• Prof.dr. Richard C. Oude Voshaar, University of Groningen, The Netherlands ([email protected])

• Miss Astrid Lugtenburg, GGZ Drenthe Mental Health Institute, Assen, The Netherlands ([email protected])

• Miss Marij Zuidersma, University of Groningen, The Netherlands ([email protected])

The Netherlands Study of Depression in Older persons (NESDO) is a clinical cohort study including 378 older persons suffering from a depressive disorder and a comparison group of 132 never depressed older persons. Within NESDO cohort, we examined the impact of the Fried Frailty Phenotype and its criteria on the two-year course of late-life depression.

With respect to the prognosis of depression, frail-depressed older patients had a significantly higher level of depressive symptoms over the course of two-years and were less often in remission at the two-year follow-up. Paradoxically, the improvement of the severity of depressive symptoms were larger in frail-depressed compared to non-frail-depressed patients. This raises the question whether the remaining symptoms should be considered as residual depressive symptoms (in need of psychiatric treatment) or physical frailty (in need of geriatric rehabilitation).

To address this latter issue, we have searched for data-driven depressive subgroups by conducting a latent profile analysis on the subscales of the Inventory of Depressive Symptomatology Self Report (IDS-SR), cognitive performance (processing speed, interference, working and verbal memory) and physical frailty (gait speed, handgrip strength). Half of the depressed patients were suffering from a pure depressive disorder (consisting of two subgroups being either mildly or severely depressed), whereas the other half of the sample consisted of three different subgroups of frail-depressed patients, namely a subgroup suffering from amnestic depression, a subgroup of physically dominated frail-depressed patients and finally a subgroup of cognitively dominated frail-depressed subgroup. The three frail -depressed subgroups had differential outcomes with respect to depressive symptom severity, course of frailty parameters and mortality.

Best practice in dementia care is support in the home. Yet, crisis is common and can result in hospital admission. Home-treatment of crisis is an alternative to hospital admission that can have better outcomes and is the preference of people living with dementia.

To report an investigation of the management of crisis for people with dementia living at home and managed by a Home Treatment Crisis Team.

To identify critical factors for successful resolution of crisis and avoidance of hospital admission

The research was mixed-methods case study design. It was an in depth investigation of what happens during crisis in people with dementia and how it is managed by a home treatment crisis team to resolution and outcome at six weeks and six months. Methods were observation of the management of crisis in the home setting for 15 people with dementia (max 3 per person, total 41 observations), interviews with people with dementia (n=5), carers (n=13), and 14 professionals (range 1 to 6 per person, total 29), a focus group with professionals (n=9) and extraction from medical records of demographics and medical history.

The analysis focused on the identification of key treatments, behaviours, education and context important for home treatment to prevent hospital admission.

The study recruited 15 of the 88 accepted referrals to the service for management of a crisis in a person with dementia.

The seven key factors key for crisis resolution were

• a systems approach with embedded respect for personhood,

• attention to carer needs independently of the person with dementia,

• review and monitoring of the effect of medications,

• awareness and promotion of potential benefits with treatment at home,

• education of the health and social care workforce in dementia care,

• local availability of respite and other social care services.

• a dynamic and flexible working ethos and meaningful MDT working with flattened hierarchy

The Home Treatment Crisis Team created a ‘Safe Dementia Space’ for the person with dementia in crisis. In the first instance, this was immediate but temporary with on-going assessment and intervention until negotiated permanent support was in place coproduced and agreed by stakeholders to be a sustainable dementia space with acceptable risk of harm to the person with dementia or others. The approach enabled avoidance of hospital admission in more than 80% of referrals.

This is the first study to collect data during crisis at home for people with dementia and to investigate process and management. It reveals the Home Treatment Crisis Team created sustainable ‘Safe Dementia Space’ to enable the person with dementia to continue to live in the community during and after crisis, thus avoiding hospital admission. The identified key components of the management approach for crisis resolution are important considerations in the design and delivery of home treatment services for people with dementia in the UK and beyond.

Using as a starting point a clinical case, the authors performed a literature review to clarify the relationship between Behçet disease and acute psychosis.

Analysis of the patient's clinical process and brief review of the latest available literature on the subject, published in PubMed/Medline databases.

Male patient, 55 years old, brought to the emergency room by fever, headache, hetero-aggressive behavior, disinhibited behavior, mood swings, euphoria, persecutory delusions and insomnia, in the last 4 days. He had no insight into his illness. There was no personal or family history of psychiatric illness and toxicological habits were irrelevant. Due to the personal history of posterior uveitis with bilateral macular edema, retinal vasculitis, genital aphthosis, papulo-vesicular lesions and recurrent bipolar aphthosis, the hypothesis of neuro-behçet was raised.

