In the 19th century, von Bismarck, the Chancellor of Germany, made an extraordinary announcement. He declared 65 to be the age of retirement, when a pension could be received. It was a somewhat cynical exercise, since it was meant to keep the veterans of the France-Prussian War quiet. It was thought they might not rebel if they got a pension. Nevertheless, since most people in those days lived to only 50, there was not much of a demand on the Exchequer. This 65-year-old cutoff is amazingly still recognized, though some sensible countries have chosen to ignore it. Demography, biological aging, personal vanity, and a host of other factors have made it a nonsense. Yet, for the time being, we still yield to it. It represents something symbolic, if not real. It is the next to last hurdle in life. It raises the specter of whether retirement is a predeath experience.

On April 1st, 2003, at its meeting in Geneva, the Board of Directors (BOD) of the International Psychogeriatric Association (IPA) voted to create the post of Editor Emeritus of International Psychogeriatrics. A few minutes later the BOD voted to appoint former Editor-in-Chief Robin Eastwood to the post.

This supplementary issue of International Psychogeriatrics, titled “Vascular Burden of the Brain,” is the product of a special meeting of the International Psychogeriatric Association (IPA), with involvement from Alzheimer's Disease International, the World Federation of Neurology Dementia Study Group, the United States Food and Drug Administration (FDA), and the European Commission for Pharmaceutical and Medicinal Compounds (CPMP). The meeting was held in Madrid in November 2001 and was a closed gathering of many leading international experts on various aspects of vascular brain disease. Attendees included basic scientists, psychiatrists, neurologists, epidemiologists, and neuroradiologists. This wealth of expertise, both from clinicians and scientists, emphasized the necessity for interdisciplinary research into vascular disorders of the brain that affect cognition and behavior. One aim of the meeting was to produce a position paper that summarized the current situation in this field, both highlighting recent advances and identifying important areas where further progress is required. This paper, entitled “Vascular Cognitive Impairment,” has been published in Lancet Neurology (O'Brien et al., Lancet Neurology, February 2003, 2, 11–20). This issue of International Psychogeriatrics contains the individual articles submitted by participants in the special IPA meeting in November 2001.

This is the 48th and final regular issue of International Psychogeriatrics to be produced by Springer Publishing since the first appearance of the journal in 1989. There have also been several popular supplements. It is time to say farewell and thank you to the publishing company that helped to inaugurate what I and my colleagues on the editorial panel hope is and will be the preeminent peer-reviewed journal devoted to the mental health of older people.

Who remembers the Royal Shakespeare Company production of Romeo and Juliet that followed the brilliant Peter Brook conception? Who can speak for 10 minutes about the U.S. President who succeeded Abraham Lincoln? How (if he hadn't lost his head for being a tax farmer) would Lavoisier have topped his discovery of the existence of oxygen? These thoughts crossed my mind on January 3rd as I took over day-to-day editorial responsibility for International Psychogeriatrics from Robin Eastwood.

It is timely for me to record, on behalf of the IPA, the great debt owed to Robin Eastwood by the IPA with regard to his contribution during his tenure as Editor of the Journal. As I know only too well through my own role in the International Journal of Geriatric Psychiatry, being an editor is a difficult and often thankless task, which Robin has executed with skill and diplomacy throughout his time.

The history of vascular dementia can be traced back to cases of dementia postapoplexy described by Thomas Willis in 1672. During most of the 18th and early 19th century, “brain congestion” (due in all likelihood to the effects of untreated hypertension) was the most frequent diagnosis for conditions ranging from stroke to anxiety and to cognitive decline, and bloodletting became the commonplace therapy. The modern history of vascular dementia began in 1894 with the contributions of Otto Binswanger and Alois Alzheimer, who separated vascular dementia from dementia paralytica caused by neurosyphilis. In the 1960s, the seminal neuropathological and clinical studies of the New Castle school in England inaugurated the modern era of vascular dementia.

Background: We determined the incidence, probable risk factors, causes, and long-term survival of delirium in patients hospitalized in a medical specialty teaching hospital in Mexico City. Method: From June to December 1995, 667 elderly patients 60 years and older were hospitalized and assessed within 48 hours, excluding those with delirium at admission, those sedated, on respiratory support, or unable to speak. Results: Twelve percent of the population developed delirium, identified by means of the daily application of the Confusion Assessment Method; its appearance was attributed in 50% to two or more causes, in 10% to an insufficient control of pain, in 7.5% to a preceding surgical event, and in the rest to other causes. Each case was compared randomly with three nonpaired control patients of the same cohort who did not develop delirium. There was a significant increase in the number of cases of delirium in patients older than 75 years (p < .001), those with low schooling (p = .04), those with greater comorbidity (p < .001), those with a hematocrit lower than 30% (relative risk [RR] 2.1, confidence interval [CI] 1.2–4.1), and those with a glucose level greater than 140 mg/dl (RR 2.1, CI 1.2–3.6). Patients with delirium remained hospitalized longer than controls (p = .02). There was no significant difference in the intrahospital mortality of both groups, although during 5 years' follow-up, survivors demonstrated a significant increase in mortality (p = .03) in the group of individuals with delirium during the hospital stay when compared to controls. Conclusion: In this geratric polulation of Mexican patients, delirium incidence was similar to that previously reported in the worldwide literature. Its incidence is associated with longer hospital stay and greater mortality. Age, low level of schooling, greater comorbidity, high glucose levels, poor pain control, and hematocrit lower than 30% were independently associated with a greater incidence of delirium.

In the past decade, pharmacological, behavioral, educational, and environmental interventions for individuals with dementia have addressed a variety of goals: improving cognitive status, delaying the onset of symptoms, reducing behavioral problems such as depression and agitation, and maximizing activities of daily living. It is important not only to ameliorate symptoms but also to evaluate the extent to which an intervention improves the quality of life (QOL) of the person being treated (Logsdon et al., 2002).

