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

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

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

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

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

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

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

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

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

Background:Reports in the literature on the effects of behavioral problems in patients with dementia on the decision to institutionalize the patient have shown conflicting results. Few studies have taken into account the possibility that specific behavioral problems may have differential effects on the decision to institutionalize the patient. Moreover, it is probably not patient behavior itself that causes nursing home placement (NHP), but caregivers’ emotional reaction to it. The aim of the present study was to examine the impact of specific behavioral subsyndromes and caregivers’ emotional reaction on NHP.

Methods:A total of 119 patients with dementia and their informal caregivers were followed up for 2 years. Time to NHP was measured in months from the date of the baseline interview to the date of NHP. Behavioral disturbances in the patient and caregivers’ emotional reactions were measured with the Neuropsychiatric Inventory (NPI). Cox regression analyses were used to determine the probability that caregivers would institutionalize the patient when patient behavioral problems or caregiver distress were present at baseline.

ResultsForty-one percent of the patients were institutionalized during the 2-year follow-;up. Caregiver distress related to patient behavior was a significant predictor of NHP, while behavior in itself did not predict NHP. Contrary to our expectations, we did not find a differential impact of specific aspects of problem behavior. Children caregivers, especially daughters, were associated with shorter time to NHP compared to spouses.

Conclusions:Our findings indicate that the caregiver's emotional reaction to patient behavior is more important than problem behaviors per se in the decision to institutionalize patients. Interventions aimed at teaching caregivers strategies to better manage difficult patient behaviors may provide caregivers with the necessary resources to continue care at home. Future interventions need to account for the specific needs and problems of different caregiver groups.

Background: Dementia is associated with progressive cognitive impairment and behavioral and psychological symptoms. Sleep–wake cycle disturbances are common in patients with dementia. This study evaluated the efficacy and safety of risperidone in the treatment of the behavioral and psychological symptoms of dementia (BPSD) and associated sleep–wake cycle disturbances.

Methods: In this open-label, 12-week, observational, prospective study, the effects of risperidone were assessed using the Neuropsychiatric Inventory (NPI) total and subscale scores. Sleep–wake cycle disturbances were rated by patients/caregivers using a newly developed sleep behavior questionnaire that included assessment of sleep duration, quality, awakenings, and effects on daily activities. Tolerability assessments included the Udvalg for Kliniske Undersogelser (UKU) subscale for extrapyramidal symptoms (EPS) and the recording of adverse events.

Results:A total of 338 patients entered the study, with 321 patients completing. Following 12 weeks of risperidone treatment (mean dose 1.49 mg/day at end-point), the mean NPI score was reduced to 10.6 from a baseline score of 28.7. Compared with baseline, patients/caregivers reported significant improvements following 12 weeks of risperidone in total sleep hours at night (5.5 vs. 7.1 hours), hours awake in bed at night (2.3 vs. 1.2 hours), insomnia (40.1% vs. 8.4%), and other sleep-related variables. Six patients reported a total of 10 adverse events, including somnolence (n = 3) and sialorrhea (n = 2). Scores on the UKU subscale of EPS improved significantly (mean 4.0 at baseline vs. 1.7 at week 12).

Conclusions: Risperidone is effective and well tolerated in the treatment of BPSD and associated sleep disturbances.

Background: Risperidone significantly improves behavioral and psychological symptoms of dementia (BPSD), including aggression, agitation and psychosis, as shown by randomized, placebo-controlled trials.

MethodsAn 8-week, multicenter, naturalistic, open-label study was carried out to examine whether the benefits of risperidone apply to clinical practice. A total of 4499 patients were treated with risperidone at flexible doses chosen by physicians, and were included in the safety evaluation. Of these, 3909 patients met the intended study criteria (at least 65 years of age, dementia, and the presence of BPSD) and were included in the efficacy analyses.

Results:At the end of the study (after 8 weeks of treatment), risperidone (average final dose 1.6 mg/day) significantly improved all symptoms studied (agitation, aggressiveness, disturbance of the sleep–wake rhythm, social withdrawal, suspiciousness and delusions) as rated by physicians on a five-point scale of severity. On a four-point scale of global efficacy, more than 90% of patients were rated improved by both physicians and caregivers after 8 weeks of treatment. A significant improvement in sleep-wake cycle disturbances was also noted. A total of 422 adverse events were documented in 346 of the 4499 patients (7.7%); these included insufficient efficacy (2.6%), extrapyramidal symptoms (0.89%), deterioration of psychiatric symptoms (0.73%), sedation (0.56%), gastrointestinal disturbances (0.49%), cardiovascular disorders (0.38%), and cerebrovascular adverse events (0.36%).

Conclusions: Risperidone is an effective and well-tolerated treatment for BPSD in routine clinical practice.

Background:The possibility that low-dose antipsychotic treatment is associated with increased risk of cerebrovascular events (CVEs) in elderly patients with dementia has been raised. The objective was to determine whether risperidone is associated with an increased risk of CVEs relative to other commonly considered alternative treatments.