Behçet's disease can present with neurological involvement - neuro -behçet - and can manifest itself with several psychiatric symptoms (euphoria, lack of insight, disinhibited behavior, agitation or psychomotor retardation, persecutory delusions, obsessive thoughts, anxiety, depression, insomnia or memory changes). Fever and headache usually appear in the prodromal stage and can be signs of onset or recurrence of the disease. The prevalence of neuro-behçet ranges from 2 to 50% and usually occurs 1 to 10 years after the first symptoms of the disease. Since it appears as the first manifestation of the disease in only 3% of cases, it is difficult to diagnose. The literature suggests that symptoms are generally resistant to treatment with conventional psychotropic drugs and so it is an important cause of morbidity and mortality.”

Cognitive frailty (CF) has been considered as a subtype of frailty characterized by concurrent physical frailty and potentially cognitive impairment (Kelaiditi et al., 2013). Early detection of CF is an important issue in order to implement prevention and intervention to improve quality of life in aging. The aim of this study was to explore the prevalence of cognitive frailty in a sample of Portuguese old people, living in the community, and determine its relationship with sex, age, education and comorbidity.

Two hundred forty nine community-dwelling participants aged over 60 years and without dementia and other neurological and psychiatric diseases were assessed to obtain sociodemographic, functional, health, physical, cognitive and socio-affective measures. Participants were classified with/without mild cognitive impairment using the Montreal cognitive test (MoCa Test), and as physically robust, pre-frail and frail using the criteria of Fried et al. (2001). A cognitive frailty classification variable was created with six groups that were compared on sociodemographic variables and on comorbidity measured with the Charlson Index Scale (ChIS).

A 20.1% of participants were classified as physically robust and cognitively normal (Group 1), a 28.5% as physically pre-frail and cognitively normal (Group 2), a 11.2% as physically frail and cognitively normal (Group 3), a 6.8% as physically robust with cognitive impairment (Group 4), a 14.9% as physically pre-frail with cognitive impairment (Group 5), and a 18.5% as physically frail with cognitive impairment (Group 6). No significant group differences were registered in the distribution by sex. Significant differences were observed between Group 6 and Group 1 and Group 2 in age [F(5, 243)=6.20, p<.01] and in education [F(5, 243)= 6.54, p<.01], being the first older and with lower education level than the two last ones. Regarding comorbidity, Group 6 had significant higher scores in the ChIS [F(5,243)=9.91, p<.01] than all the other groups

The study reveals that a 33.4% of the older adults and with less education level living in community suffer the two more advanced stages of cognitive frailty. Prevention and interventions measures are need to improve their quality of life.

The screening was attended by 300 respondents (150 Kazakhs and 150 Kyrgyz) aged 60 to 90 years (average age 65.6). The material was collected using the Questionnaire for the Champ Clinic and the MOCA test (cut-off point <26) based on the city polyclinics of Almaty and Bishkek.

moderate cognitive impairment was detected - 39.9%, mild cognitive impairment - 33.4%, normal cognitive function - 26.7% in Kazakhs. In the Kyrgyz population, a moderate cognitive impairment was identified - 48.3%; pronounced cognitive impairment - 15.4%, dementia - 8.2%. Expected risk factors for cognitive impairment: 1) in Kazakhs, arterial hypertension - 86.89%, cardiac ischemia, angina pectoris - 70.21%, pathology of the thyroid gland and pancreas (diabetes, hyperthyroidism and hypothyroidism) - 29.50%, atherosclerotic vascular diseases - 29.9%, brain injury - 18.22%, education level - 4.24%, depression - 0.6%, respectively. 2) in Kyrgyz: arterial hypertension - 49%, cardiac ischemia, angina pectoris - 13%, pathology of the thyroid gland and pancreas (diabetes, hyperthyroidism and hypothyroidism) - 21%, low level of education - 11%, Bad habits of smoking and alcohol - 25 %, 20%, respectively.

The transformation of the demographic burden can have important implications for the social security system.We have an urgent need to continue screening the population to identify the main risk factors for moderate cognitive impairment in individuals in the Kazakh and Kyrgyz populations.

Studying those who have achieved exceptional longevity can provide a model of successful ageing, however current research remains limited. Previous work on centenarians has primarily focused on depression and anxiety; life satisfaction remains understudied.