The world's older population has been growing at a rate of 2.4% per year during the past decade, and in the year 2000 there were 580 million people aged 60 years or older (World Health Organization, 1998). With the 85 years and older group being the fastest growing segment of the population, age-related diseases and disabilities are rapidly increasing. Psychiatric morbidity is common in later life; 15% of older adults have clinically significant mental health disorders, with neurodegenerative conditions such as dementia taking the lead (Regier et al., 1998). Substantial progress has been made in the quest to unravel the pathophysiological mechanisms leading to dementia, improve the accuracy of early diagnosis, and develop dementia treatment-specific compounds. However, such developments may take decades to have a significant impact on clinical practice.

Monogenic disorders account for only a minority of strokes. Yet, they have been particularly helpful in exploring basic disease mechanisms. This article summarizes some recent data on monogenic stroke while focusing on two conditions: CADASIL, as a genetic variant of ischemic small vessel disease, and familial forms of cerebral amyloid angiopathy, which share many properties with sporadic disease.

Background: Early diagnosis of Alzheimer's disease (AD) is critical for adequate treatment and care. Recently it has been shown that functional magnetic resonance imaging (fMRI) can be important in preclinical detection of AD. The purpose of this study was to examine possible differences in memory-related brain activation between persons with high versus low risk for AD. This was achieved by combining a validated neurocognitive screening battery (the 7-minutes test) with memory assessment and fMRI. Methods: One hundred two healthy community-living persons with subjective memory complaints were recruited through advertisement and tested with the 7-minutes test. Based on their test performance they were classified as having either high (n = 8) or low risk (n = 94) for AD. Six high-risk individuals and six age-, sex-, and education-matched low-risk individuals were investigated with fMRI while engaged in episodic memory tasks. Results: The high-risk individuals performed worse than low-risk individuals on tests of episodic memory. Patterns of brain activity during episodic encoding and retrieval showed significant gourp differences (p < .05 corrected). During both encoding and retrieval, the low-risk persons showed increased activity relative to a baseline condition in prefrontal brain regions that previously have been implicated in episodic memory. By contrast, the high-risk persons did not significantly activate any prefrontal regions, but instead showed increased activity in visual occipito-temporal regions. Conclusion: Patterns of prefrontal brain activity related to episodic memory differ between persons with high versus low risk for AD, and lowered prefrontal activity may predict subsequent disease.

Effective management depends on good communication. This is as relevant in health care as it is in industry, or in governing a nation, or when putting battle plans into effect, or in household management. It is important for people to understand each other's statements. Messages need to be clear and unambiguous.

Objective: The purpose of this research was to identify environmental and personal factors that could be related to the variability in the age of onset of familial Alzheimer's disease (FAD) (36–62 years). Methods: A sample was taken of 49 subjects with FAD and with the mutation E280A in the presenilin-1 gene on chromosome 14; the sample was divided into two subgroups: 27 individuals with age of onset of the disease between 36 and 46 years (early onset) and 22 individuals whose disease began between 47 and 62 years (late onset). Information on environmental and personal factors was collected by means of a questionnaire answered by the patients if their clinical condition allowed it, or by their relatives; such information was organized in a categorical way. Comparisons between the two groups for each categorical variable were done by means of the chi-square test. Noncollinear variables that showed statistical significance were included as independent variables in a logistic regression analysis to predict their association with early onset of the disease. Results: Only 5 of the 140 studied variables were different between the two groups in univariate analysis: education, surgical history, type of stressful event, depression, and affective losses. The logistic regression model was constituted by education, depression, and affective losses. High-level education had approximately 15 times more probability of association with an early onset of the disease; both the history of affective losses and depressive symptoms had 4 times more probability of a similar association. Conclusions: The association of high-level education and early onset of the disease could be related to an earlier detection of symptoms, in turn determined by greater intellectual and environmental demands. The occurrence of depression and affective losses has been considered a prodromic manifestation of the disease. Our findings are evidence of high clinical heterogeneity even in a genetically homogeneous group.

There is always hope—even now that immunization with beta-amyloid has not busted international psychogeriatrics; now that a term once so popular in European neuropsychiatry—“Parkinson plus”—has been de-constructed with the tools of a smart modern neurology (and that dementia with Lewy bodies has been reinvented); now that molecular biology has left some temporary responsibility for clinicians dealing with demented patients themselves, would it not be thrilling to attempt a fundamental reconsideration of some basic concepts of great—albeit temporary—practical relevance?

Background: This study focused on the identification of risk profiles for institutionalization among older adults diagnosed with cognitive impairment-not dementia or dementia in 1991/92 and subsequent institutionalization in the following 5-year period. Methods: Data were from a sample of 123 individuals aged 65+ and their unpaid caregivers in Manitoba, Canada. Cluster analysis was conducted using baseline characteristics of age, cognition, disruptive behaviors, ADLs/IADLs, use of formal in-home services, and level of caregiver burden. Results: Three distinct groups emerged (high-risk [n = 12], medium risk [n = 40], and low risk [n = 71]). The high-risk group had the poorest cognitive scores, were the most likely to exhibit disruptive behaviors, were the most likely to need assistance with ADLs and IADLs, and had the highest level of burden among their caregivers. Follow-up of the groups validated the risk profiles; 75% of the high-risk group were institutionalized within the next 5 years, compared to 45% of the medium-risk group and 21% of the low-risk group. Discussion: The risk profiles highlight the diversity among individuals with cognitive impairment and the opportunity for differential targeting of services for the distinct needs of each group.