When we manage our patients both they and we would like to know that the interventions we prescribe have been tested and shown to be safe and effective for the uses to which they are put. The most powerful tool to determine the utility of specific interventions in the discipline of medicine is the double-blind placebo-controlled randomized clinical trial (RCT). Some of the complex problems encountered in psychogeriatrics do not lend themselves to straightforward yes or no outcomes, and some of the multifaceted interventions developed for the management of common psychogeriatric syndromes are difficult to test using standard RCT design, especially with regard to effective blinding and appropriate control conditions (Llewellyn-Jones et al. 1999; Haynes, 1999; Ames, 1999). Nevertheless, there are specific interventions for which RCT data have been very useful in refining treatment guidelines and advice (e.g. Doody et al., 2001) and, where this is the appropriate trial design, RCTs comprise the “gold standard” by which to assess the efficacy of a treatment or “management package”.

Background: Older adults with dementia commonly exhibit agitated behavior that puts them at risk of injury and institutionalization and is associated with caregiver stress. A range of theoretical approaches has produced numerous interventions to manage these behavior problems. This paper critically reviews the empirical literature on behavioral interventions to reduce agitation in older adults with dementia.

Method: A literature search yielded 23 articles that met inclusion criteria. These articles described interventions that targeted wandering, disruptive vocalization, physical aggression, other agitated behaviors and a combination of these behaviors. Studies are summarized individually and then evaluated.

Results: Behavioral interventions targeting agitated behavior exhibited by older adults with dementia show considerable promise. A number of methodological issues must be addressed to advance this research area. Problem areas include inconsistent use of functional assessment techniques, failure to report quantitative findings and inadequate demonstrations of experimental control.

Conclusions: The reviewed studies collectively provide evidence that warrants optimism regarding the application of behavioral principles to the management of agitation among older adults with dementia. Although the results of some studies were mixed and several studies revealed methodological shortcomings, many of them offered innovations that can be used in future, more rigorously designed, intervention studies.

Background: To investigate the characteristics of patients in whom artificial nutrition and hydration (ANH) is forgone, duration of survival after the decision and factors that are associated with duration of survival.

Methods: Observational study based on written questionnaires in 32 Dutch nursing homes. Of 178 nursing home patients with dementia, their treating nursing home physician (NHP) filled in a questionnaire directly after the decision was made to forgo ANH. The maximum follow-up was 6 weeks. Cox proportional hazards analysis was used to determine predictors of survival.

Results: Decisions to forgo ANH in Dutch nursing homes were made most often in patients with severe dementia who also had an acute illness. More than half the patients (59%) died within 1 week after the decision. Patients with dyspnea and/or apathy were more likely to die during follow-up than patients without these symptoms. Patients who were considered more severely ill by the NHP were more likely to die than those who were considered less severely ill. The presence of restlessness indicated a higher chance of survival.

Conclusions: The clinical judgment of the NHP of the severity of illness appeared to be a strong predictor of patient survival. NHPs should not rely solely on their clinical judgment concerning survival, but they should also consider the presence or absence of dyspnea, apathy and restlessness.

Objective: To examine the current pattern of use of psychotropic medication in Sydney nursing homes and compare this with the pattern noted 5 and 10 years earlier.

Method: Data were recorded from medication cards concerning psychotropic medications prescribed for the 3093 residents in the 51 nursing homes in the Central Sydney Health Area. Documented diagnoses and demographic details were noted from their clinical files.

Results: In late 2003, 47.2% of residents were taking one or more psychotropic drug regularly and another 3.5% had been given “as required” (prn) doses at least once in the preceding 4 weeks. Fewer residents were taking hypnotics (11.3%) and anxiolytics (4.1%) regularly, when compared to 1998, but more were taking antidepressants (20.5%). Selective serotonin reuptake inhibitors were prescribed to 11.4%, venlafaxine to 2.6%, mirtazapine 1.6% and tricyclics to 3.6%. Although the proportion taking antipsychotics had not fallen since 1998, there were over twice as many residents (16.4%) taking atypical neuroleptic medication in 2003 as there were taking conventional neuroleptics (8.1%). Most of them did not have schizophrenia.

Conclusions: There have been further reductions in the use of hypnotics and anxiolytics in Sydney nursing homes, with increased prescription of antidepressants and a striking change towards use of atypical rather than conventional neuroleptic medication.

Objectives: To assess the attitude of elderly lay people towards the concept and symptoms of dementia.

Methods: A population-based, cross-sectional study of 859 residents without dementia, aged 70 years or older, living in an urban area in Istanbul. Nine questions with yes/no responses were designed to investigate the attitudes of the responders to the concept of dementia and symptoms related to particular aspects of dementia. The χ2-test was used to test for differences between proportions of respondents in different age, sex and education groups.

Results: Dementia was considered as normal by the majority of respondents and age and education did not influence this attitude. Women were significantly less inclined to consider dementia and its associated problems as normal.

