions: Our findings suggest that shorter sleep duration is associated with worse self-reported physical functioning in caregivers. Longitudinal studies are needed to determine whether poor sleep predicts functional decline in caregivers.

Background: This study sought to investigate the extent to which structural and functional social support promotes psychological well-being among nursing home residents in a Chinese society.

Methods: 71 nursing home residents (57 women, 14 men) provided ratings on contact frequency and emotional and instrumental support exchanges with network members. Psychological well-being was measured using depression, loneliness, positive affect, and life satisfaction.

Results: Network size was associated with well-being, but was largely nonsignificant after controlling for frequency of contact or functional support. Contact and support from staff and fellow residents were consistently related to all well-being variables, whereas interactions with family were associated with life satisfaction and positive affect only. Being able to reciprocate support was also related to well-being in this sample of frail elderly, controlling for other factors.

Conclusion: Interactions with staff and residents in the institution are more protective of well-being than interactions with family members. Even in a society where familism is strongly valued, assimilation into the institution facilitates support exchange when needed.

Psychogeriatricians commonly undertake home visits, often under unusual and sometimes challenging circumstances. We report a home visit to a zoo to see an unusual case, a 49-year-old confused gorilla. A diagnosis of post-infarct delirium was made, subsequently validated by autopsy. We describe a primate observation scale which was used in the assessment of cognition this case, which may be helpful for use when cognitive assessment of primates is required.

Background: Apathy, a complex neuropsychiatric syndrome, commonly affects patients with Alzheimer's disease. Prevalence estimates for apathy range widely and are based on cross-sectional data and/or clinic samples. This study examines the relationships between apathy and cognitive and functional declines in non-depressed community-based older adults.

Methods: Data on 1,136 community-dwelling adults aged 50 years and older from the Baltimore Epidemiologic Catchment Area (ECA) study, with 1 and 13 years of follow-up, were used. Apathy was assessed with a subscale of items from the General Health Questionnaire. Logistic regression, t-tests, χ2 and Generalized Estimating Equations were used to accomplish the study's objectives.

Results: The prevalence of apathy at Wave 1 was 23.7%. Compared to those without, individuals with apathy were on average older, more likely to be female, and have lower Mini-mental State Examination (MMSE) scores and impairments in basic and instrumental functioning at baseline. Apathy was significantly associated with cognitive decline (OR = 1.65, 95% CI = 1.06, 2.60) and declines in instrumental (OR = 4.42; 95% CI = 2.65, 7.38) and basic (OR = 2.74; 95%CI = 1.35, 5.57) function at 1-year follow-up, even after adjustment for baseline age, level of education, race, and depression at follow-up. At 13 years of follow-up, apathetic individuals were not at greater risk for cognitive decline but were twice as likely to have functional decline. Incidence of apathy at 1-year follow up and 13-year follow-up was 22.6% and 29.4%, respectively.

Conclusions: These results underline the public health importance of apathy and the need for further population-based studies in this area.

Almost all elderly suicide victims have mental illness, and up to 90% have depression (Shah and De, 1998). A significant number of elderly suicide victims in Western countries consult their general practitioner or psychiatrist or contact mental health services between one week and six months prior to the suicide (Catell, 1988; Conwell et al., 1990; 1991; Catell and Jolley, 1995; Vassilas and Morgan, 1993; 1994). This offers an opportunity for identification and treatment of the mental illness. Thus, the availability of appropriate healthcare services may be an important factor associated with elderly suicide rates.

Background: This study is the first to explore the relations between attachment styles, ageism, and quality of life (QoL) among elderly people. The attachment theory describes how human beings relate to each other, according to their attachment style. Previous studies have examined the connection between attachment styles and prejudice toward distinctive social groups and minorities. Ageism as a form of prejudice is a way of relating negatively to people because they are old. QoL among the elderly was found to be associated with negative age-perceptions. It was therefore hypothesized that QoL, attachments styles, and demographic characteristics can explain ageism among the elderly.

Methods: Four questionnaires were administered: Fraboni Scale of Ageism (FSA), which comprises four scales (separation, affective, stereotype, and intergeneration); Experiences in Close Relationships Scale, which measures four attachment styles (secure, dismissive, fearful, and preoccupied); SF-36 health status inventory (eight scales); and sociodemographic questions. Ninety-four elderly men and women aged 64–85 years living in the community completed the questionnaires.

Results: MANCOVAS indicated that securely attached individuals score higher on separation than fearfully attached individuals, and that securely and dismissively attached individuals score higher than fearful and preoccupied individuals on seven QoL scales. Multiple regression analyses showed that attachment styles, age, gender, and some QoL scales contribute to the explained variance of ageism.

Conclusions: Secure attachment in late life seems to be related to less ageism and a better QoL. The enhancement of a secure attachment base in elderly people may assist in moderating ageism and improving older people's QoL.

An 81-year-old female with no previous psychiatric history presented with late-onset obsessive compulsive disorder following an acute right macular hemorrhage and loss of vision. Following a thorough organic screen to exclude a physical cause, various high doses of selective serotonin reuptake inhibitors were tried with no therapeutic benefit. The patient had significant remission of her symptoms following a course of electroconvulsive therapy.

Background: Interdisciplinary teams are sometimes used in the provision of health care to populations who present with complicated needs, such as older adults experiencing dementia. Moreover, there is an international consensus that health care students should receive training in interdisciplinary care.

Methods: 157 health care students from Xavier University's College of Social Sciences, Health, and Education in Cincinnati, U.S.A. participated in a five-hour symposium on an interdisciplinary approach to treating older adults with dementia. The Attitudes Toward Health Care Teams Scale (ATHCTS; Heinemann et al., 1999) was used to assess student attitudes before and after the symposium.

Results: A paired-sample t-test was conducted to compare pre and post-test ATHCTS overall and subscale scores. There was a statistically significant increase in the overall pre-post ATHCTS scores and Quality of Care/Process Subscale scores. There was a significant decrease in the Physician Centrality Subscale scores.

Conclusions: The findings suggest that, after the symposium, participants reported more positive overall attitudes about health care teams, and about the quality of care provided by such teams and the teamwork to achieve good patient care. Participants also displayed a decrease in their beliefs about how essential physicians are as leaders of health care teams. These results affirm the use of a brief interdisciplinary educational approach in changing student attitudes about the use of health care teams. Students who develop more positive attitudes about working on an interdisciplinary health care team recognize the team's value and therefore may be more receptive to and effective in working as professional team members in the future.