Background: Older people are commonly admitted to the acute hospital and increasing numbers will have dementia. In this study we systematically reviewed the prevalence, associations and outcomes of dementia in older people in the general hospital, to examine the range of diagnostic tools used and highlight gaps in the literature.

Methods: We searched the English language literature using Embase, PsychInfo and Medline. Studies were included if they used validated criteria for diagnosing dementia, involved subjects over the age of 55 years and were set in the general hospital.

Results: Fourteen papers were identified. Prevalence estimates for dementia in studies with robust methodology were 12.9–63.0%. Less than a third of studies screened for delirium or depression and therefore some subjects may have been misclassified as having dementia. The data were highly heterogeneous and prevalence estimates varied widely, influenced by study setting and demographic features of the cohorts. Patients with dementia in the acute hospital are older, require more hours of nursing care, have longer hospital stays, and are more at risk of delayed discharge and functional decline during admission.

Conclusions: When planning liaison services, the setting and demographic features of the population need to be taken into account. Most study cohorts were recruited from medical wards. More work is required on the prevalence of dementia in surgical and other specialties. A wider range of associations (particularly medical and psychiatric comorbidity) and outcomes should be studied so that care can be improved.

Background: In many parts of the world the provision of psychogeriatric inpatient units (PGUs) remains limited. More units will be required over coming decades given rapid population aging.

Methods: Medline (1950–2010), psycINFO (1806–2009), EMBASE (1980–2009) and CINAHL (1982–2009) were searched for papers about PGU design. Selected non-peer reviewed literature such as government reports and unpublished academic dissertations were also reviewed. Data were also obtained from the literature related to general adult psychiatry inpatient units where there was limited information from studies of units designed for older people. Over 200 papers were reviewed and 130 were included.

Results: There are few good quality studies to guide the design of acute PGUs and much of the existing literature is based on opinion and anecdote or, at best, based on observational studies. Randomized controlled studies comparing different designs and assessing outcomes are virtually non-existent. Several studies have identified violence and trauma resulting from hospitalization as significant problems with current acute PGU care. Despite its limitations the available literature provides useful guidance on how PGU design can optimize patient and staff safety and improve clinical outcomes.

Conclusions: There are significant problems with current acute PGUs, and patient mix on existing units is an important issue. Future research should examine patient and staff perceptions of different PGU ward environments, the relationship between ward design and clinical outcomes, the effects of segregating patients with challenging behaviors in dementia and the benefits or otherwise of gender segregation.

Background: As autism spectrum disorders (ASD) have largely been neglected in old-age psychiatry, the objective of the present paper is to describe the diagnostic process in elderly patients.

Methods: A systematic review of the literature on ASD in older age was undertaken and illustrated by a case series of three elderly patients first diagnosed with ASD in later life by a tertiary mental health clinic.

Results: The search of the literature only yielded three papers on late-life ASD, while the review of the available diagnostic procedures among adults suggests some relevance for screening instruments (Autism Questionnaire), diagnostic instruments (Module 4, Autism Diagnostic Observation Schedule), and neuropsychological examination to profile impairments. Nonetheless, the case reports clearly showed that taking a thorough history with the patient, corroborated and supplemented by a close relative or caregiver who has known the patient for at least ten years, still remains the most important diagnostic tool.

Conclusion: The three case studies show that in clinical practice ASD can easily be missed in elderly individuals presenting with comorbid psychiatric disorders, potentially causing iatrogenic damage. Although further research on phenotyping and diagnosing ASD in older people is warranted, the most important step at this point is to create a greater awareness of the possibility of ASD in old age among health-care professionals working with people in this age group.

Background: Family carers of people with dementia are at risk of psychological morbidity, and it is suggested that this may also be the case in paid carers as caring for people with dementia can be emotionally and physically demanding. Care homes have historically had difficulty recruiting and retaining staff, and job stress has previously been linked to high turnover amongst long-term care staff. We performed a systematic review of studies of the prevalence of psychological stress in staff caring for people with dementia in residential long-term care settings.

Methods: We conducted a comprehensive literature search of MEDLINE, PsychINFO and Web of Science databases up to May 2009, supplemented by a search of the references of all relevant articles. Search terms encompassed nursing staff, residential care and psychological distress. Validity of studies was graded by two authors independently using a standardized checklist.

