The recently published revised National Institute on Aging/Alzheimer's Association clinical diagnostic criteria for Alzheimer's disease (AD) (Albert et al., 2011; Jack et al., 2011; McKhann et al., 2011; Sperling et al., 2011) have been hailed for incorporating a number of timely and important advances. They reflect new understanding that has been gained since the previous criteria were published in 1984 (McKhann et al., 1984). They include recognition of the state of mild cognitive impairment that is present before the threshold is crossed into dementia; they recognize the potential role of biomarkers in enhancing the specificity of diagnosis; they also address emerging work in the preclinical stage of AD that could help in understanding the sequence and stages of the core pathology before symptoms emerge. Among the previously listed diagnostic features that have disappeared was the requirement that onset of dementia occur before the age of 90 years. Meanwhile, the Neurocognitive Disorders Work Group for DSM-5 (the 5th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association, 2010) is also doing away with the previous distinction between early-onset and late-onset dementia in AD, where an arbitrary division had been placed at age 65 (American Psychiatric Association, 2000). These changes are driven by the lack of biological data to support the age-based dichotomy, while recognizing the unique genetic characteristics of the relatively rare, autosomal dominantly inherited forms of AD which typically occur early. However, the disappearance of the age-based diagnostic dichotomy by no means implies that age is irrelevant to AD.

In clinical medicine, diagnostic criteria are not only useful everyday tools for the practicing physician, but also represent a conceptual concentrate of the understanding of the etiology and pathophysiology of diseases at a given point in time. Although different sets of diagnostic criteria for Alzheimer's disease (AD) have been developed, the most widely used and best validated by clinico-pathological study to date are the NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke – Alzheimer's Disease and Related Disorders Association) criteria which were published in 1984 (McKhann et al., 1984). These criteria are largely based on the exclusion of other conditions that may cause dementia and can be succinctly but fairly summarized as defining AD as an “acquired progressive cognitive, behavioral, and functional impairment with no other obvious cause”. Clearly, the NINCDS-ADRDA criteria were etiology- and pathophysiology-agnostic in that they failed to point at any specific etiology, not even a degenerative one. They were also developed before other important causes of dementia, such as dementia with Lewy bodies, fronto-temporal dementia and subcortical vascular dementia had been fully described and characterized. The recent publication of a substantially revised version of these criteria (Sperling et al. 2011; Albert et al., 2011; McKhann et al., 2011), heralded by a largely European initiative four years ago (Dubois et al., 2007) has been greeted with great interest by the field. The newly proposed criteria reflect the substantial insights on disease pathophysiology gained over the last decades, especially regarding the molecular pathology of AD and the time course of such pathology in relation to clinical symptoms and disease.

The question of what constitutes a dignified old age has always been a topic of philosophical enquiry. Already in the writings of the stoic philosophers we can find relevant contributions to an ethic of “successful” aging. Seneca, for instance, reflects upon the pleasures of old age in several of his famous “Letters to Lucilius” (Seneca, 1967). However, he also writes about the bad years that may lie ahead and confides to his pupil: “Do not hear me with reluctance as if my statement applied directly to you, but weigh what I have to say. It is this. I shall not abandon old age, if old age preserves me intact for myself, and intact as regards to the better part of myself; but if old age begins to shatter my mind, and pull its various faculties to pieces, if it leaves me, not life, but only the breath of life, I shall rush out of a house that is crumbling and tottering . . .”

Knowledge about some of the rarer causes of dementia is now quite advanced (Lautenschlager and Martins, 2005), which can in turn inform other more common causes of dementia. Such is the case with the monogenic disorder of Huntington's disease (HD) when compared to, say, Alzheimer's disease (AD). HD is an autosomal dominant hereditary neurodegenerative disease, which involves the basal ganglia, its connections to the frontal lobe and related neural circuits. The onset of HD is typically in mid-life (but onset can range from childhood to old age), with motor, cognitive and neuropsychiatric symptoms. There is currently no cure for this devastating and inevitably fatal neurodegenerative disease, with current treatment approaches being solely symptomatic. The highest frequencies of HD are found in Europe and in those countries whose populations are of predominately European origin such as the USA and Australia (approximately 1 case per 10,000 people).

Increasingly, a large number of neuroimaging techniques are being developed and used for research, with some ultimately entering clinical practice (Scheltens et al., 2002; O'Brien, 2007). For most clinicians working with dementia patients, it can be very hard to keep abreast of developments in the field. For example, when does a potentially exciting new technique for diagnosis or monitoring disease progression become sufficiently validated to be accepted by the scientific community? When does such a validated method for research then become justified for use in routine clinical practice? Closely linked to this, when does one have sufficient evidence that a diagnostic tool changes practice to engage with discussions with those commissioning or paying for health services to make a strong business case for funding for the method to be made available? It is also often far from clear, when faced with a patient with cognitive difficulties, exactly what scan should be requested, at what point and why. If one scan is uninformative or equivocal then what should be the next steps? Are there factors that limit sensitivity of a given technique, such as age? Is it worth suggesting another form of brain imaging to find further information, should one wait and monitor the patient clinically over time, or even repeat the same scan to look at progression? These are challenging but important questions which are all addressed in this supplement. Different papers look critically at what imaging methods are currently available – or may very soon become available – in the clinic, what they can show in particular circumstances, how they should be interpreted and how and when such scans should be requested.