To compare the psychological profile of near-centenarians (95-99) and centenarians (100+) with and without dementia. To compare the psychological distress and life satisfaction in near-centenarians and centenarians without dementia with younger age groups. To identify the risk and protective factors of psychological distress and life satisfaction in near-centenarians and centenarians without dementia.

The Sydney Centenarian Study (SCS) collected data from 343 participants aged 95 years and older, of whom 119 had dementia. Psychological distress was assessed using the Kessler Psychological Distress Scale (K10). Life satisfaction was measured using the Satisfaction with Life Scale (SWLS). Persons aged 70-90 years from the Sydney Memory and Ageing Study (MAS) were used as a cross-sectional comparison group, for which dementia was an exclusion. Multiple linear regressions were undertaken to investigate the predictors for psychological distress and life satisfaction in SCS.

There was no significant difference in K10 or SWLS score between SCS participants with and without dementia. SCS participants without dementia reported significantly higher levels of psychological distress (15.3, 13.4, t=3.869, p<0.001) and life satisfaction (6.0, 5.6, t=5.835, p<0.001) compared to cognitively intact younger age groups in MAS. In SCS, a greater number of psychotropic medications and less contact with friends and family were associated with higher psychological distress. Higher scores on the Mini -Mental State Examination and greater contact with friends and family were associated with higher life satisfaction.

Psychological health was similar in near-centenarians and centenarians whether or not they had dementia. Although near-centenarians and centenarians without dementia demonstrated higher levels of psychological distress in the past 4 weeks than younger age groups, their satisfaction with life was higher. Social support and cognition may be protective factors against poor psychological health and promote greater life satisfaction. Factors identified as associated with psychological distress and life satisfaction may be targets for interventions to maintain good psychological health in this vulnerable population.

Using as a starting point a clinical case, the authors performed a literature review to clarify the relationship between visual hallucinations and treatment with ropinirole.

Analysis of the patient's clinical process and brief review of the latest available literature on the subject, published in PubMed/Medline databases.

Female patient, 89 years old, without psychiatric illness, brought to the emergency room by visual hallucinations, in the past 3 days “I see red, blue and green spots and roses on your sweater and a lot of flowers on that lady's blouse”sic. She recognised them as unreal (pseudo hallucinations) “no, nothing is there. It's from my eyes. I am fine of the head”sic. She has a personal history of glaucoma for decades, and restless legs syndrome for about 1 year, medicated with ropinirole. Adherence to therapeutic has been explored and it was found that she has been increasing, progressively and by its own initiative, the dose of ropinirole. She claims to be currently taking two pills of 8 mg twice daily (the recommended daily dose is 24 mg).

Studies indicate that the incidence of hallucinations during the treatment of RLS with ropinirole is less than 1%, which can be justified by its high affinity for D3 receivers compared to D2 receivers. However, it is also known that the over-stimulation of dopamine receptors (by overdose or rapid titration) can cause hallucinations, which may have been the cause of the patient's clinical condition. This clinical case also allows to alert for the importance of excluding organic causes in the diagnosis of visual hallucinations.

A dementia diagnosis can prevent people from participating in society, leading to a further decline in cognitive, social and physical health. However, it may be possible for people with dementia to continue to live meaningful lives and continue to participate actively in society if a supportive psychosocial environment exists. This feasibility study seeks to create such an environment by determining the feasibility of conducting a multifaceted complex resilience-building psychosocial intervention for people with dementia and their caregivers living in the community.

Ten participants with dementia and their primary caregivers living in the community were recruited and received the CREST intervention. The intervention provided (a) a 7-week cognitive stimulation programme (CST) followed by an 8-week physical exercise programme for people with dementia and (b) a 6-week educational programme for caregivers. Members of the wider community were invited to a dementia awareness programme and GP practices to a dementia-training workshop. Trained professionals delivered all intervention components. Outcomes assessed the feasibility and acceptability of all study processes such as: recruitment; intervention content and delivery; and data collection methods.

Recruiting participants was difficult, with local community organisations/groups proving more successful than GP practices. Preliminary results indicate that participants (people with dementia and carers) enjoyed the content of the CREST intervention, that the delivery method and timing worked well and overall found the programme beneficial. Carers reported that the educational programme provided them with valuable information which was accessible and easy to understand. However, the group activities and learning from each other was identified as crucial to their enjoyment and learning. The people with dementia likewise enjoyed the CST and exercise components, some reporting that the CST enhanced their concentration and that exercising with an exercise buddy was more sociable and enjoyable.