Results: We identified 601 studies of which five met our inclusion criteria. Two studies reported on prevalence rates of staff distress and found 37% and 5% levels of being “at risk” from burnout, four studies reported mean stress scores and all were low.

Conclusions: All studies were either small or used instruments with unsatisfactory psychometric properties and so our conclusions are limited by the lack of good quality evidence. The preliminary evidence suggests that most staff who remain working in homes do not have a high prevalence of psychological stress or level of symptoms.

Background: The Wisconsin Card Sorting Test (WCST) has long been used to investigate deficits in executive function in humans. The majority of studies investigating deficient WCST performance focused on the number of categories achieved (CA) and the number of perseverative errors of the Nelson type (PEN). However, there is insufficient evidence that these two measures reflect the same neural deficits.

Methods: Twenty AD patients with high PEN scores, and 20 age- and sex-matched AD patients with low PEN scores were selected. All 40 subjects underwent brain SPECT, and the SPECT images were analyzed by Statistical Parametric Mapping.

Results: No significant differences were found between high and low PEN score groups with respect to years of education, Addenbrooke's Cognitive Examination scores, and Mini-Mental State Examination scores. However, higher z scores for hypoperfusion in the bilateral rectal and orbital gyri were observed in the high PEN score group compared with the low PEN score group.

Conclusions: Our results suggest that functional activity of the bilateral rectal and orbital gyri is closely related to PEN scores on a modified WCST (mWCST). The PEN score on a mWCST might be a promising index of dysfunction of the orbitofrontal area among patients with mild AD.

Background: Mild cognitive impairment (MCI) is commonly associated with memory impairment. There have been a number of studies attempting to ameliorate this through memory interventions including memory rehabilitation and training. The current paper reviews the evidence for the effectiveness of such interventions in enhancing learning of specific information, their impact on untrained material, compensation for memory impairment and improving everyday functioning.

Methods: The literature was systematically searched for studies focusing on interventions targeting memory impairment in MCI using relevant search terms. Studies were screened for inclusion or exclusion using a priori criteria and, once identified, studies were examined for quality using pre-specified criteria.

Results: A total of 226 studies were identified in the search, ten of which were included in the final review. Only one study was an RCT of “adequate” methodology. It was tentatively suggested that people with MCI can learn specific information, although there was little evidence to suggest that memory training can generalize. There was some limited evidence of ability to learn to compensate for memory difficulties and contradictory findings regarding improvement in everyday life.

Conclusions: The poor methodological quality of the included studies implies that the ability to draw conclusions is limited. MCI is a controversial concept and there is a need for good quality trials examining the efficacy of memory interventions. There are some indications that memory impairment in MCI might best be targeted by interventions developing compensatory strategies and targeting the learning of specific information relevant to the individual.

Background: This paper describes an evaluation of a redevelopment program in a mental health service for older people, stimulated by U.K. Department of Health policy. IQCOL (Improving Quality of Care for Older People in Lambeth) was a two-year program to modernize and expand an inner-city service, with objectives to improve access, embed new functions, and tune the service towards the needs of the local community. The program evaluation aimed to contribute to knowledge on service planning and methodology for evaluating complex interventions.

Methods: The study evaluated the progress and outcomes of this multifaceted program. The realist model of evaluation was followed, with a dual emphasis on utility and generalizability. With an iterative approach, the pragmatic, longitudinal design comprised a combination of qualitative and quantitative methods to explain the process of change and to measure achievement of objectives.

Results: A high level of participation in evaluation activities was achieved. The workforce generally responded well to the program. However, progress in one team was hindered by understaffing and resistance to change, emphasizing that while localized provision may be desirable, team viability requires adequate resources and professional support. Improved access was indicated by a 13% increase of referrals. Data suggested earlier referral of dementia cases. Carer support was implemented, but assertive outreach was impeded by professional boundary issues. Ethnicity data showed that the service was responding to demographic trends. Positive views towards the program were associated with team resources and recent professional training.

Conclusions: This case study demonstrates how whole system change can be achieved if sufficient attention is given to the needs of staff implementing the program. The evaluation emphasizes the importance of context in producing generalizable evidence on service development, and contributes useful methodological insights.

Background: The increasing prevalence of dementia will precipitate a significant burden in terms of the costs of caring for people with dementia over the next 30 years; sleep disturbances in dementia are an important factor contributing to this burden.

