Psychogeriatric research has explored many factors likely to influence our mental health in later life, but one which has received surprisingly little attention given the current interest in genetic determinants has been paternal age. We now know that both delayed motherhood and delayed fatherhood may have a significant detrimental effect on the mental health of the offspring, but by different mechanisms. While delayed motherhood has been associated with higher rates of obstetric and perinatal problems, delayed fatherhood has been associated with higher risk of new inheritable-mutation disorders. Tarin et al. (1998) have postulated that this is because aging leads to a reduction in the activities of antioxidant enzymes within the seminal plasma and spermatozoa making them more vulnerable to mutational changes. In most syndromes the mutation rate increases with paternal age at an exponential rate. This rate is much higher than in elderly women, perhaps due to the greater number of cell divisions in the male germ line (Crow, 1997).

Background: The objective of this study was to review available dementia screening instruments that could be recommended for self-administration, particularly in electronic format. Owing to the gradual loss of insight associated with the progression of dementia, a broad definition of self-administration including self-administration by concerned informants (family, friends, carers) was used.

Method: A systematic search of PubMed, PsychINFO, and the Cochrane Library Database was conducted. Only available full-text articles about dementia screening instruments written in English were included. Articles reporting on instruments used in a non-English context were excluded unless a validated English version of the instrument was available. Included instruments were assessed against the precise criteria and characteristics of the Mini-mental State Examination (MMSE), the most widely used screening instrument.

Results: The Concord Informant Dementia Scale (CIDS) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were the only instruments meeting all selection criteria. The Memory Impairment Screen (MIS) also met the criteria, although it lacks validation for self-administration. No instrument has been validated for self-administration in electronic format.

Conclusions: It is recommended that the MIS, the CIDS and the IQCODE be validated for self-administration in electronic format.

Background: Clock-drawing tests are popular components of dementia screens but no single scoring system has been universally accepted. We sought to identify an optimal subset of clock errors for dementia screening and compare them with three other systems representative of the existing wide variations in approach (Shulman, Mendez, Wolf-Klein), as well as with the CDT system used in the Mini-Cog, which combines clock drawing with delayed recall.

Methods: The clock drawings of an ethnolinguistically and educationally diverse sample (N = 536) were analyzed for the association of 24 different errors with the presence and severity of dementia defined by independent research criteria. The final sample included 364 subjects with ≥5 years of education, as preliminary examination suggested different error patterns in subjects with 0–4 years of education and inadequate numbers of normal controls for reliable analysis.

Results: Eleven of 24 errors were significantly associated with dementia in subjects with ≥5 years of education, and six were combined to identify dementia with 88% specificity and 71% sensitivity: inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, or refusal to attempt clock drawing. Time setting was the most prevalent error at all dementia stages, refusal occurred only in moderate and severe dementia; and ethnicity and language of administration had no effect. All critical errors increased in frequency with dementia stage. This simplified scoring system had much better specificity than two other systems (88% vs 39% for Mendez's system – 63% for Shulman's) and much better sensitivity than Wolf-Klein's (71% vs 51%). Stepwise logistic regression found the simplified system to be more strongly predictive of dementia than the three other CDT systems of dementia. Substituting the new CDT algorithm for that used in the original CDT Mini-Cog improved the Mini-Cog's specificity from 89 to 93% with minimal change in sensitivity.

Conclusions: Only six errors need be assessed to capture most of the power of clock drawing to discriminate between people with dementia and normal subjects, and improves specificity over older systems in subjects with ≥5 years of education. These errors require minimal conceptual classification and are easily detected and scored by non-specialists.

Background: There is little, though growing, interest in the research area of attitudes held among physicians towards disclosing the diagnosis of dementia and Alzheimer's disease (AD), or the current practice on AD disclosure. This study aimed to investigate the practice and attitudes of specialized physicians towards AD diagnosis disclosure in Brazil.

Methods: A questionnaire was devised to survey the current practice and attitudes regarding diagnosis disclosure of AD in Brazil and sent to specialized physicians (170 geriatricians, 300 neurologists and 500 psychiatrists) by electronic mail.

