Worldwide, the number of individuals with dementia is growing in an epidemic manner, with an estimated 35.6 million people affected in 2010 (Prince et al., 2013). With the population aging in Asia, dementia care will become a major public health challenge in this region in the coming decades. Over half of the patients with dementia in the world will live in Asia by 2030. In China alone, a recent review of dementia studies showed that there were 9.2 million dementia patients in 2010 (Chan et al., 2013). These figures are staggering. In many Asian countries, dementia is regarded as a shameful illness, and the local terms for dementia are derogatory. Dementia carries a stigma that may lead to patients’ reluctance in seeking treatment and delay in diagnosis. In addition, local names for dementia frequently conjure up pictures of severe stage of dementia, and may lead to therapeutic nihilism, discouraging mental health professionals from working with elderly patients with dementia. As Asia faces the challenges of a rapidly aging population and provisions of care for growing number of dementia patients, change in local names for dementia has become an issue of attention.

The causes of dementia continue to be the subject of huge research efforts, and post-traumatic stress disorder (PTSD) has recently gained attention as a possible contributor. PTSD is considered to be present if the sufferer develops persistent re-experiencing, avoidance and emotional numbing and symptoms of increased arousal not present before the sufferer was exposed to a traumatic incident. PTSD is now classified in DSM-5 as a trauma- and stressor-related disorder, unlike DSM-IV where it was previously categorized as an anxiety disorder, lending it more prominence now as a stress-related condition. However, it remains placed near the anxiety, obsessive compulsive and dissociative disorders in recognition of the close relationship with these other diagnoses. The nosology of PTSD is interesting as the symptoms can vary considerably. Some individuals with PTSD exhibit anxious or fear-based symptoms, while others can experience anhedonic, dysphoric, aggressive or dissociative symptoms (American Psychiatric Association, 2013).

People are good for your brain. Decades of research have shown that individuals who have a larger number of people in their social network or higher quality ties with individuals within their network have lower rates of morbidity and mortality across a wide range of health outcomes. Among these outcomes, cognitive function, especially in the context of brain aging, has been one area of particular interest with regard to social engagement, or more broadly, socially integrated lifestyles. Many studies have observed an association between the size of a person's social network or levels of social engagement and the risk for cognitive decline or dementia (e.g. see review by Fratiglioni et al., 2004). The dementia risk reduction associated with a larger social network or social engagement shown by some epidemiological studies is fairly large. The population effect size of increasing social engagement on delaying dementia disease progression could exceed that of current FDA approved medications for Alzheimer's disease.

Two important aspects of the epidemiology of suicides in the elderly people can potentially be applied to dementia. The first is the well-established observation of the independent effects of age, birth cohort membership, and the period on the risk of suicide in the elderly people (Murphy et al., 1986; Surtees and Duffy, 1989; Snowdon and Hunt, 2002). The second is the recently developed concept of the epidemiological transition hypothesis of suicide in the elderly people (Shah and Bhat, 2009; Shah, 2010; Shah et al., 2008). These epidemiological aspects, in addition to the theoretical aspects, may also have clinical and public health implications for dementia.

With the global aging of our societies and predicted increase of cognitive impairment and dementia, it is no surprise that there is an increasing interest in the research community, but also among clinicians and the general population to learn more about how to focus on modifiable protective factors and how to avoid modifiable risk factors. A recent review of systematic reviews and meta-analyses on significant risk factors for Alzheimer's disease (AD) highlighted the importance of diabetes, hypertension, obesity, smoking, depression, cognitive inactivity, and physical inactivity (Barnes and Yaffe, 2011). For physical inactivity, for example, the authors reported that up to one million cases of AD could be prevented globally if a physical inactivity could be reduced by 25%. However, we should not forget about the various stages of prevention, and especially in the field of psychogeriatrics should also ask what preventative measures might be effective for older adults who have already experienced cognitive impairment. So we could focus on a secondary prevention approach for individuals with mild cognitive impairment (MCI) or on a tertiary preventative approach for patients with dementia. The number of randomized controlled trials (RCT) investigating the effectiveness of physical activity on cognition is limited for healthy participants and those with MCI, but is even more sparse for those with dementia. Even with the limited number of studies it often is difficult to compare RCTs due to the huge variation in inclusion and exclusion criteria, methodology, instruments used and outcomes, intervention and duration of interventions, and observations.

Theleritis and co-workers should be commended for producing the most comprehensive review on the neuroimaging correlates of apathy in Alzheimer's disease (AD). The authors assessed studies using different imaging modalities such as structural neuroimaging with three-dimensional magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), single photon emission tomography (SPECT), and positron emission tomography (PET). This scholarly review will be an excellent resource for future publications on neuroimaging in apathy.

