Elder abuse is generally understood in terms of the types of abuse that older people can be subjected to – financial, physical, psychological, sexual, and neglect. However, these definitions often fail to take into account the broader social context in which elder abuse is allowed to occur. Older people are rarely asked about what elder abuse means to them but when they are, they define it in societal terms – social exclusion, the belittling of their views and contribution, and violation of their rights. An effective approach to elder abuse requires intervention at a societal level to combat ageism and age discrimination.

The elderly population size is increasing worldwide due to prolonged life expectancy and falling birth rates. Traditionally, suicide rates increase with age. For example, a recent cross-national study of 62 developing and developed countries reported an increase in suicide rates with aging in males and females in 25 and 27 countries respectively (Shah, 2007a). Thus, suicides in the elderly are an important public health concern. While much is known about proximal (individual level) risk and protective factors for elderly suicides (e.g. Conwell et al., 1991; Cattell and Jolley, 1995; Harwood et al., 2001), less is known about more distal (societal or population level) risk and protective factors (Rehkopf and Buka, 2006). Moreover, detailed knowledge of these distal factors may have greater public health relevance for the development of comprehensive prevention strategies (Knox et al., 2004).

In June 2011, Dr. Willmar Schwabe Pharmaceuticals sponsored a two-day expert meeting in Amsterdam, The Netherlands. The meeting brought together 19 dementia experts from a range of disciplines and countries to review preclinical and clinical data on Ginkgo biloba special extract EGb 761® in the context of recent developments in the diagnosis and treatment of age-related cognitive decline and Alzheimer's disease (AD). Ginkgo biloba special extract EGb 761® is formally approved and reimbursed for the symptomatic treatment of age-related cognitive decline or dementia by numerous authorities worldwide. The meeting therefore focused on relevant research questions and potential study designs with appropriate target populations to prove the efficacy of Ginkgo biloba special extract EGb 761® as a disease-modifying product in AD and to reveal further relevant modes of action.

I am very pleased to be able to introduce the three research papers which have placed first, second and third in the 2011 International Psychogeriatric Association (IPA) Junior Research Awards in Psychogeriatrics. These papers represent the work of three promising young researchers in psychogeriatrics, and both IPA and International Psychogeriatrics are pleased to support such researchers by bringing their research findings to a wide audience.

There is massive evidence that a healthy lifestyle, especially involvement in active exercise, reduces the risk of cardiovascular disease, diabetes type 2, and obesity (Taylor et al., 2004). There is less strong but nevertheless good evidence that it reduces the risk of depression in the older adult population (Strawbridge et al., 2002). The evidence that it reduces the risk of Alzheimer's disease is contestable (Rolland et al., 2008), but if it reduces vascular disease there can be no argument that it must reduce the risk of vascular dementia.

Mental illness in old age is one of the most important healthcare issues of our times: if dementia were a country, it would be the world's 18th largest economy (Alzheimer's Disease International, 2010). In 1989, the UK Department of Health formally recognized old age psychiatry as a specialty in its own right, and by 2010 it had come of age. This anniversary was commemorated with a special edition of Old Age Psychiatrist, the newsletter of the Royal College of Psychiatrists, Faculty of Old Age Psychiatry (2011). To produce this, we called for “Janus” articles drawing on past experiences and giving thought to the future. Thirty-seven authors, ranging from students to retired colleagues, responded. Most contributors were UK-based but five worked elsewhere and provided an international perspective. The majority were psychiatrists who had devoted many years to the specialty, but their thoughts were set in context by representatives from other disciplines closely aligned to specialist healthcare services for mentally ill older people.

Dementia is a cause of significant burden across countries and cultures. Many issues related to mental health problems among older people living in low- and middle-income countries (LMICs) have been highlighted in the literature. However, much of the work in LMICs examines these issues through Western international perspectives. The dearth of local contextually relevant investigations forces academics to rely on universal facts and concepts, discounting uniqueness of the context and cultures.

