During the past 30 years, the growth of geriatric psychiatry services has been dramatic. Indeed, in this issue of International Psychogeriatrics, Reifler and Cohen report that most developed countries can boast of an impressive range of clinical services that include a variety of hospital-based, community-based, and long-term-care programs.

Following on from the hypothesis of a role for the ApoE ε4 and ε2 alleles as risk and protective factors, respectively, for late-onset Alzheimer's disease (AD) came inevitable questions regarding other psychiatric conditions of late onset including depressive illness and schizophrenia. Is ApoE ε4 a risk factor in these diseases and do carriers have an earlier age of onset? Does ApoE ε2 have a protective role, with carriers of this allele having a later age of onset?

This journal is international, which means that it reaches an international audience with articles from international authors. What does this mean for international authors?

This issue of the journal inaugurates another innovation, to be tried over the next year: the rapid communication. Despite or perhaps partly due to the explosion of biomedical journals in the last 20 years, timeliness can still be a problem for authors and editors alike. With the journal's turnaround and publication schedules now on track, attention has been turned to the need to publish timely data that can inform-or provoke-current controversies; and that can allow for the publication of novel findings likely to stimulate and improve patient care, teaching, or research.

The dramatic and unexpected increase in life expectancy observed over the past few decades in Western countries is undoubtedly one of the great medicosocial achievements of this century. These gains have principally been made at higher ages and are reflected in the proliferation of centenarians. In France, the estimated number of centenarians was 200 in 1953, around 3,000 at the present time, and 6,000 projected for the end of the century. Similar trends are observed in the United Kingdom; the Royal Secretary sent messages of congratulations on behalf of the Queen to 300 centenarians in 1955 and to 3,300 in 1987. In parallel with these demographic observations, research on centenarians is becoming increasingly widespread with clinical and general population studies now having been conducted in France, Hungary, Japan, Italy, Finland, Denmark, the United States, and China. A database on mortality trends in the oldest old has been established by Vaino Kannisto and Roger Thatcher at the Center for Research on Aging, Odense University Medical School, providing validated data on centenarians from 12 Western European countries and Japan since 1950. Additionally, the Danish centenarian register established by Bernard Jeune contains data on centenarians back to the 1700s.

The authors conducted a survey of members of the International Psychogeriatric Association (IPA) to determine the state of development of both the profession of geriatric psychiatry and services for mentally ill elderly. Ratings for both issues were based on a scale of 1 to 4, with 1 being little to no development and 4 being the highest. A rating of 2 was set as the desired minimum, and 12 countries met this goal in both categories, with 6 more countries reaching this goal in service development only. We conclude that although the field of geriatric psychiatry and services for mentally ill elderly are still underdeveloped in much of the world, in many countries they are developed sufficiently enough that the IPA is in an excellent position to provide both information and technical assistance to nations wishing to advance.

Dementia with Lewy bodies (DLB) is common. Symptomatic treatment can be difficult. We reviewed nine consecutive patients with DLB (mean age 77.5 [range 67 to 84] years; seven men and two women; mean duration of disease 3.7 [range 1.5 to 8.0] years) who had been treated with donepezil. Each initially received 2.5 to 5 mg per day of donepezil, and was stabilized on 5 mg per day. Donepezil was increased to 10 mg per day in five patients. The mean observation period was 12 (range 8 to 24) weeks. Target symptoms included cognition, hallucinations, parkinsonism, and functional abilities. By both cognitive testing and family reports, cognition improved in seven of nine patients, remained the same in one of nine, and fluctuated in one of nine (mean Mini-Mental State Examination change 4.4 ± 6.3 points). Function was improved or maintained in six of nine patients and fluctuated in two of nine. Hallucinations initially worsened, then fluctuated in one patient, but improvement in frequency, duration, and content was reported in eight of nine cases. In three of nine patients, treatment with donepezil resulted in worsening of parkinsonism, which in each case responded to levodopa/carbidopa. Treatment of DLB patients with donepezil for 12 weeks most commonly improved hallucinations, and sometimes improved cognition and overall function. Treatment with donepezil was sometimes associated with worse parkinsonism.