Results: From 970 potential respondents, 181 physicians who usually attend AD patients returned the questionnaire. There were no significant differences between the three specialties regarding the frequency with which they informed patients of their AD diagnosis (p = 0.17). The results revealed that only 44.8% of the physicians would regularly inform the patient of the diagnosis, although 85.6% of these use clear terminology. Despite their usual practice, 76.8% would want to know their diagnosis if they themselves were affected by AD.

Conclusions: Disclosure of AD diagnosis is not common among specialized physicians in Brazil and different factors are involved. In the clinical context, discussion on advantages of diagnosis disclosure can be useful for improving the care of AD patients and their families.

Objective: This study examines the psychometric properties and clinical experience in using the Mandarin translation of the Quality of Life–Alzheimer's Disease (QoL-AD) instrument in Chinese patients with dementia in Singapore.

Methods: A Mandarin version of QoL-AD was established following standard guidelines for transcultural adaptation of QoL measures. The instrument was administered to 70 patient-carer dyads; patients with severe dementia (MMSE < 10) were excluded. Reliability by internal consistency and test-retest, and construct validity by correlating the known domains of QoL-AD with validity measures for the respective domains, was performed. Guidelines for Rating Awareness Deficits (GRAD) measured patients' insight into their deficits.

Results: Three patients were not able to complete the QoL-AD. Internal consistency (Cronbach's α) was high for both patient (0.9) and carer (0.8) QoL-AD ratings, as was test-retest reliability, intraclass correlation coefficient (ICC) 0.7 and 0.8 respectively. Correlation of QoL-AD with domain measures was moderate for carer ratings (0.21 < r < 0.51) and poor for patient (−0.17 < r < 0.13). Patient self-rated QoL correlated poorly with, and was significantly higher than, carer-rated QoL. Correlation between patient and carer QoL-AD was stronger in patients with better insight (GRAD 3–4).

Conclusions: The results suggest that while the Mandarin version of QoL-AD can be used reliably in our population, patients' self perceived QoL can be different from carer ratings and from objective QoL measures. The disparity can be attributed to patients' poor insight, denial, fear of “losing face,” normalization and accommodation of standards with aging. The patients' lack of education and seclusion from Western cultural exposure are also contributory.

Background: Preliminary evidence indicates that the quality of the carer-care recipient relationship predicts those carers most at risk from anxiety. Attachment style is related to higher carer burden, psychological morbidity and increased care recipient institutionalization. We tested, for the first time, the hypothesis that carer burden and the coping strategies used mediate a relationship between attachment style and anxiety.

Methods: We interviewed 83 people with Alzheimer's disease and their family carers, originally recruited for a larger community study. Carers filled in a validated measure about their attachment style, the Hospital Anxiety and Depression Scale, the COPE to measure coping strategies, and the Zarit-Burden interview.

Results: More avoidant attachment (β = 0.28) and less secure attachment (β = −0.32) predicted anxiety. After adding coping strategies to the equation, the relationship with avoidant attachment (β = 0.15) was no longer significant, and that with less secure attachment was reduced (β = −0.23). A well-fitting structural equation model supported our finding that dysfunctional coping mediated the relationship between attachment style and anxiety.

Conclusion: Carers who were less secure or more avoidantly attached reported higher anxiety. Interventions that aim to modify coping strategies have shown promise in reducing carer anxiety. Our finding that coping strategies also appear partially to explain the excess of anxiety among less securely attached carers suggests they are likely to benefit from such interventions.

Background: Caring for spouses with dementia is a risk factor for increased levels of depression. Less is known about specific symptom differences between groups of caregivers and non-caregivers. This study characterizes differences on the CES-D depression screening scale between caregiving and non-caregiving spouses.

Methods: Data were obtained from 391 spouse caregivers of persons with dementia and 226 control subjects. Significant between-group differences on demographic variables determined covariates used in two multivariate ANCOVA analyses, on the set of four CES-D subscales and on the set of the 20 CES-D individual items. Significant multivariate analyses were followed by univariate tests between the two groups.

Results: Dementia caregiving spouses had significantly more depressive symptoms than non-caregiving married adults, after controlling for group differences. Proportion of variance in the set of CES-D subscales explained by caregiver group status was 13.4%. The greatest between-groups difference in univariate analysis was found in the Positive Affect subscale, and significant differences were found in 11 of the 20 CES-D items. Caregiver spouses experienced less hope for the future and less happiness and enjoyment in life than the non-caregiving spouses. They also reported greater degrees of sadness, being bothered, and loneliness than the non-caregivers.

