Dementia is one of the most frequent and disabling health problems of our times. During the past twenty years, we have witnessed growing public and professional interest in dementia, its diagnosis and causes. This has led to the introduction of better methods of detection of cognitive impairment, coupled with early diagnosis of Alzheimer's disease and, to a lesser degree, of other forms of dementia. However, if the clinical presentation of patients does not follow the typical pattern of progressive memory loss starting in later life, then currently available diagnostic methods are less likely to be useful and patients with dementia may go unidentified for prolonged periods of time. Some of the less frequent causes of dementia may initially present with psychological or behavioral disturbances, others are associated with prominent neurological signs and symptoms. Patients may also present with marked deficits in cognitive domains other than memory, such as impaired language, which makes the diagnostic workup more difficult and onerous.

If the practice of ethics consists of the justifiable application of moral principles, then the challenge will always be to ensure, first, that the principles are well chosen and, second, that their application to the case in point is overtly justifiable. In this editorial, having briefly mentioned “principlism”, which itself involves the application of ethical principles in practice, we shall make the case for casuistry (case-based) reasoning.

Over half of the world's population lives in Asia. With the Asian population aging, it is predicted that there will be a concomitant rapid rise in the number of people with dementia. Unfortunately, most countries in this region are still not well prepared to provide quality services for people with dementia.

Psychogeriatrics began as an extension of psychiatry, with an emphasis on the unique manifestation of psychiatric disorders in the elderly. Early in the history of psychogeriatrics there was an emphasis on late-onset or late-enduring depression; paraphrenia and late-onset psychotic disorders; the late-life phases of schizophrenia; and anxiety and substance abuse disorders in the elderly. Growing recognition of the increasing frequency of Alzheimer's disease (AD) in the course of aging and the high prevalence of behavioral disturbances in patients with AD led psychogeriatricians to study the diagnosis and management of this disorder.

Depression in late life is extremely common. Of those aged 65 years or older, 2–5% have syndromal depression, but up to 20% of elderly people have depressive symptoms (Horwath et al., 2002). Both syndromal and subsyndromal depression carry a high risk of long-term complications and both are associated with elevated risks of morbidity and mortality (Penninx et al., 1999). Despite repeated alerts, depression is consistently under-recognized in acute medical settings, in nursing homes and in primary care (Volkers et al., 2004). For reasons that are inadequately understood, late-life depression seems to be under-treated to an even greater extent than depression in mid-life (Mackenzie et al., 1999). This issue is particularly important, given that effective and safe treatments for depression are available (Bartels et al., 2003), even though the evidence regarding maintenance therapies in older people is inconsistent (Geddes et al., 2003; Wilson et al., 2003). Recent evidence suggests that a package of care can improve the care of older depressed patients in primary care settings (Bruce et al., 2004) and in nursing homes (Ciechanowski et al., 2004). This has led to the development of several clinical guidelines specifically for late-life depression (Baldwin et al., 2003; Charney et al., 2003; Lebowitzet al., 1997). Yet, in the recent National Institute of Clinical Excellence (NICE) guidelines for the management of depression in primary and secondary care, no distinction was made between early, middle and late-life depression (Malone and Mitchell, 2005).

Aim: To appraise the effectiveness of acute hospital service delivery in old age psychiatry.

Method: A systematic literature search of the Medline, PsycINFO, CINAHL, EMBASE and Cochrane Collaboration databases was undertaken to obtain articles published in English from 1966 to May 2004 about old age psychiatry services. Articles were excluded if they did not focus on subjects over 60 years of age, did not include quantitative data on outcomes, or if the intervention was purely pharmacological or a specific non-pharmacological technique. The two authors independently assessed data quality. The overall quality of the evidence for the effectiveness of old age mental health service delivery was rated on an evidence hierarchy that has four levels of evidence.

Results: Forty-six studies were identified that met our criteria. The only randomized controlled trials (RCTs) were of consultation/liaison service provision and delirium prevention and hence the best quality evidence is for interventions to prevent delirium, reduce costs and length of stay (LOS) in medical wards (level II). There is lower quality (level III/IV), albeit consistently positive, evidence that acute hospital treatment by old age psychiatry services is effective. By contrast, there is no evidence (level I) that non-psychiatric hospital medical services improve mental health outcomes.

Conclusion: There are gaps in our knowledge regarding the effectiveness of acute hospital treatment of mental disorders in old age. Multicenter studies involving comparisons of day hospitals, multidisciplinary community teams and acute hospital settings (old age mental health and adult mental health, with and without post-discharge community care) are required.