When the Titanic sped towards New York, the captain was less concerned about icebergs than about transatlantic records. Nevertheless when the ship crashed, the captain did his duty and went down with the ship. Captains lead lonely, but not necessarily isolated, lives. What about editors? I do not wish to drown, but do lament the lack of letters (or correspondence as it is called elsewhere in the English-speaking world). Despite the pleas, nobody answers the call for letters to the editor. Like the captain, I want to know what's going on and what people think.

Synaptic pathology has attained increasing attention as being central in the pathogenesis of Alzheimer's disease (AD). To address the question whether synaptic pathology in AD involves the whole synapse, or is limited to specific components thereof, we studied three different synaptic vesicle proteins (rab3a, synaptotagmin, synaptophysin) and also the presynaptic membrane protein GAP-43 and the postsynaptic protein neurogranin. The material included post-mortem brain tissue (frontal cortex, hippocampus, and cerebellum) from 8 patients with early-onset AD (EAD), 11 patients with late-onset AD (LAD), 6 patients with vascular dementia (VAD), and 9 control subjects. A reduction of all synaptic proteins was found in AD, more pronounced in EAD than in LAD, in both the frontal cortex (EAD 30% to 70% vs. LAD 82% to 88% of control value) and hippocampus (EAD 22% to 82% vs. LAD 76% to 89% of control value), whereas only minor changes were found in VAD. The finding that all synaptic proteins were reduced in AD suggests a degeneration and loss of whole synaptic elements that are more pronounced in EAD than in LAD.

This study compares the demographic and clinical characteristics of homebound (HB) elders referred for psychiatric services (N = 251) with those of inpatients (IP) admitted to a geriatric psychiatry unit (N = 594). Demographically, HB patients were older (78.8 vs. 74.7 years), were more likely to be women (83% vs. 68%), were widowed (54% vs. 44%), and had fewer years of education (10.3 vs. 11.1), but were similar in race, income, and proportion living alone. Clinically, HB patients had less functional disability, less severe depression, less cognitive impairment, and fewer medical problems. However, they were similar in the distribution of most psychiatric diagnoses except dementia (higher in the IP group) and dementia with depression (higher in the HB group). Outcome data for the HB group over 15 (range, 1 to 38) months revealed medical hospitalization in 20.7%, psychiatric hospitalization in 16.3%, nursing home placement in 9.2%, and mortality in 8.4%. These preliminary data show that the HB group had psychiatric problems that were comparable to those of the IP group but were not as severely impaired.

Behavioral disturbances are common in dementia. Polypharmacy due to progression of disease and fluctuation of symptoms among patients might increase risk of overtreatment and/or undertreatment. Drug prescription habits were studied in relationship to symptoms of dementia after relocation of patients to group-living care units (GC). Seventy-six demented patients (mean age 81 years) were assessed before, 12 months after, and 24 months after relocation to GC. Vascular dementia was found in 47%, Alzheimer's dementia in 46%, and other dementias in 7%. Medications, regular or as required, were recorded from medication lists. Repeated observations of symptoms like depressive mood and lack of vitality were made with validated scales. Eighty percent of the patients were prescribed drugs; 40% were given neuroleptics and 9% were given antidepressants. During the 2-year follow-up, polypharmacy increased; patients with five drugs or more increased from 15% to 35%; usage of neuroleptics or sedatives, as required, increased from 8% to 25%, p < .01. Depressive mood was noted in 86% after 2 years and 74% showed aggressiveness and anxiety, but only 12% of the patients with depressive symptoms were on antidepressants. Analgesics were prescribed to 26% of patients. In conclusion, a high proportion of patients with dementia had depressive mood and undertreatment of depressive disorder might be suspected. Polypharmacy increased during the 2-year follow-up; this finding calls for careful monitoring of adverse drug reactions, because of the deteriorating cognitive function of these patients.