Conclusions: The differences, particularly caregivers' lack of positive affect, suggest the need for appropriate intervention approaches to assist spouse caregivers.

Background: The potentially negative consequences associated with providing care to older adults are well documented. Recently, there has been an increasing interest in the positive aspects associated with caregiving. Both aspects are believed to represent a continuum of caregiving experiences. Long-term care (LTC) staff members often report high levels of burnout associated with their work. Whereas several job characteristics and objective indicators of socioeconomic status have been identified as potential predictors of LTC staff caregiving experiences, the role of subjective socioeconomic status (i.e. one's view of one's place in society) has not yet been evaluated.

Methods: A cross-sectional design of 122 LTC staff members. LTC staff completed the Maslach Burnout Inventory and the Positive Aspects of Caregiving questionnaire. They also completed questions about job characteristics (i.e. staff-to-resident ratio, number of hours worked per day, and years of experience working with older adults), objective sociodemographic variables (i.e. level of education, professional affiliation), and subjective socioeconomic indicator (i.e. MacArthur Scale of Subjective Social Status). Hierarchical regression analyses were conducted to identify the unique contribution of job characteristics, objective socioeconomic status, and subjective socioeconomic status to LTC staff caregiving experiences.

Results: Subjective socioeconomic status remained a significant predictor of LTC staff experience even once job characteristics and objective indicators of socioeconomic status were entered into the model. Those who placed themselves higher on the subjective social ladder reported higher levels of positive caregiving experiences and lower levels of burnout.

Conclusions: Building a sense of community identity and improving one's status within the community might result in lower levels of burnout and better caregiving experiences among LTC staff.

Objective: To examine, in an exploratory analysis, the association between vascular conditions and the occurrence of neuropsychiatric symptoms (NPS) in a population-based sample of incident Alzheimer's disease (AD).

Methods: The sample consisted of 254 participants, identified through two waves of assessment. NPS were assessed using the Neuropsychiatric Inventory. Prior to the onset of AD, data regarding a history of stroke, hypertension, hyperlipidemia, heart attack or coronary artery bypass graft (CABG), and diabetes were recorded. Logistic regression procedures were used to examine the relationship of each vascular condition to individual neuropsychiatric symptoms. Covariates considered were age, gender, education, APOE genotype, dementia severity, and overall health status.

Results: One or more NPS were observed in 51% of participants. Depression was most common (25.8%), followed by apathy (18.6%), and irritability (17.7%). Least common were elation (0.8%), hallucinations (5.6%), and disinhibition (6.0%). Stroke prior to the onset of AD was associated with increased risk of delusions (OR = 4.76, p = 0.02), depression (OR = 3.87, p = 0.03), and apathy (OR = 4.48, p = 0.02). Hypertension was associated with increased risk of delusions (OR = 2.34, p = 0.02), anxiety (OR = 4.10, p = 0.002), and agitation/aggression (OR = 2.82, p = 0.01). No associations were observed between NPS and diabetes, hyperlipidemia, heart attack or CABG, or overall health.

Conclusions: Results suggest that a history of stroke and hypertension increase the risk of specific NPS in patients with AD. These conditions may disrupt neural circuitry in brain areas involved in NPS. Findings may provide an avenue for reduction in occurrence of NPS through the treatment or prevention of vascular risk conditions.

Background: The literature on health services (HS) use for mental health problems by community-living seniors with depression is sparse. This study aimed to characterize patterns of HS use for mental health problems by seniors with depressive disorders and symptoms during the previous 12 months.

Method: The study used data from the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being (N = 7736). Information was collected on demographic, social, mental, physical and functional variables and HS use for mental health problems. We obtained simple univariate and bivariate descriptions of the data and developed multivariate predictive models for each of the HS utilization variables.

Results: Rates of any HS use for mental health problems ranged from 1.8% for those with no depressive symptoms to 31.1% for those with major depression. Variables predicting increased HS use were: depressive disorder or symptoms, clinically significant distress or impairment, age 65–84, single, post-secondary education, religiousness, disability, co-morbid mental disorder and fewer friends and positive social interactions. Variables predicting HS use among depressed seniors were physical health, psychiatric co-morbidity and activity limitation.