In order to conceptually define quality of life (QOL) in dementia, the literature on QOL in the elderly population, in chronic disease and in dementia was studied. Dementia is a progressive, age-related, chronic condition and to avoid omissions within the dementia-specific concept of QOL, a broad orientation was the preferred approach in this literature study. Adaptation is a major outcome in studies investigating interventions aimed at improving QOL in chronic conditions, but to date, it has not been used in the definition of QOL. It is argued that adaptation is an important indication of QOL in people with chronic diseases and therefore also in dementia. Some crucial issues in assessing dementia-related QOL that are relevant to clarify the continuing debate on whether QOL, particularly in dementia, can be measured at all, are discussed. Then the following conceptual definition is offered: dementia-specific QOL is the multidimensional evaluation of the person–environment system of the individual, in terms of adaptation to the perceived consequences of the dementia.

The results of in vitro and animal studies provide a strong rationale for the use of hormone replacement therapy (HRT) to prevent dementia and Alzheimer's disease (AD). In humans, the results of 16 observational studies are consistent with the hypothesis that estrogen use reduces the risk of AD by 10 to 60%. However, women who are prescribed HRT are less likely to have hypertension, diabetes and history of stroke than nonusers. As all of these factors have been associated with increased risk of dementia (including AD), this “prescription bias” may have a significant impact on the results of observational studies. Randomized trials are designed with the aim of avoiding many of the potential biases and confounding (measured or unmeasured) of observational studies. The results of the Women's Health Initiative Memory Study (WHIMS) indicate that HRT (estrogen plus progestin or estrogen alone) increases the risk of dementia (hazard ratio, HR=1.8, 95% CI=1.2–2.6). Taking into account the results of the WHIMS and the adverse health events associated with the use of estrogen plus progestin or estrogen alone, we conclude that HRT cannot be recommended as a safe and effective strategy to prevent dementia.

The search for the possible causes of common and uncommon forms of dementia has a long and interesting history. This paper presents a brief review of how the concept of dementia has evolved over time and an historical outline of the causative factors associated with these disorders. Currently available evidence leads to the conclusion that there is only one common cause of dementia: Alzheimer's disease with or without other overlapping pathological processes (such as cerebrovascular disease, traumatic brain injury, etc.). All other forms of dementia are, in isolation, uncommon.

This issue of International Psychogeriatrics sees the introduction of what I hope will become a regular journal feature: a “for debate” section. Several other journals have a policy of airing two opposing points of view on controversial topics, sometimes followed by a commentary. Although there are some things upon which all (or nearly all!) health professionals working in the field of psychogeriatrics can agree, it is also true that there are a number of issues on which available evidence is too thin, the balance of benefit and cost (or even harm) too delicately poised, or ethical viewpoints too diverse, to allow consensus to emerge. It also seems likely that some of the things that we do as routine or believe as gospel today, may one day turn out to be viewed quite differently (e.g. insulin coma therapy), so I think it is healthy that we should identify such areas of disagreement and rehearse in print the cases for and against certain practices or points of view. The aim is not to make everybody agree, nor solely to entertain our readership with the spectacle of two irreconcilable sides of an argument slogging away at each other until both succumb to a technical knockout (rather like the TV program, Monty Python's Flying Circus, which proposed a show called A Brick Wall in which two people of utterly opposed views would throw bricks at one another in front of a studio audience!), but rather, by outlining what is known and how it can be viewed, to assist us all in better understanding some of the difficult issues faced by our discipline, and to further comprehension and respect of divergent points of view.

Over 90% of people with dementia develop behavioral problems or psychiatric symptoms at some point during their illness (Ballard et al., 2002). These symptoms are clearly important, but that does not legitimize widespread use of dangerous treatments.

Studies on laypersons' beliefs and knowledge about mental disorders have proliferated in recent years. However, attention has been focused mainly on depression and schizophrenia and on young adults. The aim of this paper is to summarize research in the area, and to discuss the need to expand research in the elderly population. The unique characteristics of older persons in terms of the prevalence and type of mental disorders, especially Alzheimer's disease (AD) and other dementias, as well as in terms of their being victims of “double jeopardy” require special attention and research. The present review has three main objectives. First, it summarizes the findings of studies examining different aspects of mental health literacy. Second, the importance of age in the study of mental health literacy is discussed. Third, findings of the few studies examining laypersons' beliefs in the area of AD are presented. Finally, research directions are suggested with special emphasis on the importance of geriatric mental health and mental health literacy.

