Technological developments in medicine have conspired to increase costs, not only because they often require more expensive procedures, but also because they increase the size of the patient population who, at least potentially, could benefit from treatment. Health care has been considered a right of citizenship to which every person must have guaranteed equal and unlimited access. However, because of relentless pressure on public health care budgets, health care is now being treated in much the same way as food or housing or pensions – the government simply establishes a guaranteed base level of protection. Economics is about getting better value from the deployment of scarce resources when a choice has to be made. An important purpose of economic evaluation is that it should serve as a tool for decision-making regarding the allocation of scarce resources (Drummond et al., 1997). Cost effectiveness means cutting costs, but not at the expense of less effective outcomes (Mooney and Drummond, 1982). There appear to be lots of mental health issues with health economic implications.

Does the pharmaceutical industry exert excessive influence on prescribing, research and publication in the field of psychogeriatrics? This is a topic about which I receive a significant number of emails and one which often gets discussed when those active in research in our discipline get together (at both sponsored and unsponsored events!).

The pharmaceutical industry has made significant contributions to the field of geriatric psychiatry. Drug treatment has improved the quality of life for many vulnerable patients suffering from burdensome psychogeriatric syndromes. We do not dispute here the contributions of the pharmaceutical industry to patient care. Rather, we describe how the industry, driven by the need to produce profits, has implemented conscious strategies to promote the prescribing and thus the sales of drugs, without regard to patients' best interests. The industry has influenced the conduct and publication of research, and the promotion of drugs to physicians and patients, for purely marketing purposes.

Concerns increasingly have been raised about the influence of pharmaceutical companies on doctors and their practice of medicine. The pharmaceutical industry has grown in profitability and influence over the past twenty years and is now second only to armaments in the U.S. economy (Public Citizen, 2002). Guidance is available from most Royal Colleges on the appropriateness of using finances/gifts and other benefits from pharmaceutical companies. A declaration of conflict of interest is required for most journals, and evidence shows that there are signs of a small but increasing proportion of articles declaring competing interests in some journals (Hussein and Smith, 2001). Concerns are probably greater in psychiatry, as psychiatric research is particularly susceptible to the influence of vested interests because of the subjective nature of diagnosis and outcome, the variable course of most psychiatric disorders, and the importance of placebo effects, including the context of participating in a research project (Moncrieff et al., 2005).

In 1919 the Dodge brothers successfully sued Henry Ford for his intended largesse, i.e. decreasing dividend payments by using his company to pursue broader social goals “to employ still more men, to spread the benefits of this industrial system to the greatest possible number, to help them build up their lives and their homes,” one of the mechanisms of which included increasing their wages. The Michigan Supreme Court stated that a corporation exists to benefit its stockholders, and may not use profits for “other purposes” (Hood, 1998). This landmark case demonstrated that the prime purpose of any corporation is to maximize its profits for shareholders. Therefore, it is probably naïve of doctors, researchers and the general public to expect the pharmaceutical industry to be driven by other principles, regardless of how noble they might seem. As a result, the driving force that supports the interests of the pharmaceutical industry may not be always aligned with the interests of doctors, patients and the communities to which they belong. How are we to judge that this conflict has evolved in such a way as to produce “excessive” influence of the pharmaceutical industry over other interested parties?

Background: Among the general public there is a deep fear of developing dementia, which has led to an increasing number of people “at risk” seeking ways (such as advance directives) to avoid undergoing progressive mental decline. The views of people with dementia are vital in obtaining a real answer to the question of how the disease affects people's lives and whether it actually involves the suffering that so many fear.

Method: A review of the international literature is provided on what is known about living through dementia from the patient's perspective.

Results: A total of 50 papers met the inclusion criteria. The findings of these reviewed papers give insight into the impact of dementia and the ways that those who have it deal with its effects by using different coping strategies. The literature on the perspective of the patient gives no solid support to the widespread assumption that dementia is necessarily a state of dreadful suffering. Although the impact of dementia and the experiences of loss resulting in multiple “negative” emotions cannot be denied, our findings also indicate that people do not undergo the disease passively and use both emotion-oriented and problem-oriented coping strategies to deal with its challenges. The experiences of living through dementia as told by the sufferers appear to yield a more subtle picture than the assumptions made by the general public.