The evidence from participants indicates that CREST is feasible and acceptable to carers and people with dementia in the community.

Current treatments for Major Depression are only moderately effective. In fact, 20-30% do not achieve full recovery despite multiple interventions. Interestingly, while it is well recognised that cognitive impairment is associated with Major Depression, available treatments do not address cognitive impairment. In this regard, cognitive training (CT) represents a promising intervention, however CT is not typically offered in public health settings.

To evaluate the feasibility of a blinded, randomised controlled trial of group-based CT in a hospital sample of older adults with clinically significant depressive symptoms or history of a major depressive episode within the last five years, and in doing so, to adapt and translate research findings to the clinical setting.

40 older adults, aged at least 65 years, with depression or a history of depression, and without dementia were randomly allocated to Club Connect, a 10-week group-based healthy brain ageing CT program, or a waitlist, treatment-as-usual control group. Baseline assessment including review by a psychogeriatrician and a brief neuropsychological assessment was completed within a fortnight of the intervention starting, and follow-up assessment was completed within a fortnight of the intervention ceasing. Primary outcomes included feasibility of trial design, tolerability of the intervention, and acceptability of random allocation and data collection procedures (as perceived by both participants and clinicians). We also examined the most sensitive clinical outcomes and measurement tools to inform larger scale trials.

The current health, social and economic costs of late-life depression, especially in those with concomitant cognitive impairment, renders the holistic treatment of depression in older adults a public health priority. CT represents an efficacious therapeutic intervention in this regard, however, there appears to be a paucity of CT programs being offered in public health settings. This trial represents the first step in addressing the ‘implementation gap’ that exists between care that is known to be effective and care that is delivered. We must recognise the need to evaluate not only health outcomes, but also to perform formative evaluations that assess the extent to which implementation is effective in order to optimise intervention benefits, to prolong sustainability, and to promote dissemination of findings.

Suicide rate tends to peak in old age, and major depression is the most salient risk factor for late-life suicide. However, few studies have focused on the neuroscientific facet of suicide in the context of late-life depression (LLD).

We recruited 114 participants of LLD (28 with history of suicide attempt and 86 without) and 47 elderly controls. They received MRI scanning and behavioral assessment. White matter hyperintensity (WMH) was quantified by an automated segmentation algorithm and graph theoretical analysis was applied to resting-state fMRI. We used ANCOVA to compare group difference in WMH loading and multivariate generalized linear model to compare global and local topological parameters in fMRI signals, controlling for demographics. Partial correlation was conducted between imaging parameters and behavioral data in group of suicide attempters.

We found significant higher WMH in suicide attempters than those of LLD without suicide attempts and elderly controls (F =7.091; p = 0.001). Suicide attempters also had increased betweenness centrality (BC) in right superior occipital gyrus (SOG) (Bonferroni corrected), right precuneus (False positive corrected) and right superior temporal gyrus (uncorrected) and decreased BC in left hippocampus (uncorrected). In suicide attempters, higher BC in right SOG correlated with higher WMH, higher depression severity, higher illness awareness and insight, and lower cognitive function (digit backward), while higher BC in right precuneus correlated with higher decrease awareness and insight and higher cognitive function (digit backward).

Resonating with the vascular hypothesis in LLD, higher WMH was found in those having history of suicide attempts. However, the re-organized brain topology changes are related with divergent cognitive function and convergent heightened disease insight.

Even if cognitive-behavioral therapy (CBT) for caregiving relatives of people with dementia (PwD) has been found to be effective across various outcome measures, investigations into the long-term effects of these interventions remain scarce. Therefore, the purpose of the present study was the evaluation of a CBT intervention for caregiving relatives of PwD three years after intervention onset.

273 caregivers were randomly assigned to receive the intervention (IG) or usual care (CG). IG participants received over 6 month twelve 50-min sessions of individual CBT by trained psychotherapists. Symptoms of depression (CES-D), physical health symptoms (GBB-24), challenging behavior (BEHAVE-AD), quality of life (WHOQOL-BREF), utilization of psychosocial resources (RES), burden of care, coping with the care situation, and emotional well-being (visual analogue scales) were assessed three years after baseline. Data were analyzed using generalized ANCOVA.