Cognitive decline has commonly been considered an inevitable result of brain aging and has been of clinical interest principally because of related difficulties with everyday functioning. Since the 1990s the “normality” of age-related cognitive decline has been called into question, being commonly attributed to a number of underlying disorders. Numerous concepts have been proposed which link subclinical cognitive change to pathological states (mild cognitive disorder, mild neurocognitive disorder, mild cognitive impairment). Of these, mild cognitive impairment (MCI) has become the most popular, driven on the one hand by industrial interests seeking to extend new dementia treatments for a more prevalent subclinical syndrome, and on the other by researchers attempting to identify at-risk populations. MCI has been both criticized for “medicalizing” behavior still within normal limits (Stephan et al., 2008; Moreira et al., 2008) and welcomed in that it suggests cognitive decline with aging may not be inevitable, but rather due to abnormalities which could ultimately be treated. Recently, in both Europe (DuBois et al., 2007) and the USA (Albert et al., 2011), panels of experts have scrutinized the concept of MCI and more broadly the pre-dementia stages of neurodegenerative diseases and offered new research diagnostic criteria. These proposed criteria have highlighted the (potential) value of biomarkers in assisting diagnosis, although some have considered the elevation of biomarkers to this level of importance in diagnosing disease before dementia develops to be premature given both the extent and quality of diagnostic biomarker data currently available (McShane et al., 2011a; 2011b).

In neuropsychiatric tradition, Alzheimer's disease (AD) is a clinical diagnosis that requires demonstration of a progressive memory-predominant type of dementia and exclusion of alternative causes. This simple set of criteria is neither sensitive for early clinical stages of AD since amnestic dementia only arises when the underlying neurodegeneration is fairly advanced, nor is it specific because it also occurs in other brain disorders involving the medial temporal lobe and cannot be easily distinguished from AD on clinical grounds. Efforts to identify AD before full-blown amnestic dementia develops, i.e. at a prodromal or even asymptomatic stage, and to treat the driving components of the pathology rather than its end products, are fueling the search for diagnostic indicators that unveil the neurodegeneration independently of its typical clinical manifestation. Such indicators are termed biomarkers in current technical parlance.

Given the rather modest clinical effects of cholinesterase inhibitors, an important question is: For how long should they be prescribed? The clinical trials that supported marketing of the drugs were only 3–6 months in duration. A couple of 12-month, placebo-controlled donepezil trials showed some advantage for Mini-Mental State Examination (MMSE) scores and maintaining a level of activities of daily living (ADL) function during that interval (Mohs et al., 2001; Winblad et al., 2001). The controversial AD2000 trial in the UK tended to show MMSE and ADL efficacy over at least two years (Courtney et al., 2004), but the authors questioned whether treatment was worthwhile or cost-effective.

Cures for the various diseases that give rise to dementia remain elusive and are likely to remain so for the foreseeable future. Our current capacity to slow disease progression or to manage symptoms is far from satisfactory. Pharmacological interventions have made only a modest impact to date, and carry risks as well as possible benefits (Ritchie, 2007)

Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007).

The growing proportion of older people, their longer survival and their longer period of morbidity and disability, have seen health expenditure increase exponentially, which no government can afford. Pharmaceutical expenditure is an increasingly important part of overall healthcare costs and the growing costs of prescription medicines have become a major burden to health care systems worldwide. Medicines account for 20–60% of health spending in developing and transitional countries, in which some governments consistently pay prices above the international reference prices to procure a number of medicines (Suh, 2011). Owing to the different interests of stakeholders (the pharmaceutical companies, medical professionals, patients and family members) who play a major role in healthcare policy-making, international or national policies for cost-containment are drifting or sometimes take a back seat.

Background: Sexuality in later life and its relationship to dementia is a neglected topic: greater understanding of the area has the potential to contribute to the quality of life of people with dementia, their family members, and formal carers. We review current knowledge about sexuality, aging, and dementia.