Conclusion: The overview provides a good starting point for improving the adjustment of care to the experience and wishes of people with dementia.

Background: The aim of the present study was to evaluate the validity, reliability and responsiveness of a Swedish translation of the Quality of Life in Late-Stage Dementia (QUALID) Scale.

Method: A total of 169 elderly residents at 19 dementia special care units in eight long-term care facilities in the Gothenburg city region participated in the study. Assessments were made by 107 proxy informants.

Results: Results showed satisfactory levels of internal consistency reliability (Cronbach's α coefficients 0.74), acceptable inter-rater reliability between informants (0.69), and high test-retest reliability (0.86). As hypothesized, QUALID scores were also associated with those from other quality-of-life (QoL) indices (criterion validity), as well as with use of psychoactive drugs, and with tests of cognitive impairment (clinical validity). The responsiveness of the questionnaire was also acceptable.

Conclusions: As important clinical decisions may derive from perceived QoL effects, it is vital that the QoL data be reliable, valid and sensitive to change. Our evaluations of the psychometric properties of the Swedish QUALID indicate that it satisfactorily meets the need for an instrument to assess QoL in late-stage dementia in Sweden, in a wide range of settings and applications.

Background: The Cognitive Abilities Screening Instrument (CASI) consists of items which are designed to measure the nine domains of cognitive ability. Its total score is used clinically to represent the overall underlying cognitive ability of the patient. This study aimed to evaluate the justification of the uses of the all-domain-total-score as an overall cognitive measure and the domain scores as measures of designated individual cognitive ability.

Methods: To justify the use of total score of all the items as an overall measure of cognitive ability, a second-order confirmatory factor analysis was performed to examine whether the items in CASI contributed significantly to a common underlying construct. The uses of domain scores were also examined by inspecting the loadings of the items on their designated domains. The CASI data from 608 patients, 68 normal and 540 with Alzheimer's disease, were analyzed.

Results The goodness-of-fit indices for the second-order factor model were as follows: CFI was 0.912 for WLSMV and 0.977 for WLSM; TLI and RMSEA values were 0.975 and 0.090 respectively. The loadings of the items on the common underlying construct are all salient (>0.3). The loadings of all but the long-term memory items on their respective subdomains were also salient.

Conclusions: The items of the CASI C-2.0 were useful not only in profiling the correlated cognitive domain scores, but also in forming an overall measure of the underlying cognitive ability of the patients.

Background: Very few studies have approached the issue of persistent vegetative state (PVS) within the elderly population. This study aims to assess the prevalence, determinants and prognosis of elderly patients with PVS admitted to a long-term geriatric facility.

Methods: We conducted a cohort study in the setting of a Skilled Geriatric Nursing Department. All patients admitted during a 17-month period (N = 88) were included and tested for a diagnosis of PVS according to the Disability Rating Scale (DRS).

Results: A clinical diagnosis of PVS was given to 15% of patients upon admission, whereas the DRS diagnosed 30.5% of patients as having PVS. During the study period, 12 out of 31 patients with PVS died, with a median survival of 127 days (range: 1–517 days).

Conclusion: Our study suggests that PVS is an advanced stage in the natural history of dementia in the elderly. The low proportion of patients with PVS recognized as having this disorder upon admission suggests a low awareness among hospital personnel. Further studies of the prevalence and determinants of PVS in the severely disabled elderly population are warranted.

Background: A fall experienced by an elderly person is of special note because it appears to hold a reciprocal causal association with the fear of falling. This study attempts to determine the temporal relationship between the fear of falling and falling among community-dwelling elderly.