Methods: We reviewed sleep disturbances in people with dementia and their carers and describe the various diagnostic, assessment and treatment strategies available to physicians in the management of this clinically significant problem.

Results: Sleep disturbances in people with dementia and their carers (i) are highly prevalent; (ii) impact significantly on quality of life of both people with dementia and their carers; (iii) increase the rate of cognitive decline; and (iv) accelerate the breakdown of community-based care. The training of physicians in the assessment and treatment of sleep disturbances in dementia and caregiving is scant despite a wide range of assessment strategies and treatment approaches, which comprise both pharmacological (including hypnotic/sedative medications) and non-pharmacological approaches (including: environmental; psychobehavioral; exercise and activity; and multi-component interventions). Specific diagnostic criteria for sleep disturbances in people with dementia and their carers remain lacking despite established criteria for general insomnia. Further to this, proposed changes to diagnostic criteria for DSM-V do not include a specific focus for the diagnosis and management of sleep disturbances in people with dementia or their carers.

Conclusions: This review suggests that the improved training of physicians to meet the needs of these vulnerable groups of older people is a priority, especially in the context of a rapidly increasing demand for accurate, early diagnosis and efficient management of sleep disturbance in these groups.

Background: The needs of younger people with dementia have become increasingly recognized in service development. However, little is known about the impact of a diagnosis of young onset dementia on people aged under 65 years and their families. This paper reviews the literature on the experiences of younger people with dementia and their families in the U.K., and outcomes for carers.

Methods: Twenty-six studies, encompassing a variety of themes concerning this population, were reviewed following a systematic literature search.

Results: Results are divided into the impact on the individual and the impact on the family, specifically carer outcomes and the impact on children.

Conclusions: The studies reviewed reveal a number of negative outcomes for the individual and carers, and highlight the need for further research.

Clinical neuroimaging is increasingly being used in the diagnosis of neurodegenerative diseases and has become one of the most important paraclinical tools in the diagnosis of dementia. According to current guidelines, neuroimaging, preferably magnetic resonance imaging (MRI), should be performed at least once during the diagnostic work-up of patients with suspected or definite dementia. MRI is helpful in identifying or excluding potentially treatable causes of dementia; however, these account only for a small proportion of dementias. In addition, MRI is able to support the clinical diagnosis in a memory clinic setting by identifying certain patterns of atrophy and vascular damage. Visual rating scales are well-established methods in the clinical routine for the assessment and quantification of regional/global cortical atrophy, hippocampal atrophy and vascular damage. In addition, MRI is able to detect certain aspects of pathology associated with dementia, such as cerebral microbleeds which are related to cerebral amyloid angiopathy and Alzheimer pathology. This review paper aims to give an overview of the application of structural MRI in the diagnostic procedure for memory clinic patients in terms of excluding and supporting the diagnosis of various diseases associated with dementia.

Background: Preventive home visits (PHVs) are considered a promising intervention to improve health and independent functioning of the elderly whilst reducing health care costs. This systematic review focuses on cost-effectiveness of PHVs, analyzing randomized controlled trials evaluating incremental cost-effectiveness ratios in fall prevention interventions.

Methods: Based on an online search (PubMed) and bibliographic findings in the eligible articles, five studies providing relevant information were reviewed.

Results: While three studies indicate cost-effectiveness, one delivered no statistically significant results, and one proved cost-effectiveness only for a subgroup of the study sample.

Conclusions: Cost-effectiveness of PHVs appears to depend on careful adaptation of particular measures, for certain settings in special environments for designated patients and disease patterns, on a case-by-case basis. Starting points for further research are the components of the economic evaluation, the setting, personnel and measures of the intervention, as well as the careful selection and analysis of the study sample and its subgroups. A uniform follow-up time, standardized cost measurement as well as the use of standardized denominators like quality adjusted life years (based on the EQ-5D questionnaire) could build a foundation for comparable results.

Background: Ideally putative disease-modifying therapies for Alzheimer's disease (AD) should be tested in patients who have minimal morbidity. Current barriers to such trials in early disease include the lack of disease-specific early biomarkers, insensitivity of quantitative cognitive outcome measures, and expensive trial designs requiring large sample sizes and long duration. This paper describes principles and progress towards a novel trial design that overcomes these problems, utilizing wide-scale cognitive performance screening to define pre-trial cognitive decline trajectories which can serve as trial outcome measures to assess AD disease-modifying efficacy.