Objectives: To investigate the efficacy and tolerability of transdermal estrogen patches for the adjunctive treatment of aggressive behavior in male patients with advanced dementia.

Methods: The study was designed as an 8-week, randomized, controlled trial in acute aged psychiatry inpatient units and specialized nursing homes in Melbourne, Australia, between 1998 and 1999. The participants were 27 men with established dementia, identified as displaying aggressive behavior not responding to treatment for at least 2 weeks prior to referral. The instruments used to measure aggressive behavior were the Rating Scale for Aggressive Behavior in the Elderly (RAGE), the Cornell Scale for Depression in Dementia (CSDD) and the Mini-mental State Examination (MMSE). Physical examination was performed and biochemistry and serum hormone concentrations were measured at baseline and at 8 weeks. Concomitant psychotropic medication use was recorded and analyzed.

Results: There was no significant difference in aggressive behavior at 8 weeks, but significant “rebound” in aggressive behavior (change in scores between week 8 and week 10, p<0.009) and benzodiazepine use in the estrogen group (p<0.03), following removal of the patches. Only behavioral items of the CSDD improved in the experimental group (p=0.031). The use of patches was associated with a significant rise in serum estrogen (p<0.001) but not with a significant decrease in serum testosterone (p=0.077). There were no adverse effects associated with their use.

Conclusions: The use of transdermal estrogen yielding up to 100μg per day was not associated with discernable improvement in aggressive behavior in men with advanced dementia. Small subject numbers, multiple variables and a lack of statistical power impair interpretation of these results. However, the tolerability and apparent rebound effect on removal of patches indicate the need for larger studies in this area.

Objectives: To investigate the prevalence of depression among the oldest old and to analyze factors associated with depression.

Methods:A cross-sectional, population-based study was undertaken in Umeå, Sweden. Out of 319 eligible participants aged 85, 90 and 95 years and older, it was possible to evaluate 242 people (75.9%) for depression. Data were collected from structured interviews and assessments in the participants’ homes, and from medical charts, relatives and caregivers. Depression was screened for using the Geriatric Depression Scale-15 and further assessed with the Montgomery–Åsberg Depression Rating Scale. Cognition was assessed using the Mini-mental State Examination, activities of daily living (ADL) using the Barthel ADL Index, nutrition using the Mini Nutritional Assessment and well-being using the Philadelphia Geriatric Center Morale Scale.

Results:The 85-year-olds had a significantly lower prevalence of depression than the 90- and 95-year-olds (16.8% vs. 34.1% and 32.3%). No sex differences were found. One-third of those with depression had no treatment and among those with ongoing treatment 59% were still depressed. Persons diagnosed with depression had a poorer well-being and a higher 1-year mortality. Logistic regression analyses showed that depression was independently associated with living in institutions and number of medications.

Conclusion:Depression among the oldest old is common, underdiagnosed and inadequately treated, and causes poor well-being and increased mortality. More knowledge about depression is essential to improve the assessment and treatment of depression among the oldest old.

A brief review of classification in psychiatry from Kraepelin to ICD-10 and DSM-IV reveals that the categorical paradigm inherent in these nosological systems has certain inadequacies when applied to dementia specifically and cognitive impairment in general. There are “outcasts” from these two systems that, with the rapid advances in an understanding of cognitive disorders, expose significant limitations in them. As and when they are revised, serious consideration of a different view, accepting a dimensional paradigm, would contribute to a more inclusive and clinically relevant nosology for dementia and cognitive disorders.

When patients present with a dementia syndrome at a young age, the experienced clinician will automatically include uncommon dementias in the diagnostic considerations, as familial uncommon dementias due to genetic mutations frequently present as early-onset dementias. This paper highlights why uncommon dementias due to genetic mutations, although marginal in terms of prevalence numbers in the total population, are of significance in the quest to unravel the underlying cause of common dementias such as Alzheimer's disease (AD), dementia with Lewy bodies (DLB), frontotemporal dementias (FTD) and vascular dementia (VaD).

Behavioral and psychological signs and symptoms of dementia (BPSD) include disorders of behavior, mood, thought content and perception (Burns et al., 1990a, b, c, d; Foli and Shah, 2000). BPSD are common (Foli and Shah, 2000) and can cause distress to patients, informal carers and professionals, and lead to institutionalization and over-medication (Shah, 1999). Both non-pharmacological and pharmacological treatment strategies have been utilized to improve BPSD. Despite the recent controversy surrounding the use of olanzapine and risperidone for BPSD, a case for judicious use of these drugs is rehearsed below.