Methods: Data on falls experienced during the previous three years were obtained from 732 community-dwelling elderly people. Participants were also asked to provide detailed information about their most recent fall, including the date, time of day, place, circumstances, consequences of the fall, fear of falling, and activity limitations due to fear of falling.

Results: Those who had fallen within the past six months had over four times greater odds of a fear of falling and approximately five times greater odds of activity restriction, compared with those who had not fallen. The association decreased linearly over time, and became nonsignificant for those who had not fallen during the past 25–36 months.

Conclusions: The experience of a fall is strongly associated with an increased fear of falling, and the association appears to persist for at least two years. An elderly person who has experienced a fall requires continuous attention to prevent the development of fear as another problem, together with early intervention to counter the fear of falling.

Background: At present, our understanding of the risk markers associated with panic disorder among older, community dwelling older adults is limited. To address this gap, we examined the prevalence, risk markers, and comorbidity of panic disorder defined using DSM-IV criteria among older adults.

Method: Using data drawn from a large, nationally representative sample of Canadians, we estimated lifetime and 12-month prevalence of panic disorder, and examined demographic predictors and patterns of comorbidity of current panic disorder in adults aged 55 years and older (n = 12,792).

Results: The 12-month and lifetime prevalence estimates of panic disorder in this sample were 0.82% and 2.45% respectively, and one-fifth of these cases reported a first onset after the age of 55 years. In multivariate models, the risk of panic disorder decreased with older age and was significantly lower among widowed respondents. Physical limitations in daily activities as well as the presence of other psychiatric disorders (major depression, and social phobia) were also significantly associated with panic disorder in this sample.

Conclusions: Consistent with previous research on panic disorder, the prevalence of the disorder decreased with age among older adults. Potential explanations for the age effect and the clinical implications of the mental health comorbidities with panic disorder are discussed.

Background: Implementation of the Long-term Care Insurance Law of 1988 in Israel has made it possible to provide services to frail elderly people in the community. This study compares two specific services that are offered to elderly people as part of the law: (1) help offered to elderly people by homecare workers, and (2) help offered in day-care centers.

Methods: The study sought to analyze the impact of the two social service approaches on the self-esteem of the care seekers, and included 300 elderly women (150 of whom received services at home and 150 at day-care centers).

Results: The findings showed that the self-esteem of elderly women receiving services in a day-care center was higher than that of elderly women receiving the same services at home.

Conclusions: The study shows that the provision of services in a social context is important in giving elderly people proper attention which increases their self-esteem, self-evaluation and sense of mastery.

Background: Research with nondepressed adults suggests that social networks and social support are stable over the life course until very late age. This may not hold true for older adults with depression. We examined baseline status and trajectories of social networks and social support at the group and individual levels over five years.

Methods: The sample consisted of 339 initially depressed adults aged 59 or older (M = 69 years) enrolled in a naturalistic study of depression. Measures of social ties, including social network size, frequency of interaction, instrumental support, and subjective support, were administered at baseline and yearly for five years.

Results: Latent growth curve models were estimated for each aspect of social ties. On average, social network size and frequency of interaction were low at baseline and remained stable over time, whereas subjective and instrumental support were high at baseline yet increased over time. There was significant variation in the direction and rate of change over time, which was not predicted by demographic or clinical factors.

Conclusions: Because increasing social networks may be ineffective and may not be possible for a portion of people who already receive maximal support, interventions to increase social support may only work for a portion of older depressed adults.

Objectives: The aim of this study was to investigate factors associated with depression among men and women aged 85 and over.

Method: A population-based study was undertaken in northern Sweden. Out of 527 eligible participants, aged 85, 90 or ≥95, 363 were evaluated for depression. Data were collected from structured interviews, assessments and medical charts and from relatives and caregivers. Depression was screened for using the Geriatric Depression Scale-15 and further assessed using the Montgomerysberg Depression Rating Scale (MADRS).

Results A higher proportion of women were diagnosed with depression (33% vs. 18.6%, p = 0.006). In both men and women experienced loneliness (OR 3.4 vs. 7.0) and not going outside independently (OR 2.6 vs. 26.0) were associated with depression in the final regression model. Depression among men was also independently associated with loss of a child/children during the preceeding ten years (OR 30.0).