Methods: Theoretical principles important for the detection of intra-individual cognitive decline and a practical example are described.

Results: Serial evaluations of community-based volunteers demonstrate how a screening tool method to detect subtle cognitive decline can predict in vivo amyloid pathology as a trigger for etiological evaluation. Trajectories of decline appear consistent over at least two years, suggesting they could be used as a trial inclusion criterion and ameliorable outcome measure together with other AD biomarkers. Informative trial durations could be 6–12 months, or extend to incorporate staggered random withdrawal or start designs, with as few as 20 individuals per treatment arm.

Conclusions: This trial methodology offers significant advantages over current AD trial designs, including treatment at earlier stages of disease, shorter trial duration, obviation of informed consent difficulties, smaller sample sizes, reduced cost and – given adequate screening programs – sufficient subjects for multiple simultaneous trials. Importantly, it allows the rapid evaluation of putative treatments that may only be efficacious in pre-dementia states.

Background: The latest version of the State-Trait Anxiety Inventory (STAI-Y) is commonly used in older adults, even though this anxiety scale was developed in and for young adults. Norms and associated factors of the STAI-Y are lacking for older adults in the general population. The objectives of the present study were to produce norms on the STAI-Y State scale for older adults using a large sample of older adults selected from a general population and to examine the sociodemographic and health-related factors associated with the STAI-Y State score.

Methods: 993 community-dwelling individuals aged 66 years and over from the PAQUID study were evaluated at home by a psychologist for the following variables: age, education, marital status, proximity of relatives, self-assessment of income sufficiency, occupation during active life, depressive symptomatology, objective and subjective health, objective and subjective cognitive functioning, adverse life events, activities of daily living, drug use, and cigarette consumption.

Results: Norms were stratified for age, sex, and education and were produced separately for older adults with and without depressive symptomatology. Multivariate analyses revealed that younger age (66–79 years), female sex, lower education, perception of income insufficiency, depressive symptomatology, poor subjective health, subjective cognitive complaints, psychotropic drugs use, and recent adverse life events were independently associated with higher STAI-Y State score.

Conclusions: This study provides norms for the STAI-Y State anxiety inventory in a general population of older adults and indicates the specific factors linked with state anxiety. Such factors should be taken into account by clinicians in order to better understand state anxiety in older adults.

Background: Doctors working in the majority of medical subspecialties provide care for patients with dementia, but there is current international concern that many do not have adequate knowledge or skills to deliver appropriate care for these patients in hospital or community settings. The aim of this review is to draw together recommendations for medical education on dementia and empirical research on teaching interventions concerning dementia in order to assess the current provision of training using the UK model as an example.

Methods: Database and manual searches were undertaken to identify relevant articles for a narrative review.

Results: UK national guidelines recommend that dementia-specific education should be available to trainees in the undergraduate and postgraduate environment. A sample of undergraduate curricula shows considerable variation in the delivery of teaching about dementia. “Non-specialist” postgraduate curricula make reference to care of patients with confusion, but do not always include learning outcomes specific to cognitive impairment or dementia. Teaching interventions trialed in the postgraduate environment provide encouraging qualitative feedback from participants, but do not consistently demonstrate improvement in participants' knowledge, skills or attitudes.

Conclusions: There is a pressing need to improve undergraduate medical education on dementia in order to help future doctors obtain the ability to provide competent care for patients. There is scope for ongoing research to refine existing curricula covering dementia and to build an evidence-base for successful dementia-specific teaching interventions.

Background: There are challenges in attracting and sustaining a competent and stable workforce in aged care, and key issues of concern such as low staff job satisfaction and feelings of not being able to provide high quality care have been described. This study aimed to explore the association between person-centered care provision and job satisfaction in aged care staff.

Methods: Residential aged care staff (n = 297) in Australia completed the measure of job satisfaction and the person-centered care assessment tool. Univariate analyses examined relationships between variables, and multiple linear regression analysis explored the extent to whichperceived person-centredness could predict job satisfaction of staff.