There is a large body of published research relating to depression in residential homes for older people (also called long-term-care homes, and including both nursing homes and hostels) (Ames 1990; 1993; Seitz et al., 2010; Snowdon and Purandare, 2010; Snowdon, 2010). However, despite increased detection and more frequent treatment in recent years, depression remains a significant problem for many older people living in such settings. This guest editorial summarizes current knowledge about prevalence, etiology, detection and screening, treatment and outcomes of depression in residential homes and concludes with a summary of key issues requiring urgent future action.

Good health care, readers of this journal know, requires more than the physician practicing “evidence-based” medicine, using the wizardry of modern technology in combination with honed diagnostic skills to identify medical troubles and their treatment. It depends on the physician's understanding of the patient's emotional and social needs, and requires skill and sensitivity in relating to patients and their family members.

Having announced my editorship with an editorial whose title was in French (Plus ça change . . .) (Ames, 2003), it seems appropriately symmetrical to commemorate my departure (“editor eject” as opposed to “editor elect”?) with a final editorial whose title is drawn from another major European language. The German title serves four functions: it offers homage to the ethnic origins of our incoming German-born Editor-in-Chief (though given the idiomatic excellence of Nicola Lautenschlager's English I suspect it will be the last bit of German seen in these pages for several years), acknowledges the struggle I have had to try and learn something of the German language in formal weekly lessons since April 2006, and, in addition to its relevance to my situation as outgoing editor, it is also a quotation, from Hugo von Hofmannstahl's libretto to Richard Strauss's opera Der Rosenkavalier (translatable as The Knight of the Rose or simply The Rose Bearer) (Strauss and Hofmannsthal, 1910) which is a work that deals, as much as anything, with questions of transition and adjustment.

In 1945 Vannevar Bush made a report to the President of the U.S.A. in which he argued for the value of basic and public welfare research in the post-war era (Bush, 1945). Since then, the research industry has burgeoned, albeit with constant appeals for greater funding. Alongside this growth in research, the consumer movement has also grown. Since the 1970s, for example, the “consumer/survivor” movement in the U.S.A. has been calling for greater roles for people with mental health disorders in the running of their mental health services. This movement was one result of a societal change towards empowerment of people in what some considered to be an authoritarian, hierarchical system of health care provision. In the late twentieth and early twenty-first century, the two movements have started to collide, as consumer groups request more transparency and a bigger role in research funding allocation, and researchers ponder the merits of consumer involvement in their highly technical fields of expertise.

Depression is a common and disabling mental disorder that affects people of all ages, cultures and ethnic backgrounds (Henderson et al., 2000; Mathers et al., 2001; Kessler et al., 2005; Prince et al., 2007). Its presence has been recorded throughout history (Berrios, 1985), which suggests that the signs and symptoms of depression are not simply a product of our time. However, given the overwhelmingly negative consequences of depression (Broadhead et al., 1990; Ellis and Gordon, 2004), it may seem surprising that depression is so ubiquitous and that evolution by means of natural selection has not eliminated it from our midst.

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”.

Background: We assessed the relationship between cognitive impairment (including mild cognitive impairment with no signs of dementia, and dementia) and risk for depression in old age (60 years and older).

Methods: MEDLINE, EMBASE and the Cochrane Library database were used to identify potential studies. All of the clinical studies that produced data on the association between cognitive function and risk of depression among individuals aged 55 years or older were identified and included in this review. The studies were classified into cross-sectional and longitudinal subsets. The quantitative meta-analysis of cross-sectional and longitudinal studies were performed. For prevalence and incidence rates of depression, odds risk (OR) and relative risk (RR) were calculated, respectively.

Results: Since all but two studies found in the search were for individuals aged 60 years or over, we assessed and reported on results for this larger group only. In this review we included 13 cross-sectional and four prospective longitudinal studies. The quantitative meta-analysis showed that, in old age, individuals with non-dementia cognitive impairment had neither significant higher prevalence nor incidence rates of depression than those without (odds risk (OR): 1.48, 95% confidence intervals (95% CI): 0.87–2.52; relative risk (RR): 1.12, 95% CI: 0.62–2.01). In old age, individuals with dementia had both significant higher prevalence and incidence rates of depression than those without (OR: 1.82, 95% CI: 1.15–2.89; RR: 3.92, 95% CI: 1.93–7.99).