Lack of early childhood education has been implicated as a risk factor for dementia in late life. It is unclear whether dementia risk is also associated with less education in the adult years. The purpose of the present study was to determine whether amount of postsecondary education (i.e., education beyond the high school or 12th-grade level) is associated with dementia after age 60. Cognitive function (assessed by a neuropsychological test battery) and the prevalence of dementia (assessed by clinical criteria) were determined in 86 Jesuit priests (age 60 to 98) who had from 0 to 23 years of postsecondary education. Logistic regression was used to estimate the odds of dementia as a function of postsecondary education. The risk of dementia was increased in those with less postsecondary education (odds ratio = 3.4; 95% confidence interval, 1.2 to 10.0) after adjustment for age, IQ, and depression. These findings support an association between amount of postsecondary education and risk of dementia in late life.

The occurrence of episodes of getting lost was examined in 104 subjects with dementia who were assessed every 4 months over 5 years. All subjects were initially living at home with a caregiver who could give good information. Forty-three subjects needed to be brought back home at least once. Five subjects repeatedly got lost. Forty-six subjects were kept behind locked doors at some point. Subjects who got lost were more likely to become permanently resident in institutions (odds ratio = 7.3; 95% confidence interval: 3.0 to 17.8). Patients who performed better on a behavioral test of topographical memory were less likely to get lost over the subsequent 5 years (negative predictive value: 90%). The risk of patients with dementia getting lost is substantial and requires frequent intervention by caregivers. This risk is a major reason for institutionalization. A simple test may help in assessing the risk of getting lost in patients with dementia.

The purpose of this study was to examine whether premorbid personality traits predispose to noncognitive symptoms in Alzheimer's disease (AD). The Munich Personality Test was used to evaluate caregivers' perception of personality prior to symptom onset in 56 outpatients with probable AD. Caregivers also completed the “mood” and “disturbed behavior” scales of the Nurses' Observation Scale for Geriatric Patients. A neuropsychiatrist rated depressive symptoms on the Cornell Scale for Depression and the occurrence of personality change in four domains according to ICD-10. Under statistical control of confounding variables, results showed a moderate association between (high) premorbid neuroticism, subsequent troublesome behavior, and personality change, on the one hand, and (low) frustration tolerance and depression, on the other. Premorbid personality traits may indeed predispose to subsequent noncognitive symptoms in AD.

In order to understand what cognitive changes can be expected with aging versus those caused by disease, the New England Centenarian Study examined correlations between neuropsychological evaluation and neuropathological studies of centenarian subjects. Sixty-nine subjects were administered an extensive neuropsychological test battery designed for centenarians. Six brain donors from this group have subsequently died, and neuropathological studies of their brains have been performed to determine the presence of Alzheimer's disease (AD) and other pathological states. Of these six centenarians, three subjects had Clinical Dementia Rating scores of 0 and no dementia on neuropsychological testing, and subsequent neuropathology showed very limited AD changes. In fact, despite a range of neuropsychological findings, none of the subjects in this series met neuropathological criteria for a diagnosis of definite AD. Findings suggest that dementia is not inevitable with aging and that dementia in this age group is surprisingly often not attributable to AD.

The strain of caregiving associated with the care of demented persons living at home often continues after relocation, and group-living-care units (GL), designed for a small number of subjects, have been developed. The aim was to prospectively describe caregiver burden in relationship to symptoms of patients with dementia after relocation to GL. Sixty-four caregivers and 64 demented patients were assessed before, 6 months after, and 12 months after relocation. Thirty-six caregivers were children, 7 were spouses, and 21 were others. Validated scales were used for caregiver burden and dementia symptoms. Total burden of caregivers decreased after 12 months, but the degree of isolation was unchanged and feeling of disappointment increased significantly. The burden was not related to changes of activities of daily life or disorientation. Patients' lack of vitality at relocation independently predicted caregiver's burden 1 year later. Hallucinations and changes of symptoms during the first year were associated with less caregiver burden, probably due to greater detachment of the relationship. The caregiver burden remains 1 year after relocation and any support to the caregiver should consider patients' symptoms, especially lack of vitality.

