Background: The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).

Method: The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.

Results: An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.

Conclusion: There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.

Dementia is, of course, the label for a clinical syndrome with many different causes. Alzheimer's disease (AD) is the most common cause of dementia, followed by vascular dementia, dementia with Lewy bodies (DLB) and (especially at younger ages) frontotemporal dementia. Other possible causes of the dementia syndrome with relevance to a debate on the use of neuroimaging include space-occupying lesions, normal pressure hydrocephalus and other rarer neurological diseases which can be associated with variable cognitive impairments, such as progressive supranuclear palsy, multi-system atrophy and corticobasal degeneration. There is a great and, with the aging of the population, ever growing demand for the investigation of patients with suspected dementia, as exemplified by the rapid expansion of services such as memory clinics. It is essential that everyone presenting with signs suggestive of cognitive failure is given the opportunity to undergo a full assessment to help determine the subtype of dementia, which will include appropriate investigations. However, it is equally essential that investigations are appropriately targeted, according to their evidence base, and only performed when they have the potential to have a significant bearing on diagnosis or management.

Traditionally, suicide rates increase with aging in many countries (Shah and De, 1998). However, exceptions to this observation are emerging. Data from the World Health Organization (WHO) in 1995 revealed that female suicide rates did not increase with age in Mauritius, Colombia, Albania and Finland (Shah and De, 1998). Suicide rates increased with age in Switzerland (Ajdacic-Gross et al., 2006), Brazil (Mello-Santos et al., 2005) and China (Yip et al., 2000), but there were smaller peaks in the younger age-bands. Suicide rates among Australian, New Zealand and white American males increased with age, but suicide rates for females initially increased with age, peaking at menopause, and declining thereafter (Skegg and Cox, 1991; Woodbury et al., 1988; Snowdon and Snowdon, 1995). Suicide rates among non-white Americans (Seiden, 1981; Woodbury et al., 1988), Indians (Adityanjee, 1986; Bhatia et al., 1987), Jordanians (Daradekh, 1989), Indian immigrants to the U.K. (Raleigh et al., 1990; Needleman et al., 1997) and some east European countries (Sartorius, 1995) declined with increasing age.

Studies reported in the literature indicate a wide range of movement disorders associated with anti-epileptic treatment (Easterford et al., 2004). Valproic acid is a well-known cause of reversible neurotoxicity characterized by symptoms resembling idiopathic Parkinson's disease (PD) and cognitive impairment (Armon et al., 1996; Onofrj et al., 1998).

Delusional parasitosis (DP) is a rare psychiatric disorder, predominantly observed in middle aged and elderly patients. It can manifest itself as an isolated delusional disorder (primary DP), as a symptom of another psychiatric disorder or as an organic or toxic psychosis. The typical antipsychotic pimozide was traditionally considered to be the gold standard for treating DP. Compared with pimozide, atypical antipsychotics have many advantages in terms of tolerability, but their effectiveness has only been shown in a few case reports, which do not differentiate between primary and other forms of DP.

We present the case of a 77-year-old woman with primary DP who responded markedly to the atypical antipsychotic olanzapine (2.5 mg daily). She was treated in a psychiatric outpatient department with a follow-up period of 3.5 years. This is the first report of a successful olanzapine mono-therapy in primary DP in such a setting and the longest follow-up period ever reported. The need for maintenance treatment was demonstrated. Olanzapine in age-adapted doses should be considered as an alternative treatment. This paper also provides a review of all published cases in which primary DP was treated with atypical antipsychotics.

Professor Wahlund has made a convincing case that structural imaging is not useful as adjunct investigation for all cases of dementia in the primary care situation. In my opinion, no-one has ever suggested that it would or should be. Indeed, there would be insufficient resources to do so and it would be overkill, to say the least. Primary care is not the setting in which brain imaging should be performed and so I agree with Wahlund in this regard. However, following primary care evaluation of a patient with suspected dementia, a referral to a second line setting often occurs. This can happen for a number of reasons, including the need for treatment, and it is here that imaging should always be performed. The first approach then should always be a structural one, not only to exclude the odd case of a primary glioma or subdural hematoma, but to show evidence of medial temporal lobe atrophy, shown by the Swedish SBU to be of high diagnostic accuracy for AD (SBU, 2006). Additionally, vascular changes may be demonstrated, which may prompt the specific treatment of risk factors, or else focal atrophy suggestive of another specific neurodegenerative disorder may be seen (Scheltens et al., 2002; van der Flier and Scheltens, 2005). The recent surprising observation of a relatively high frequency of microbleeds in AD patients (18%) and VaD patients (65%), which may caution the clinician against the use of oral anticoagulation, again underlines the need to perform MRI in demented patients (Cordonnier et al., 2006). The only exception to this would be the sound judgment of the clinician that no nosological diagnosis is warranted in a specific case (usually because of high age, presence of severe dementia and/or extensive comorbidity). It is important to note that, in the case of medial temporal lobe atrophy, however it is measured, there is a tendency for reduced diagnostic utility (reduced specificity) at a higher age, making age specific norms a requirement (van de Pol et al., 2006).