Methods:An analysis of Medicaid data from 1999 to 2002, representing approxi-mately 8 million enrollees from multiple states, was conducted. The primary outcome was the incidence of acute inpatient admission for a CVE within 3 months following initiation of treatment with atypical antipsychotics (risperidone, olanzapine, quetiapine, or ziprasidone), haloperidol, or benzo-diazepines.

Results:Descriptive analyses found similar rates of incident CVEs across evaluated agents. Multivariate analyses found no differences in comparisons of risperidone with olanzapine or quetiapine. Risperidone and other antipsychotics as a group were also not associated with a higher odds ratio (OR) of incident CVE than either haloperidol or benzodiazepines. With risperidone as the reference group: olanzapine, OR=1.05, 95% CI 0.63–1.73; quetiapine, OR=0.66, 95% CI 0.23–1.87; haloperidol, OR=1.91, 95% CI 1.02–3.60; benzodiazepines, OR=1.97, 95% CI 1.30–2.98. With benzodiazepines as the reference group, the OR of incident CVE for all antipsychotics as a class was 0.49, 95%CI 0.35–0.69.

Conclusions:This study found no significant difference in the incidence of CVEs between patients taking risperidone and those taking other atypical antipsychotics. Risperidone and all atypical antipsychotics were not associated with higher risk than two common treatment alternatives (haloperidol and benzodiazepines). These findings do not support the conclusion that risperidone is associated with a higher risk of CVE than other available treatment alternatives. The data also suggest that patient characteristics other than antipsychotic use are more significant predictors of CVEs. Given the relatively low rates of incident CVEs, a larger sample of patients with groups closely balanced on a wide spectrum of potential risk factors could provide a more precise assessment of risk.

Objectives: To examine the use of psychotropic drugs in 24 rural and urban long-term care (LTC) facilities, and compare the effect of an education intervention for LTC staff and family members on the use of psychotropic drugs in intervention versus control facilities.

Methods: Interrupted time series with a non-equivalent no-treatment control group time series. Data on drug use were collected in 24 Western Canadian LTC facilities (10 urban, 14 rural) for three 2-month time periods before and after the intervention. Pharmacy records were used to collect data on drug, class of drug, dose, administration, and start/stop dates. Chart reviews provided demographics, pro re nata (prn) use, and indications for drug use. Subjects comprised 2443 residents living in the 24 LTC facilities during the 1-year study. An average of 796.33 residents (32.7%) received a psychotropic drug. An education intervention on psychotropic drug use in LTC was offered to intervention physicians, nursing staff, pharmacists and family members.

Results: Approximately one-third of residents received a psychotropic drug during the study, often for considerable lengths of time. A minority of psychotropic drug prescriptions had a documented reason for their use, and 69.5% of the reasons would be inappropriate under Omnibus Budget Reconciliation Act (OBRA) legislation. Few psychotropic drug prescriptions were discontinued or reduced during the study. More urban LTC residents received neuroleptics and benzodiazepines than their rural counterparts (26.1% vs. 15.7%, and 18.0% vs. 7.6%, respectively). The education intervention did not result in any significant decline in the use of these drugs in intervention facilities.

Conclusion: The results suggest substantial use of psychotropic drugs in LTC, although rural LTC residents received approximately half the number of psychotropic drugs compared with urban residents. A resource-intensive intervention did not significantly decrease the use of psychotropics. There is a need for better monitoring of psychotropic drugs in LTC, particularly given that voluntary educational efforts alone may be ineffective agents of change.

Background: Recent data demonstrate that moderate consumption of alcohol (13–52 grams of ethanol per day) may be beneficial to cognitive functioning among older adults.

Methods: Longitudinal growth curve analyses controlling for baseline age, body mass index (BMI), education/income, migrant status, smoking, history of diagnosed stroke, hypertension, coronary heart disease (CHD), depression, diabetes and stroke (time-varying) were used to examine the relationship between alcohol consumption, gender and cognitive performance over an 8-year follow-up period. The sample included 1624 Japanese American community-dwelling adults aged 65 and older who were cognitively intact at baseline and participated in at least one follow-up examination. Cognitive performance was measured using the Cognitive Abilities Screening Instrument (CASI; 0–100 point scale), a global test of cognitive function.

Results: Current consumers (n=480) scored significantly (p<0.05) higher on CASI (mean rate of change−1.22 CASI units) over the 8-year follow-up period than past consumers or abstainers (n=1144; mean rate of change−3.77 CASI units). There was no significant main effect for gender, or an alcohol and gender interaction.

Conclusions: This study provides further support regarding the beneficial effects of moderate alcohol consumption on cognitive performance over time. Observed benefits were not modified by gender. Future studies need to determine whether alcohol preserves cognition directly or whether other factors such as physiology or cultural drinking practices are driving the observed association.

Background: The main purpose of this study was to correlate a newly developed, simple, but comprehensive screening test for dementia called the Self Test (ST) with the Mini-mental State Examination (MMSE), and establish the reliability and validity of the ST.

Methods:The ST was administered to 42 consecutive new referrals to the memory clinic at the Cole Neuroscience Center, University of Tennessee Medical Center (UTMC), Knoxville, TN, U.S.A. and 41 age-matched control subjects at regular intervals over a 12-month period.