Loneliness is a common, distressing feeling that results when one perceives his/her social relationships and supports as inadequate. Social connectedness refers to the relationships between the individual and his or her family, friends, community, and other supports. Neither loneliness nor social connectedness has received enough research attention, in particular with regard to older adults’ physical and mental health.

The editorial team has chosen the paper by Ritchie and colleagues on C-reactive Protein (C-RP) and delirium, which immediately follows this commentary in this current issue of International Psychogeriatrics, to be the paper of the month.

There is compelling evidence that traumatic brain injury (TBI) can trigger neurodegeneration, and that this is a major determinant of long-term outcome (Smith et al., 2013). A single significant injury such as a road traffic accident or exposure to a bomb blast can predispose an individual to Alzheimer's disease (AD), and here Gilbert and colleagues show for the first time that a history of TBI also alters the progression the disease.

The paper by Kleijer and colleagues (2014) in this issue of International Psychogeriatrics describes factors that may influence antipsychotic drug (APD) prescribing rates in nursing homes in several countries. The authors conclude that the large variability is only partly explained by differences in resident characteristics, and that it is associated with certain facility characteristics such as bed size and urban/rural location. They also identify the likelihood that differences in physician prescribing patterns or facility prescribing culture may influence APD prescribing rates, as has been found in previous studies (Briesacher et al., 2005; Chen et al., 2010).

What does learning to juggle, to golf, to drive, and to be a doctor all have in common? Valkanova and colleagues, in our editors’ choice for “paper of the month,” note the impact they have on gray matter growth.

There is increasing interest in finding markers of Alzheimer's disease (AD) that are discriminative even at an early, pre-dementia stage. This interest is driven partly by a desire to improve clinical diagnosis in more mildly affected individuals, and also by the recent paradigm shift in thinking about clinical trials for AD. This shift is a result of concern that the recent failures of high-profile clinical trials conducted in patients with mild to moderate AD may have been because therapy was “too little, too late.” The implication being that if only treatments had been trialled earlier they would have had a greater chance of success. Certainly, lessons from other aspects of medicine have shown that treatments may be most, or in some cases only, effective if given early in disease. If we did have therapies that could slow disease progression at a very early stage that would increase the interest in early markers of disease. Ideally, such therapies would be given when the minimum of functional decline and irreversible neuronal loss had already occurred. From economic and public health standpoints, delaying symptom onset would be very important: a delay of five years has been estimated to reduce projections for prevalence of symptomatic AD by about 50% (Brookmeyer et al., 1998).

The editorial team has chosen the paper by Rockwood and colleagues on good and bad days in dementia, which immediately follows this commentary in this current issue of International Psychogeriatrics, to be the paper of the month.

As readers of this journal will be well aware, the last decade has witnessed a transformation in our understanding of the pathophysiology of dementias, perhaps most especially Alzheimer's disease (AD), as well as a much greater understanding of the undoubtedly complex and multifactorial etiology of the AD process. An increasing number of genetic risk and protective factors have been identified, as well as potentially modifiable risk factors, including vascular factors such as hypertension and exercise, education, lifestyle, and nutrition. In parallel, there has been considerable progress in developing and validating biomarkers for AD and other dementias. These have transformed the landscape for research, allowing in vivo patient stratification according to pathology, and now have fed through to inform our clinical diagnostic criteria. Particular examples include imaging biomarkers such as characteristic atrophy patterns on magnetic resonance imaging (MRI), hypoperfusion/hypometabolism on functional brain imaging, increased cortical amyloid uptake on positron emission tomography (PET), as well as CSF alterations in tau and β-amyloid. Several changes in blood have also been shown, including altered inflammatory markers, which may prove to be important biomarkers in the future.

Chosen as paper of the month in this issue of International Psychogeriatrics, Shenkin and colleagues (2014) tackle the complex but important issue of how older adults perceive the experience of aging and the life course factors that relate to these perceptions and attitudes. Taking advantage of data from a large, well-characterized group of healthy, community-living older persons in the United Kingdom (the Lothian Birth Cohort of 1963; Deary et al., 2007), the authors conclude that in spite of common tendencies in the medical literature, the popular press, or cultural stereotypes to focus on negative aspects of aging, older persons themselves generally report positive attitudes toward aging. Taking a life course approach, the authors conclude that the most significant and pervasive correlates associated with positive attitudes of aging across three assessed domains (psychosocial loss, physical change, and psychological growth) are personality traits. In contrast, affective disturbances (depression/anxiety) are associated with more negative attitudes to aging. The authors also identify other potentially modifiable factors associated with attitudes to aging, including physical disability, social class, or living circumstances. The authors point out several limitations of this work, including the self-selected sample limiting generalizability; psychometric and conceptual drawbacks of the Attitudes on Aging Questionnaire; and variance not explained by a priori clinically focused predictor variables.