Background: The ε4 allele of apolipoprotein E (APOE) and head injury are risk factors for dementia diseases, and may act synergistically to further increase the risk. The aim of this study was to examine the association between mild head injury, APOE and dementia.

Methods: Data were obtained from the Betula prospective population-based study of aging, memory, and health. The study included 543 participants in the age range 40–85 years, free of dementia at baseline, who were followed up within a 5-year interval. Dementia was classified using DSM-IV criteria. Information on previous head injury was obtained through screening of the participants' answers to health questionnaires at baseline and at follow-up.

Results: Subjects with head injury but without APOE ε4 had no increased risk of dementia. Subjects with APOE ε4 had an increased risk and those with both APOE ε4 and head injury had the highest risk of dementia (odds ratio = 5.2).

Conclusions:APOE ε4 constitutes a risk factor for dementia, mild injury in isolation does not increase the risk, but head injury in combination with the APOE ε4 leads to increased risk of dementia.

Dipyridamole is an antiplatelet agent and a vasodilator which is increasingly being used for the secondary prevention of ischaemic stroke and transient ischemic attack, either alone or in combination with acetylsalicylic acid. We describe an 83-year-old woman who had developed musical hallucinations within days of initiating dipyridamole. Her psychiatric and neurological evaluation was otherwise unremarkable. After the discontinuation of dipyridamole the hallucinations ceased within a couple of days. To the best of our knowledge this is the first case of auditory hallucinations associated with dipyridamole reported in the literature.

Let us hear what really happened at the Reichenbach Falls near Meiningen, when Dr. Watson (W; performed by L. O. Wahlund, with a sweet Swedish accent), Sherlock Holmes (S; by P. Scheltens, with only a touch of Dutch) and Professor Moriarty (M; heavy Continental tongue) conversed while out walking:

War is a complex, enduring trauma composed of variable forms of extreme stress, such as violence, fear of death, displacement, loss of family members, abuse and starvation (Berman, 2001). More than 90% of war victims are civilians (UNICEF, 2006). Children and women are extremely vulnerable to traumatic experiences in times of war and the risk continues even in post-war-situations (Shanks and Schull, 2000). As far as former war-children are concerned, a high prevalence of post-traumatic stress symptoms is apparent even six decades after World War II (Kuwert et al., 2006). In the 1990s, the world was shocked by reports about systematic and widespread rape in the former Yugoslavia and Rwanda (Shanks and Schull, 2000). The Lancet has published articles about wartime rape and demanded the development of clear strategies against sexual violence in conflict (Hargreaves, 2001). However, it can be concluded that sexual violence was and is common in nearly all crisis zones. One recent example was the rape and murder of a 14-year-old girl by U.S. soldiers of the 101st Airborne Division in Iraq (The Times, 2006).

Objective: Despite numerous clinical trials, it is unknown whether ethnicity affects treatment response to cognitive enhancers in Alzheimer's disease (AD). There is convincing evidence of ethnic and genetic variability in drug metabolism. This article reviews the available data on ethnicity in clinical trials for AD to answer two questions: (1) what are the challenges to diagnose and treat AD across different ethnic groups, and (2) are there differences in response to pharmacologic interventions for AD across these different ethnic groups?

Method: Available data from Alzheimer's Disease Cooperative Study (ADCS) randomized controlled clinical trials and from randomized controlled industry-sponsored trials for four cognitive enhancers (donepezil, galantamine, rivastigmine and sabeluzole) were pooled to assess the numbers of non-Caucasian participants.

Results: The participation of ethnic minority subjects in clinical trials for AD was dependent on the funding source, although Caucasian participants were over-represented and non-Caucasian participants were under-represented in the clinical trials. Because of the low participation rate of ethnic minorities, there were insufficient data to assess any differences in treatment outcome among different ethnic groups. Strategies to improve diversity in clinical trials are discussed.

Conclusion: Greater participation of ethnically diverse participants in clinical trials for AD would generate additional information on possible differences in metabolism, treatment response, adverse events to therapeutic agents, and could foster the investigation of genetic variability among ethnic groups.

The prevalence of a disorder is a function of the incidence of the disorder and the duration of the illness (which may remit spontaneously, by treatment or death). The socioeconomic status of societies may influence the incidence and duration of mental illnesses in old age by influencing life expectancy and availability of appropriate healthcare services and treatments (Suh and Shah, 2001). The relationship between a proxy measure of the socioeconomic status (per capita gross national domestic product (GDP)) and (i) the life expectancy, (ii) child mortality rates and (iii) proxy measures of the quality and quantity of available healthcare services (the proportion of GDP spent on health, per capita expenditure on health and child mortality rates) was examined. The WHO website (www.who.int/countries/en/) provided data on these variables for 191 of the 192 countries for the year 2002. The inter-correlations between all the measured variables were examined using Pearson's correlation coefficient. Because of highly significant inter-correlations between all these variables, multiple linear regression analysis, with the Enter method, was undertaken with per capita GDP as the dependent variable, and all the variables that were significantly correlated with per capita GDP on univariate analysis as the independent variables.