Conclusion: Community-living seniors with major depression, co-morbid major depression and depressive symptoms were more likely to use psychiatrist, family physician, other professional and self-help services for mental health problems but less than a third actually did so.

Background: This study aimed to examine the validity and reliability of an Arabic version of the 15-item Geriatric Depression Scale (GDS-15).

Methods: 121 community-dwelling older adults and primary care patients aged 60 and above participated in this study. Older adults with dementia, those with thyroid dysfunction, and hearing or speech impairments were excluded. Test-retest reliability was examined by re-administering the translated GDS-15 to a subset of 38 participants at least seven days after the initial interview.

Results: The Arabic GDS-15 had good psychometric properties, but the best properties were reported for the 7/8 cutoff. Cronbach's α as a measure of internal consistency reliability was high (0.88) and κ ranged from 0.57 to 0.75. The performance of the GDS-15 was equally good for both community-dwelling older adults and those in primary care settings, and for both forms of the GDS (examiner administered vs. self-administered).

Conclusion: The Arabic GDS is a useful measure to assess depression among community-dwelling older adults and primary care patients who do not have dementia. Because of the use of formal Arabic, GDS-15 can be widely used with all Arabic-speaking people.

Objective: This cross-sectional study investigated the prevalence of disturbed sleep and the association of disturbed sleep with medical conditions and service use among older adults.

Methods: A sample of 6961 household residents aged 60 and over was recruited from a population-based random sample. Each subject was examined in a face-to-face interview.

Results: The overall prevalence of disturbed sleep was 33.7%, with the condition being more prevalent in women (37.2%) than in men (27.4%). The overall rate of medical consultations was 78%, and higher in those with sleep disturbance (males 73% vs 27%; females 80% vs 20%) compared to persons without disturbed sleep. The overall rate of hospitalizations was 20.2%. In logistic regression analyses, being female, of low income, low education, younger age, with psychiatric morbidity, pneumonia, urinary infection, dermatological problems and/or hypertension were significantly associated with self-reported sleep disturbance. Ethnicity, civil status or outpatient visits in the previous six months and hospitalizations in the previous year were not associated with self-reported sleep disturbance.

Conclusion: Self-reported sleep disturbance was a frequent problem in the study population and was associated with gender, income, education, lower age and medical conditions. There was no association between sleep problems and use of medical services in the surveyed population.

Background: Cultural factors may influence cross-national variations in elderly suicide rates.

Methods: A cross-national study examining the relationship between elderly suicide rates and elderly dependency ratios was conducted with the a priori unidirectional hypothesis that lower elderly dependency ratios (ratio of people over the age of 65 years to people under the age of 65 years) may imply a greater number of younger people being potentially available to provide support and respect to the elderly and to hold them in high esteem, and this would lead to a reduction in elderly suicide rates. Data on elderly suicide rates, and the total number of elderly and young people were ascertained from the World Health Organization website.

Results: Significant positive correlations were found between the natural logarithm of suicide rates, in both sexes in two elderly age-bands (65–74 years and 75+ years), and the elderly dependency ratio for males, females and both sexes combined.

Conclusions: The impact of elderly dependency ratios on elderly suicide rates may interact with and be modified and mediated through cultural factors. The contribution of cross-national differences in cultural factors on elderly suicide rates require further study by formally measuring cultural factors with validated instruments.

Background: Elderly suicide rates may be influenced by mental health funding, service provision and national policy.

Methods: A cross-national study examining the relationship between elderly suicide rates and (i) the presence of national policy on mental health, (ii) funding for mental health, and (iii) measures of mental health service provision was undertaken by utilizing data from the World Health Organization website.

Results: The main findings are: (i) there is no relationship between suicide rates in both sexes in both elderly age-bands and different measures of mental health policy, except they were increased in countries with a substance abuse policy; and (ii) suicide rates in both sexes in both elderly age-bands were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists, psychiatric nurses, and the availability of training in mental health for primary care professionals.