Conclusion: The concept of dementia is generally not considered as a medical problem by the elderly Turkish population, independent of age and education. These results are important in guiding policy makers and shaping awareness raising campaigns of local Alzheimer's Associations.

Background: A carer-held record (CHR) was developed to enable carers to contribute to care plans for their relatives with dementia, alongside other professionals. The aim of this study was to establish whether CHRs provide any measurable benefits for carers, in the areas of health, stress, knowledge of dementia and locus of control.

Methods: This was a controlled parallel-group trial involving 84 carer/patient pairs, drawn from all new referrals to two community mental health teams (CMHTs). Subjects from one CMHT were given CHRs. The control group from the other CMHT were not offered the initiative. Carers in both groups completed instruments measuring knowledge of dementia, carer stress and strain, carer health, and locus of control (internal, external, chance, shared care) at three time points: baseline, 6 months and 1 year.

Results: Findings are reported for outcome at 6 months and 1 year on 51 carer/patient pairs. Having a CHR was associated with significantly reduced scores on the Carer Strain Index at 1 year (mean between-group difference: −1.34, 95% CI −2.67 to −0.02). Regarding locus of control, external control scores were significantly lower in the intervention group, by 2.5 points at 6 months (95% CI −4.82 to −0.18) and 3.43 points at 1 year (95% CI −5.57 to −1.29) (p = 0.01). There was a significant group by time interaction in chance control, with the difference in chance control between groups widening between 6 and 12 months. In the shared care dimension of locus of control, there was no difference at 6 months, but a significant group by time interaction, with the intervention group maintaining a higher level of internal control between 6 and 12 months, while the control group reduced. No significant differences were identified in the domains of carer health or knowledge of dementia.

Conclusions: Although not a randomized controlled trial, and limited by smaller sample size than planned, this study indicates that use of CHRs provides some benefits for carers in the domains of carer strain and locus of control.

Background: Indigenous Australians have a unique cultural heritage dating back many thousands of years. Unfortunately, there is no validated tool to assess cognition in older indigenous Australians. This study was designed to address this deficiency. The Kimberley Indigenous Cognitive Assessment (KICA) was developed with Indigenous health and aged care organizations, and comprises cognitive, informant and functional sections. The psychometric properties of the cognitive assessment section (KICA-Cog) are described in this paper.

Methods: The KICA-Cog was tested in 70 indigenous subjects, of varying cognitive abilities and diagnoses, over 45 years of age. Subjects were interviewed using the KICA-Cog and then independently assessed by expert clinical raters using DSM-IV and ICD-10 criteria. Interrater and internal reliability were determined.

Results: The KICA-Cog score showed no systematic interrater difference; the mean was −0.07 (SD = 1.83). Interrater reliability for 16 individual questions from the cognitive section revealed a κ-value ≥ 0.6 and intraclass correlations for 12 questions. Internal consistency, as assessed by Cronbach's α, was 0.88. Three items on the cognitive score (pension week, recall and free recall) effectively discriminated 85–7% of dementia cases. Sensitivity and specificity were 90.6% and 92.6%, respectively, using a cut-off score of 31/32.

Conclusions: The KICA-Cog appears to be a reliable assessment tool for cognitive impairment in an Australian older traditionally living indigenous population.

Background and objectives: Cognitive screening is a “first step” in detecting dementia and other neuropsychiatric syndromes and hence represents an important public health and clinical initiative. A plethora of cognitive screening instruments has been advocated in recent years, but the extent to which these instruments are used or their effectiveness is not well known. An International Psychogeriatric Association (IPA) survey was designed to determine which cognitive screening instruments were used most frequently by clinicians with special expertise in the neuropsychiatric aspects of old age and also to determine the ones considered most useful by these specialists.

Method: Under the auspices of the IPA, the survey was mailed in the fall of 2004 to all IPA members as well as members of the American and Canadian Associations of Geriatric Psychiatry. The survey inquired about demographic information, the frequency of use of cognitive screening instruments, and the value attributed to the cognitive screening instruments. Participants also had an opportunity to provide written commentary.

Results: A total of 334 completed surveys were processed. The majority of respondents were geriatric psychiatrists (58%). Of the 20 different instruments that were listed on the survey, only six were selected as “routinely” or “often used” by the survey respondents. These instruments in declining order were: (1) the Folstein Mini-mental State Examination; (2) the Clock Drawing Test; (3) Delayed Word Recall; (4) the Verbal Fluency Test; (5) Similarities; and (6) the Trail Making Test. “Effectiveness” and “ease of administration” were the test characteristics most highly predictive of frequency of use. Open-ended comments highlighted patient factors that continue to provide challenges, including ethnicity/culture, language, education/literacy, and sensory impairment. Respondents concluded that “no single test is adequate.”

Conclusions: Psychogeriatricians worldwide routinely use a relatively small number of brief cognitive screening instruments. Further evaluation is necessary as the need increases for cognitive screening guidelines that inform public health initiatives related to dementia and neuropsychiatric syndromes.