Previous research has shown that the presence of behavioral and psychological symptoms (BPSD) can increase the burden of care in dementia (e.g. Donaldson et al., 1998). Impaired executive functions, also called “dysexecutive syndrome” (Wilson et al., 1996), are frequent in dementia and can adversely affect social behavior in everyday life. Reduced awareness of cognitive deficits is associated with impaired executive functions, and may play a significant role in the onset and maintenance of BPSD. A recent paper by Davis and Tremont (2007) demonstrated that dysfunction of frontal systems is associated with increased burden of care in dementia, even after controlling for clinical severity and caregiver mood. In this letter, we report results that support this finding.

Corticobasal degeneration syndrome (CBDS) is a neurodegenerative disorder characterized by higher cortical dysfunctions associated with progressive asymmetric akinetic-rigid syndrome, and limb dystonia or focal myoclonus (Lang et al., 1994). One of the most typical and specific clinical features in CBDS is considered alien limb phenomenon, usually present in advanced disease stage (Doody and Jankovic, 1992).

Elderly suicide rates have been shown to be low in countries with low socioeconomic status, including those with greater income inequality and those with reduced life expectancy (Shah et al., 2007). It is therefore possible in such countries that people at risk of suicide in old age do not reach the age of increased risk. Moreover, selective survival of those at reduced risk for suicide due to genetic or constitutional factors may further compound this trend. Furthemore, those who do survive may be at reduced risk of suicide in old age because they may be better able to tolerate extra hardship in old age due to exposure to life-long adversity (Seiden, 1981; Lindesay, 1991). For example, elderly African Americans and native Americans (Indians) have low suicide rates (McIntosh, 1984) and this has been attributed to a life-long history of socioeconomic deprivation (McIntosh, 1984). Therefore, we examined the relationship between elderly suicide rates and long-term measures of economic adversity, including the average annual growth rate and average annual change in the consumer price index over a long period.

Objective: Insight into the individual care needs of the growing number of people with dementia is necessary to deliver more customized care. Our study aims to provide an overview of the literature on the subjective needs of people with dementia.

Method: Electronic databases were searched for publications on subjective needs between January 1985 and July 2005, and reference lists were cross-referenced. Extracts of needs were classified within problem areas of the (Dutch) National Dementia Program and quality of life domains, and the extracts were classified as a “need” (an implicitly communicated felt state of deprivation), “want” (expression of a need) or “demand” (suitable solution to fulfill a need).

Results: Subjective needs were found in 34 studies with various research aims, such as awareness and coping. Few studies aimed to measure needs of people with dementia. The most frequently reported needs of people with dementia were the need to be accepted and respected as they are, the need to find adequate strategies to cope with disabilities, and the need to come to terms with their situation. Explicit wants or demands were reported less frequently than needs.

Conclusion: The high number of reported needs and the limited number of wants and demands show that people with dementia do not frequently mention how they want their needs to be met. Most reported needs are not instrumental, but are related to well-being and coping. Further research to inventory these needs could help achieve more demand-directed and better attuned care in the future.

Antipsychotic medications form the mainstay of both the acute and maintenance treatment of schizophrenia. In recent years, atypical antipsychotics like risperidone, olanzapine and clozapine have come to be preferred because of their lower incidence of extra-pyramidal, anti-cholinergic and cardiac side-effects and a possible greater efficacy in reducing negative and neuro-cognitive symptoms (Ritchie et al., 2006).

Background: The Mini-mental State Examination (MMSE) has not been validated in Arabic speaking populations. The Brookdale Cognitive Screening Test (BCST) has been developed for use in low schooling populations. We investigated the influence of gender, education and occupation in a cognitively normal community sample which was assessed using an Arabic translation of the MMSE and the BCST.

Methods: Cognitively normal subjects (n = 266, 59.4% males, mean age (SD): 72.4 (5.5) years) from an Arab community in northern Israel (Wadi Ara) were evaluated. Education was categorized into levels: 1 = 0–4 years, 2 = 5–8 years, 3 = 9–12 years. Effects of gender, education and occupation on MMSE and BCST were analyzed by ANOVA, taking age as a covariate.

Results: The mean MMSE score of males [26.3 (4.1)] was higher than that of females [23.6 (4.2) points]. Two-way ANOVA showed a significant interaction between gender and education on MMSE (p = 0.0017) and BCST scores (p = 0.0002). The effect of gender on MMSE and BCST was significant in education level 1 (p < 0.0001, both tests) and level 2 (p < 0.05, both tests). For education level 1, MMSE and BCST scores were higher for males, while both scores were higher for females in education level 2. The effect of occupation was not significant for both genders.

Conclusion: Education and gender influence performance when using the Arabic translation of the MMSE and BCST in cognitively normal elderly. Cognitively normal females with 0–4 years of education scored lower than males. These results should be taken into consideration in the daily use of these instruments in Arabic.