The question of whether Mini-Mental State Examination scores should be adjusted for age and educational levels to screen for dementia in clinical populations is reexamined in the results of a recent study supporting adjustment. If the criterion is to identify the most accurate screening procedure for each sociodemographic subgroup, the evidence indicates that the unadjusted scores are preferable. Other criteria might lead to different conclusions. The validities of some of these criteria are questionable because they have the flaw that they are easily satisfied by using random decision procedures.

To examine early intellectual deficits in elderly patients with dementia of the Alzheimer type (DAT), 25 mildly impaired patients with DAT and 25 normal controls were compared using the Japanese version of the Wechsler Adult Intelligence Scale–Revised (WAIS-R). The two groups did not differ significantly in age, years of education, or sex ratio. Based on Horn's modified fluid and crystallized model, the WAIS-R subtests were classified into two categories (i.e., fluid intelligence and crystallized intelligence). The DAT group showed a significantly lower crystallized intelligence score, whereas the fluid intelligence scores did not differ significantly between the two groups. When the subtests were examined individually, the subtests for crystallized intelligence (i.e., information, comprehension, and similarities) were found to show the most significant deficits. These results suggest that elderly subjects with mild DAT have more impaired crystallized intelligence than those without dementia.

Two equivalent special care nursing home units for elders with dementing illness were randomly designated as experimental and control units for an intervention called the “stimulation-retreat” model. This model introduced a set of staffing and program changes whose purpose was to diagnose, prescribe, and apply a package of care according to individual needs for additional stimulation or relief from stimulation (“retreat”). A total of 49 experimental and 48 control unit residents completed 12 months of care and were evaluated at baseline, 6 months, and 12 months. It was hypothesized that the intervention would not affect the basic disability (cognitive and activities of daily living functions), would improve negative behaviors and observed affects, and would have maximum impact in increasing positive behaviors and affects. Over time, most functions worsened, including negative attributes and affects. Lesser decline in positive affect and increases in external engagement, however, led to the conclusion that the intervention showed a marginally significant and selective effect on positive behaviors and affect.

The assessment of activities of daily living is a central procedure in the diagnosis of dementia. Few instruments in the field allow for early detection of functional decline because the items they use refer mainly to basic activities of daily living (BADL), which do not become compromised until later in the disease process. The Interview for Deterioration of Daily Living in Dementia (IDDD) may be a valuable tool for early detection of functional decline because it includes, apart from a BADL subscale, another subscale containing a variety of instrumental activities of daily living (IADL), which are the first to be affected in dementing processes. We present an adaptation and validation of the IDDD for Spanish-speaking communities (S-IDDD). A total of 254 control subjects (CONT), 86 patients with mild memory/cognitive impairment with no dementia (CIND), and 111 patients diagnosed with probable dementia of the Alzheimer type (DAT) participated in this project. IDDD total scores (mean and SD) were as follow: CONT: 33.1 (0.4); CIND: 35.2 (3.4); DAT: 54.3 (18.6). The present validation showed no sociodemographic effects on the IDDD total scores. The IDDD demonstrated great internal consistency (α = .985) and reproducibility (intraclass correlation coefficient = .94). Correlations were high (r = .81; p < .1) when they took into account the whole sample, but decreased significantly when the groups were separated by pathologic condition. The scale showed significant differences between DAT versus CIND and CONT. The IADL subscale differentiated all three groups, which makes it extremely valuable for early detection of functional decline. The present study shows that the S-IDDD is a reliable adaptation of the of the original IDDD scale and may be used successfully in Spanish populations for staging and follow-up of subjects with dementia.