Conclusions: Cross-national ecological studies using national-level aggregate data are not helpful in establishing a causal relationship (and the direction of this relationship) between elderly suicide rates and mental health funding, service provision and national policies. The impact of introducing national policies on mental health, increasing funding for mental health services and increasing mental health service provision on elderly suicide rates requires further examination in longitudinal within-country studies.

Background: Many older patients have difficulty in swallowing their tablets and capsules. Dose form modification, by crushing tablets or opening capsules, is often used by nurses to administer such medication.

Methods: Electronic searches of five literature databases on tablet crushing and capsule opening were carried out. A review of medication incident reports involving tablet crushing from the U.K. National Reporting and Learning System (NRLS) was also undertaken. An observational study of medication administration on two long-stay wards for older mentally ill inpatients was carried out in a large psychiatric hospital.

Results: Only 17 incidents involving tablet crushing were reported to NRLS in 13 months. In the observational study, the administration of 1257 oral doses of medication at 36 medication rounds was observed. Tablets were crushed or capsules opened for 25.5% (266/1045) of solid oral doses. For 44.0% (117/266) of these doses the tablet crushing had not been authorized by the prescriber. For 4.5% (12/266) of doses crushing was specifically contra-indicated by the manufacturer. In 57.5% (153/266) of doses, tablet crushing was avoidable by the correct use of more suitable preparations. Crushing caused contamination, spillage and hygiene problems.

Conclusions: Although tablet crushing and capsule opening are common practices, they are rarely reported as causing patient harm. Tablet crushing can often be avoided by the use of more suitable preparations. Crushing tablets and opening capsules are contra-indicated for some preparations. Older patients' medication may benefit from review by a pharmacist in order to optimize safe medication administration. Where tablet crushing is unavoidable, attention to cleanliness, contamination and spillage are necessary.

Background: The treatment of depression in Australian aged psychiatry units has been found to be effective in terms of symptom improvement and readmission rates. There is little information, however, about how such hospitalization is viewed by the patients themselves. While users' views are increasingly seen as important for the evaluation of mental health services and for improving outcomes, the views of older patients are less likely to be sought. In this study, former patients were asked about their experience of admission, which aspects were helpful and which were not. Negative experiences have been described in an earlier paper. This paper focuses on what study participants considered to be the positive aspects of their time in hospital.

Methods: Fifty former patients from three Melbourne hospitals were interviewed in their own homes using a semi-structured, open-ended questionnaire.

Results: Forty-six percent expressed an overall favorable view of their hospital stay; 34% had some reservations; and 20% had a poor overall view. Favorable views did not necessarily preclude distressing incidents or complaints but were associated with the ward environment, experienced as a safe haven; the re-evaluation of negative experiences; and, in most but not all cases, recovery.

Conclusions: Retrospective accounts are useful for understanding the ways in which hospital experience is processed. Remembering the experience as positive is, in itself, a good therapeutic outcome. In addition, it may influence readiness to seek future treatment, help prevent relapse, and, indirectly, be helpful to others with similar problems.

When confronted with the question “Should validated dementia self-assessment and screening tools be made widely available in electronic format and on the internet?”, a cascade of associated questions follows, often starting with “What if . . . ?”. What if the population targeted is not internet savvy? What if individuals cannot understand the implications of the results? What if, after finding out that one might be at risk of dementia, no adequate service or treatment is available? What if these tools are abused by unscrupulous relatives? What if a false positive or false negative result is produced?

We recently completed an audit on cognitive testing used in routine practice within our Older People Community Mental Health Team in East Dorset, U.K. We measured the frequency of use of the Addenbrooke's Cognitive Examination (ACE) following its introduction as the baseline test for cognition, comparing it to the Mini-mental State Examination (MMSE) (Folstein et al., 1975).

We recently cared for a patient with hypertension who presented with severe amnesia. Magnetic resonance imaging of the brain revealed localized intracerebral hemorrhage in the left medial temporal lobe. There have been only a few case reports of severe amnesia caused by a restricted hemorrhagic lesion in the unilateral medial temporal lobe (Arai et al., 2006). Here, we present an elderly woman who developed severe amnesia due to left hippocampal hemorrhage. The authors obtained informed consent to the publication of this letter from the patient's son, who was her legal guardian.