Methods: We undertook a review of the recent literature to examine of the following areas: what is known about sexuality and aging, and about attitudes to sexuality and aging; what is known about the relevance of sexuality and aging to people living with dementia and their care; and the management of sexual behaviors causing concern to others.

Results: Sexual activity decreases in frequency with increasing age but many older people remain sexually active; there is no age limit to sexual responsiveness; and sexuality is becoming more important to successive cohorts of older people, including people living with dementia and gay, lesbian, bisexual, and transgendered elderly people. Attitudes and beliefs toward sexuality and aging are strongly influenced by stereotypes and myths, not only among the general public but also among those working in health and social care.

Conclusions: Professional bodies should include sexuality, aging, and dementia in their training curricula. More work is needed on the impact of environmental issues, particularly in group living situations, on older adults’ sexuality, and on consent issues. Ethical decision-making frameworks can be useful in practice. Organizations should investigate how to support staff in avoiding a problem-orientated approach and focus on providing holistic person-centered care.

Background: Patient and carer participation in old age psychiatry is less developed than in other areas of mental health. What can we learn from the historical context about increasing participation and how can it be conceptualized?

Methods: The historical and policy context of patient and carer participation in the National Health Service is reviewed and related to the development of old age psychiatry in England and the parallel development of the mental health user movement.

Results: Systemic theory is offered as a way of understanding how partnership between healthcare professionals, patients and carers might lead to service evolution by bringing a range of perspectives together in order to co-construct a mutually influenced outcome. It is further suggested that this might empower not only patients and carers but also healthcare staff at a time when they are under increasing pressures.

Conclusions: Old age psychiatry patients and carers struggle to be heard but have much to offer to services in partnership with healthcare professionals as partners and allies in service development.

Background: The social and economic burden of Alzheimer's disease (AD) and its increasing prevalence has led to much work on new treatment strategies and clinical trials. The search for surrogate markers of disease progression continues but traditional parallel group trial designs that use well-established, but often insensitive, clinical outcome measures predominate.

Methods: We performed a systematic search across the Cochrane Library and PubMed abstracts published between January 2004 and August 2009. Information regarding the clinical trial methodology, outcome measures, intervention type and primary statistical analysis techniques was extracted and categorized, according to a standard protocol.

Results: We identified 149 papers describing results from clinical trials in AD containing sufficient detail for our purposes. The largest proportion (38%) presented results of trials based on tests of cognition as the primary outcome measure. The primary analysis in most papers (85%) was a univariate significance test of a single primary outcome measure.

Conclusions: The majority of trials reported a comparison of baseline and end-point assessment over relatively short patient follow-up periods, using univariate statistical methods to compare differences between intervention and control groups in the primary analysis. There is considerable scope to introduce newer statistical methods and trial designs in treatment evaluations in AD.

Background: Frontotemporal lobar degeneration (FTLD) is a relatively rare disease compared to Alzheimer' disease (AD), but nevertheless causes higher burden and stress to caregivers. Only little is known about the problems and needs of the caregivers of patients with FTLD. Such information is crucial for the development of caregiver support interventions. The aim of the current study is to systematically review publications on (1) burden, problems, and needs of FTLD caregivers, and (2) the feasibility and efficacy of caregiver interventions in FTLD.

Methods: A systematic review was conducted. Medical, psychological, and social sciences databases were searched for publications on burden, problems, needs of FTLD caregivers, and support interventions.

Results: Very little published data are available on burden, problems, and needs of FTLD caregivers. Burden among FTLD caregivers is higher than among AD caregivers and correlated with neuropsychiatric symptoms. Specific problems include delayed diagnosis, young age of patients, behavioral disturbances, lack of information and suitable care facilities, caregivers' depression, social isolation, and neglect of personal needs. Hardly any literature is available on the actual needs of FTLD caregivers. Regarding interventions for caregivers, no randomized controlled trials exist. Eight publications could be identified that provide narrative reports on structured caregiver support groups or respite care in combination with caregiver support intervention or advanced practice nursing.