Results: Perceived person-centred care provision was significantly associated with job satisfaction, and person-centred care provision could explain nearly half of the variation in job satisfaction. The regression model with the three person-centered care subscales as predictor variables accounted for 40% of the variance in job satisfaction. Personalizing care had the largest independent influence on job satisfaction, followed by amount of organizational support and degree of environmental accessibility. Personalizing care and amount of organizational support had a statistically significant unique influence.

Conclusions: As person-centered care positively correlated with staff job satisfaction, supporting staff in providing person-centered care can enhance job satisfaction and might facilitate attracting and retaining staff in residential aged care. The findings reiterate a need to shift focus from merely completing care tasks and following organizational routines to providing high quality person-centered care that promotes the good life of residents in aged care.

Background: It has been suggested that hypercortisolism contributes to the pathophysiology of Alzheimer's disease (AD), based on the fact that excess glucocorticoid exposure has potent adverse effects on the central nervous system. In contrast, dehydroepiandrosterone (DHEA) has been linked to a broad range of beneficial physiological effects including neuronal excitability and neuroprotection and even memory enhancing properties. Of note, proinflammatory cytokines are present in neuritic plaques (a hallmark of AD) and may regulate cortisol/DHEA release. In this exploratory study, we hypothesized that there is a flattened diurnal curve of cortisol and DHEA in mild to moderate AD, linked to increased cytokine levels.

Methods: Diurnal profiles of cortisol, adrenocorticotropic hormone (ACTH), and DHEA were studied in 15 patients with mild to moderate AD (7 men and 8 women, 75.6 ± 5.5 years) and 15 healthy elderly controls (7 men and 8 women, 73.3 ± 5.8 years, respectively). Interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and soluble TNF receptors were analyzed.

Results: Women with AD had significantly increased morning levels of ACTH, DHEA, and IL-6 compared to healthy elderly women. Cortisol levels were significantly increased in men with AD at 0300 h versus healthy elderly men, in spite of slightly decreased ACTH levels.

Conclusions: Our data suggest important sex differences in hypothalamic–pituitary–adrenal (HPA) axis regulation and steroid hormone clearance in patients with AD. Increased secretion of IL-6 may have a contributory role in this difference.

Background: Paratonia is a progressive motor problem that is observed in individuals with dementia and is not a well-known phenomenon. This study explores the development and risk factors of paratonia in moderate stage dementia patients.

Methods: A multi-center, longitudinal, one-year follow-up cohort study was performed. Patients with an established diagnosis of dementia, with a score of 6 or lower on the Global Deterioration Scale (GDS) were included. The participants were assessed using the Paratonia Assessment Instrument (PAI), the Timed Up and GO test, the Qualidem, the Global Deterioration Scale (Reisberg et al., 1982) and the Mini-mental State Examination. Information about each patient's diagnosis of dementia, comorbidities and use of medication were obtained from the participant's medical file. The PAI was assessed every three months, the other variables at baseline and after 12 months. Cross-tabulation χ2 and logistic regression tests were used for the statistical analyses.

Results: Baseline measures were assessed in the 204 participants – 111 (54%) female and 93 (46%) male, with a mean age of 79.8 years (56–97). Seventy-one patients (34.8%) were diagnosed with paratonia at baseline, and 51 patients developed paratonia over one year. The highest hazard ratio (3.1) for developing paratonia within one year was observed in the vascular dementia group. The logistic regression analysis revealed that the presence of diabetes mellitus (OR = 10.7) was significantly related to the development of paratonia (Wald χ2 p-value < 0.01).

Conclusions: Diabetes mellitus and likely vascular damage are risk factors for the development of paratonia.

Background: Patients living in squalor have a wide range of psychiatric diagnoses, but these may have a common neural basis involving frontal systems. This study investigated frontal executive function, theory of mind, emotional processing including disgust, and appreciation of squalor in elderly patients found living in squalor.

Methods: Six patients referred to an old age psychiatry service underwent a battery of neuropsychological tests, assessment of living conditions and awareness of self and others’ squalor.

Results: All six patients showed impairment in frontal executive function, typically accompanied by amnesic deficits. Theory of mind and emotional processing were surprisingly preserved. While five of the patients could recognize severely unclean or cluttered living conditions in newspaper photographs, more than half did not appreciate that their own living conditions were squalid.

Conclusion: Deficits in frontal executive function appear important in the genesis of squalor although functions linked to orbito-frontal ability appear preserved.