164 participants (IG: n = 83, CG: n = 81; 60% of the baseline sample) participated in the three-year follow-up. Based on changes in the caregiving situation at three-year follow-up, we divided the sample into three subgroups: “still caring at home” (n = 52), “nursing home placement of the care recipient” (n = 29), “bereaved caregivers” (n = 83). Positive effects were found in the subgroup of caregivers “still caring at home” (on burden of care, coping with challenging behavior, social relationships QoL-domain) and “bereaved caregivers” (on overall QoL and physical health QoL-domain) compared to the CG. However, IG participants who decided for “nursing home placement of the care recipient” had poorer outcomes on a few measures (overall QoL, psychological health, emotional well-being, utilization of resources related to well-being).

It is impressive that CBT for caregiving relatives yielded positive effects in caregivers still caring at home and bereaved caregivers investigating long-term effects three years after baseline. Many challenges arise over the course of the different caregiving trajectories with changes in the caregiving situation being probably particularly influential. We will provide some ideas on how effects could be further sustained and discuss the need for further investigating the impact of changes in the caregiving situation.

With Singapore’s ageing population, it was anticipated that the increasing number depressed elderly would make recurrent and expensive demands on old age services. There were evidence-based studies that demonstrated the benefits of group therapy in older people with depression, anxiety, low self-esteem and maladaptive behaviour. Aside from being cost effective, group therapy can be more helpful than individual therapy when social support and learning about interpersonal difficulties are objectives of treatment. This paper described the process of setting up and running an outpatient support group for depressed elderly in the psychiatric setting and highlighted the challenges encountered.

English-speaking subjects > 65 years old with a diagnosis of depressive disorder (ICD-10) with no significant cognitive impairment were recruited. Participants attended a weekly closed group for 12 consecutive weeks with each session lasting 75 minutes. Participants continued with their treatments offered by their psychiatrists. The content of the discussion was determined by the group members. Discussion notes were taken by the facilitators after each session. Depression and well-being rating scales were used to assess depression severity at baseline and at the end of 12 weeks.

The response for the study was poor with reluctance to participate in group treatment despite attempts made by the department to encourage participation. 8 participants were eventually enrolled with 3 dropouts. Attendance was disrupted due to sickness, medical appointments, hospitalizations and grandparenting duties. There was a trend of improvement in the evaluation scores of the participants. The main themes identified were (1) ageing and health concerns; (2) reminiscence of the past; (3) regrets and burdens; (4) strategies to defeat depression. Group dynamics observed included universality of painful experiences, mirroring of common experiences during Japanese occupation and strong pairing of the same gender. There were no re-admissions or suicide attempts during the study period.

The lack of response to group work amongst the elderly was consistently observed in this study. This contrasted with the popularity of such interventions in non-Asian settings. Further research would help to elucidate the cultural reluctance in sharing psychological problems amongst the elderly within a psychiatric setting.

Appropriate countermeasures that can alleviate behavioral psychological symptoms of dementia (BPSD) are proposed. However, the effectiveness of these countermeasures has not been fully verified. Conversely, the caregivers of patients with dementia encounter BPSD every day and adopt some kind of measures against that particular BPSD.

We collected data regarding “whether or not a certain measure against a particular BPSD alleviates the symptom (care experience)” from all over Japan using Dementia Chienowa Net, which is a website we developed in 2016. We also collected patient’s data, such as sex, primary disease, and nursing care level, which is an indicator of dementia severity in the Long-term Care Insurance System of Japan.

In this study we analyzed 2003 care experiences (M/F:808/1192). In terms of primary disease, there were 1113 cases (55.6%) of Alzheimer’s dementia (AD), 236 cases (11.8%) of dementia with Lewy bodies (DLB), 217 cases (10.8%) of frontotemporal lobar degeneration (FTLD), and 118 cases (5.9%) of vascular dementia (VaD). Among AD patients living at home with nursing care level 1, care experiences related to forgetfulness were the most common at 43%, denial/rejection was 14%, and restless behavior was 9%. For nursing care level 2, forgetfulness was 38%, restless behavior was 15%, and denial/rejection was 9%. For nursing care level 3, restless behavior was most common at 30%, forgetfulness was 17%, and denial/rejection was 16%. Success rates were calculated; for “forgetting to take medicine,” the success rate of “use of medicine box” was 40%. The success rate of “use of medicine calendar” was 60.8%, and the success rate of “someone handing over the medicine” was 92.3%. For “poor fire management,” the success rate of “changing to equipment that is less likely to cause hazards” was 71.4%.

The frequency of DLB and FTLD in care experiences on Dementia Chienowa Net was more than the frequency of the diseases in Japan. The percentage of BPSD categories troubling patients’ families differed depending on the severity of the dementia. The success rate of some common countermeasures against BPSD frequently encountered in daily life was embodied numerically.