Conclusion: More research and funding are needed to elucidate the complex construct of burden of FTLD caregivers to identify and quantify their problems and needs in order to develop helpful interventions and services.

Late-life depression (LLD) has a complex and multifactoral etiology. There is growing interest in elucidating how glia, acting alone or as part of a glial–neuronal network, may contribute to the pathophysiology of depression. In this paper, we explore results from neuroimaging studies showing gray-matter volume loss in key frontal and subcortical structures implicated in LLD, and present the few histological studies that have examined neuronal and glial densities in these regions. Compared to results in younger people with depression, there appear to be age-dependent differences in neuronal pathology but the changes in glial pathology may be more subtle, perhaps reflecting a longer-term compensatory gliosis to earlier damage. We then consider the mechanisms by which both astrocytes and microglia may mediate and modulate neuronal dysfunction and possible degeneration in depression. These include a critical role in the response to peripheral inflammation and central microglial activation, as well as a key role in glutamate metabolism. Advances in our understanding of glia are highlighted, including the role of microglia as “electricians” of the brain and astrocytes as key communicating cells, an integral part of the tripartite synapse. Finally, implications for clinicians are discussed, including the consideration of glia as biomarkers for LLD and incorporation of glia into future therapeutic strategies.

Background: There is currently a lack of consensus on the definition of successful aging (SA) and existing implementations have omitted constructs associated with SA. We used empirical methods to develop a dimensional model of SA that incorporates a wider range of associated variables, and we examined the relationship among these components using factor analysis and Bayesian Belief Nets.

Methods: We administered a successful aging questionnaire comprising several standardized measures related to SA to a sample of 1948 older women enrolled in the San Diego site of the Women's Health Initiative study. The SA-related variables we included in the model were self-rated successful aging, depression severity, physical and emotional functioning, optimism, resilience, attitude towards own aging, self-efficacy, and cognitive ability. After adjusting for age, education and income, we fitted an exploratory factor analysis model to the SA-related variables and then, in order to address relationships among these factors, we computed a Bayesian Belief Net (BBN) using rotated factor scores.

Results: The SA-related variables loaded onto five factors. Based on the loading, we labeled the factors as follows: self-rated successful aging, cognition, psychosocial protective factors, physical functioning, and emotional functioning. In the BBN, self-rated successful aging emerged as the primary downstream factor and exhibited significant partial correlations with psychosocial protective factors, physical/general status and mental/emotional status but not with cognitive ability.

Conclusions: Our study represents a step forward in developing a dimensional model of SA. Our findings also point to a potential role for psychiatry in improving successful aging by managing depressive symptoms and developing psychosocial interventions to improve self-efficacy, resilience, and optimism.

Background: Accurate measures of mood state are important for understanding and optimizing health and well-being in later life. A range of different mood assessment measures is available, reflecting the variety of ways in which mood has been conceptualized and the different purposes for which measures have been developed.

Methods: We undertook a conceptual review of the literature relating to mood and its assessment in older populations.

Results: Moods are subjective states of mind that are typically described and quantified using self-report measures. Moods can be conceptually differentiated from the related psychological concepts of emotion, well-being, quality of life, and depression. Quantitative tools for assessing mood state include single-item mood ratings, composite factor scales, and clinical depression assessments. Mood assessments may be administered retrospectively or contemporaneously to the mood state of interest. The method and temporal perspective used to assess mood state will impact on the nature and precision of the mood data that are collected, and the types of research questions that can be addressed.

Conclusions: No single mood assessment technique can be considered optimal for all situations. Rather, both the type of tool and the temporal perspective taken must be selected according to the nature of the study design and the research question being addressed. More thorough and frank reporting of the rationale for, and limitations of, mood assessment techniques are also essential for continued development of mood research with older adults.