Introduction: Brief cognitive tests such as the Mini-mental State Examination (MMSE) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) have been used to detect cognitive impairment and dementia in studies of stroke patients. However, there are few data on their validity for such use. We have evaluated their validity in detecting cognitive impairment not dementia (CIND) and dementia in a community-based sample of first-ever stroke patients.

Methods: The standardized MMSE (S-MMSE) and the 16-item IQCODE were administered to 79 patients 1 year after a first-ever stroke. CIND and dementia were diagnosed independently using a comprehensive cognitive battery. The performances of the two tests were evaluated using receiver operating characteristic (ROC) analyses. Combined performance was evaluated when their scores were used in parallel (the “or rule”), in series (the “and rule”) or as a weighted sum (the “weighted sum rule”).

Results: Both tests were extremely poor at detecting CIND individually and in combination. For dementia, at traditional cut-points, the S-MMSE (≤23) was insensitive (0.50, 95% CI 0.16–0.84) and the IQCODE (≥3.30) nonspecific (0.63, 95% CI 0.51–0.75). An acceptable balance between sensitivity and specificity was achieved for dementia using the “or rule” combination, but with only modest positive predictive value.

Conclusions: The S-MMSE and the IQCODE were individually poor at detecting CIND and dementia after a nonaphasic first-ever stroke. The combination was useful in detecting dementia but it does not replace the need for detailed neuropsychological tests.

Background: The Dutch version of the Coping With Depression (CWD) course for older adults has been implemented in the prevention arm of the community-based mental health care system in the Netherlands. The study group included older adults with subclinical depression as well as those with a major depressive disorder; all were enrolled into the course by mental health care professionals. The effectiveness (immediate and long-term) of the course for this heterogeneous population was studied in an effectiveness trial.

Method: Participants were self-referred, responding to media announcements. A total of 119 participants aged 55–85 years (69% female), with subclinical depression and major depression, were randomized to either the CWD course (N = 61) or the waiting list (N = 58).

Results: Nine participants dropped out of the course. According to a diagnostic interview based on the DSM-IV, 39% had a major depressive disorder (MDD), 69% had had a previous MDD, and 45% had an anxiety disorder. Older adults in the intervention group showed a significant decrease in depression symptoms. Gains were maintained over 14 months. In the intervention condition 83% had a pre-treatment score ≥ 16 on the Center for Epidemiologic Studies Depression Scale (CES-D); at post-treatment 62% still scored ≥ 16.

Conclusions: The course was beneficial for participants with mild or severe depression, and treatment acceptability was high. It should be fitted into a stepped-care protocol that varies intervention intensity according to clinical needs, using the post-treatment level of functioning as an indication for the next step.

Objective: The size of the elderly population is growing rapidly in Turkey. We aimed to characterize geriatric psychiatry consultations to obtain the characteristic pattern of these patients for further interventions.

Method: A retrospective chart review was undertaken for each patient.

Results: One hundred and sixty-six patients with a mean age (± S.D.) of 75.5 ± 6.6 years were included in this study. Most referrals came from the Department of Internal Medicine (42.2%), with sleep problems (42.1%), depression (29.5%) and anxiety (28.3%) being the most common reasons for referral. Hypertension was the most frequent medical diagnosis (53.6%). The mean number ± S.D.) of medications used by each patient was 4.4 ± 2.0. The leading psychiatric diagnosis at the end of the assessment was adjustment disorder (31.3%).

Conclusion: Turkish geriatric psychiatry consultation patients display similar characteristics to elderly patients from other western countries. The main difference comes from diagnosis of adjustment disorder, which may be related to hospital conditions and strong family ties in developing countries.

We report the case of an elderly woman with Alzheimer's disease, risk factors for vascular dementia, and atrium-ventricular blockade, who presented with severe agitation and psychosis. She was treated with aripiprazole and assessed with the Neuropsychiatric Inventory (NPI) over the course of 14 weeks. NPI scores showed a marked decrease in psychosis and agitation at week 4, and complete recovery at week 14, except for depression.

The onset of obsessive–compulsive disorder (OCD) for the first time in old age is uncommon and has been mostly related to cerebral abnormalities. We report a case of late-onset OCD in a 77-year-old woman following stressful life events but with a normal cerebral structure. The contribution of life events and vulnerability factors on the genesis and the presentation of her illness are discussed in relation to the literature on OCD.

The role of the family or carer in old age psychiatry is well acknowledged. However, carer interventions are often focused on addressing carer burden alone and are usually individually rather than family based. Interpersonal conflict and family dynamics are rarely addressed. This is not surprising as there is a paucity of literature in family and systems theory applied to the older person, and clinicians are often skeptical about the efficacy of this treatment mode or daunted by the complexity of family and systems theory. Three cases are presented to illustrate the potential benefits of family-based interventions in the setting of commonly encountered clinical situations: (i) the treatment of chronically depressed older people in the community; (ii) the management of behavioral and psychological symptoms of dementia (BPSD) in residential care; and (iii) home-based support and care of the older patient with dementia.