Conclusions: Despite the methodological limitations of this meta-analysis, we found that in old age, there was no association between depression and cognitive impairment with no dementia; however, there was a definite association between depression and dementia and thus dementia might be a risk for depression.

Background: Few people with dementia have made advance plans for their health care. Advance care planning (ACP) is a process of discussion between an individual and their care providers that takes account of wishes and preferences for future care. We aimed to examine the facilitators and inhibitors to ACP in people with dementia. We also aimed to identify key themes in the literature and critically review the methodologies used.

Methods: We systematically searched the English language literature including PubMed, CINAHL, AMED, PsychINFO, EMBASE and BNI. We included empirical studies which reported the characteristics of the patient population, the type of advance care planning used and the study setting, and which involved people with dementia, family members or professional carers.

Results: We identified 17 studies (11 quantitative methods, one qualitative and five mixed methods). We found one ACP intervention which changed outcomes for people with dementia. Key themes were identified: there is a point at which cognition decreases critically so that an advanced care plan can no longer be made; factors present in family carers and professionals can influence decision-making and the ACP process; ACPs are affected by preferences for life sustaining treatments; ACP in dementia may differ from other illness groups; and there is a need for education relating to ACP.

Conclusion: The current evidence base for ACP in dementia is limited. Since UK government policy recommends that all people should engage in ACP, more evidence is needed to understand the feasibility and acceptability of advanced care plans for people with dementia.

Background: Because an increasingly large cohort of individuals is approaching their elderly years, there is concern about how the healthcare system will cope with the greater demands placed upon it. One area of concern is the impact of trauma and post traumatic stress disorder (PTSD) in the aged. Although several reviews have highlighted the lack of knowledge and research on the topic, there still remain gaps in the literature. Nevertheless, some recent behavioral, endocrinological and neuroimaging studies may provide new insights into the discussion. The central aims of this paper are to summarize the etiological, epidemiological and clinical aspects of PTSD, trauma, and the elderly, and to integrate this knowledge with (i) what is known about PTSD in adults, and (ii) the behavioral, hormonal and cerebral changes associated with healthy aging.

Methods: A comprehensive search was performed with ISI Web of Science and PubMed for articles pertinent to the psychology and biology of PTSD, trauma, and the elderly.

Results: There exist both significant similarities and differences between adults and elderly with PTSD concerning cognitive and biological profile. Evidence suggests that PTSD in the elderly does not follow a simple clinical trajectory.

Conclusions: PTSD in the elderly must be considered within the context of normal aging. Strong claims about an interaction between PTSD and aging are difficult to make due to sample heterogeneity, but it is clear that PTSD in this age group presents unique aspects not seen in younger cohorts. Further research must integrate their studies with the biological, psychological, and social changes already associated with the aging process.

Background: Previous studies have found correlations between negative perceptions of old age and perceived quality of life (QoL) among elderly people. It has also been suggested that a denial of aging mechanism is employed and might support ageist attitudes among private-sheltered housing tenants compared with elderly people who live in the community and experience intra-generational interactions. Therefore, we hypothesized that tenants of sheltered housing will report more ageist attitudes towards people of their own age, and report a lower QoL than elderly people who live in the community.

Methods: The sample included 126 volunteers, aged between 64 and 94 years, who live in private-sheltered housing (n = 32) or in the community (n = 94). The participants completed the Fraboni scale of ageism, and a QoL Inventory (SF-36).

Results: People, and men in particular, who live in sheltered housing, reported more intergenerational ageist attitudes than men and women who live in the community. Tenants in sheltered housing expressed lower evaluations of their mental health, but higher evaluations on “social functioning” (QoL scales). Women from sheltered housing reported better mental health than men. Gender and some QoL scales were associated with higher ageism.

Conclusions: Differences in ageist attitudes between both dwelling places can be interpreted according to Social Identity Theory, which refers to the impact of the ingroup on social attitudes. Differences in QoL can be understood by the accessibility of social activities in private-sheltered housing. Gender differences in ageism and QoL can be explained by women's better social adjustment. Findings should be regarded with caution because of the small sample.

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.

Neuroimaging has become part of the required investigations when assessing a patient with dementia. In this brief paper, we summarize the role of computed tomography (CT) in the routine work-up in dementia and provide some information about the role of the CT scan in the field of dementia research.

Although CT is far less sensitive than magnetic resonance imaging (MRI) in detecting changes associated with cognitive impairment, it may still have a role in this regard. This role is mainly that of detecting secondary, sometimes treatable causes of cognitive impairment, such as intracranial masses. In this sense, CT should be seen as a first-line tool. Possible advantages of CT are lower cost; shorter acquisition time, making it more adaptable to patients with poor compliance; and the possibility that it can be performed in patients with metal devices, such as a pacemaker.

The role of CT in the field of dementia research is very restricted in comparison to that of MRI, and is limited to the structural assessment of vascular lesions, and to a lesser extent, to that of degenerative changes, particularly when using specific slicing.