Conclusion: Depression was more common among women than among men. Experienced loneliness and not going outside independently seem to be closely related to depression in both men and women. Loss of a child seems to be the most important factor among men.

Background: Suicide rates generally increase with age. With the emergence of studies from several countries without an increase in suicides rates with aging, a cross-national study examining the relationship between suicide rates and age was undertaken.

Methods: The relationship between suicide rates and age was examined by ascertaining suicide rates in both sexes in seven age-bands 16–24 years, 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years and 75+ years, from the World Health Organization website for all the listed countries (N = 62).

Results: The main findings were: (i) there was a significant increase in suicide rates with increasing age in males and females in 25 and 27 countries respectively; (ii) there was no significant increase in suicide rates with increasing age in males and females in 31 and 29 countries respectively; (iii) suicide rates were the highest in the younger age-bands in countries without a significant increase in male suicides rates with increasing age; (iv) countries without a significant increase in the suicide rate with increasing age in both sexes, females only and males only demonstrated regional clustering; and, (v) in a small number of countries suicide rates declined with increasing age.

Conclusions: Potential explanations for regional and cross-national variations in the relationship between suicide rates and age require further study.

Background: The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).

Method: The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.

Results: An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.

Conclusion: There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.

Delusional parasitosis (DP) is a rare psychiatric disorder, predominantly observed in middle aged and elderly patients. It can manifest itself as an isolated delusional disorder (primary DP), as a symptom of another psychiatric disorder or as an organic or toxic psychosis. The typical antipsychotic pimozide was traditionally considered to be the gold standard for treating DP. Compared with pimozide, atypical antipsychotics have many advantages in terms of tolerability, but their effectiveness has only been shown in a few case reports, which do not differentiate between primary and other forms of DP.

We present the case of a 77-year-old woman with primary DP who responded markedly to the atypical antipsychotic olanzapine (2.5 mg daily). She was treated in a psychiatric outpatient department with a follow-up period of 3.5 years. This is the first report of a successful olanzapine mono-therapy in primary DP in such a setting and the longest follow-up period ever reported. The need for maintenance treatment was demonstrated. Olanzapine in age-adapted doses should be considered as an alternative treatment. This paper also provides a review of all published cases in which primary DP was treated with atypical antipsychotics.

Dipyridamole is an antiplatelet agent and a vasodilator which is increasingly being used for the secondary prevention of ischaemic stroke and transient ischemic attack, either alone or in combination with acetylsalicylic acid. We describe an 83-year-old woman who had developed musical hallucinations within days of initiating dipyridamole. Her psychiatric and neurological evaluation was otherwise unremarkable. After the discontinuation of dipyridamole the hallucinations ceased within a couple of days. To the best of our knowledge this is the first case of auditory hallucinations associated with dipyridamole reported in the literature.

Previous research has shown that the presence of behavioral and psychological symptoms (BPSD) can increase the burden of care in dementia (e.g. Donaldson et al., 1998). Impaired executive functions, also called “dysexecutive syndrome” (Wilson et al., 1996), are frequent in dementia and can adversely affect social behavior in everyday life. Reduced awareness of cognitive deficits is associated with impaired executive functions, and may play a significant role in the onset and maintenance of BPSD. A recent paper by Davis and Tremont (2007) demonstrated that dysfunction of frontal systems is associated with increased burden of care in dementia, even after controlling for clinical severity and caregiver mood. In this letter, we report results that support this finding.

Corticobasal degeneration syndrome (CBDS) is a neurodegenerative disorder characterized by higher cortical dysfunctions associated with progressive asymmetric akinetic-rigid syndrome, and limb dystonia or focal myoclonus (Lang et al., 1994). One of the most typical and specific clinical features in CBDS is considered alien limb phenomenon, usually present in advanced disease stage (Doody and Jankovic, 1992).