Results:The total ST scores correlated well with cognitive severity as measured by the MMSE (r = 0.71, p<0.01). The area under the receiver-operating characteristic curve (AUROCC) in the group of patients with Alzheimer's disease (AD) with less than a high school education was 0.80, and 0.89 in those with at least a high school education. Reliability analysis showed a mean inter-item correlation of 0.31 for patients with AD, and 0.47 for normal participants. Cronbach's α was calculated to be 0.70 for the AD group. Test–retest reliability was determined using intraclass correlation coefficients (ICC = 0.93, p<0.01).

Conclusions: The ST is an internally consistent, reliable and valid screening test for cognitive impairment in persons exhibiting early symptoms of dementia. In addition, the ST requires minimal nonprofessional supervision and may be administered by an untrained person.

Background: Past negative attitudes towards patients with Alzheimer's disease (AD) have changed in recent years. However, the disclosure of AD diagnosis to patients and family remains an unresoved issue. In this study, we surveyed the family members of neurological patients in Taiwan for the purpose of assessing their attitudes towards the disclosure of AD diagnosis.

Methods: The study sample consisted of family members (150, age range 23–89 years, mean 55.0±14.3) who accompanied patients to a neurology outpatient clinic from September 15 to November 24, 2003. The subjects were given an Attitude Questionnaire on AD Disclosure.

Results: An overwhelming majority (93%) of subjects favored disclosure of the diagnosis if, hypothetically, they personally were affected by AD. However, a smaller majority of family members (76%) favored disclosure of the diagnosis to current AD patients. Reasons for favoring disclosure included a patient's or family member's right to know, the possibility of assistance in coping with and understanding dementia, and slowing down the progression of the disease by early treatment, as well as the increased probability of accepting treatment and life activity training. Reasons for favoring the withholding of disclosure included the risk of causing the patient emotional disturbance, worsening the disease, the irrelevance of disclosure to drug therapy, and the possibility of causing suicidal ideation. Subjects' attitudes towards disclosure of AD diagnosis were unaffected by their knowledge of dementia, the presence of a family member with AD, their role as the primary caregiver, the length of time that AD symptoms persisted, and the number of hours per day spent in caring for AD patients.

Conclusions: In Taiwan, family members of neurological patients strongly favor being informed and the disclosure of AD diagnosis to the family.

Background: Platelet hyper-aggregability is an important risk factor for leukoaraiosis. In this study we investigated whether aggravation of leukoaraiosis can be controlled by means of long-term correction of platelet hyper-aggregability.

Methods:Twenty-one patients with leukoaraiosis and uncorrected platelet hyper-aggregability were compared with 21 controls matched for age, grade of leukoaraiosis and observation period whose platelet hyper-aggregability was corrected. Platelet aggregability was estimated by an optical analytical method with a nine-stage display using two different concentrations each of adenosine diphosphate (ADP) and collagen (the double ADP method).

Results:The mean observation period between two magnetic resonance imaging (MRI) scans for both groups was 4.1 years. In the non-corrected group, moderate to severe aggravation of leukoaraiosis was observed in a large number of patients. In the corrected group, only a small number of patients showed generally mild aggravation of leukoaraiosis. The number of patients showing aggravation of periventricular hyperintensity (PVH) was 7 in 21 in the non-corrected group versus 1 in 21 (p=0.022) in the corrected group, and for aggravation of deep white-matter hyperintensity, these values were 9 in 21 versus 4 in 21, respectively. Thus, the difference was more significant if the degree of aggravation was taken into account.

Conclusion:The progress of leukoaraiosis is greatly inhibited by long-term correction of platelet hyper-aggregability.

Background: Australia has a growing aging migrant population and rates of dementia in residential care are high. The communication of persons with dementia and limited English language proficiency in residential care is an area that has received little attention in the research literature.

Method: Thirty-nine Italian-background older persons with severe dementia residing in either mainstream (n = 20) or Italian-specific (n = 19) aged care facilities were observed and language use was recorded. Medication regime and language proficiency information was obtained.

Results: Participants in mainstream facilities engaged in less communication with co-residents and were prescribed daytime benzodiazepines at a higher rate than those in Italian-specific facilities.

Conclusions: Older persons in mainstream facilities with dementia and lower levels of English proficiency may benefit from additional language-relevant resources. The finding of higher prescription rate of daytime benzodiazepines requires further investigation.

Old age psychiatrists are often called upon to give expert evidence in challenges of testamentary capacity. The nineteenth-century English case, Banks v. Goodfellow (1870) remains the hallmark case for defining the criteria for testamentary capacity in Australia and other Common Law countries. However, a need to go beyond the traditional Banks and Goodfellow criteria for defining testamentary capacity (i.e. (i) understanding of the nature of a will; (ii) knowledge of the nature and extent of one's assets; (iii) being able to recall and understand the claims of potential heirs; (iv) being free of delusions or hallucinations that influence one's testamentary decisions) has been identified recently in the international literature (Shulman et al., 2005). Recent court rulings in Australia which have acknowledged the differences between the nineteenth-century context and today are therefore of international interest, as are recently adapted guidelines for clinicians asked to assess capacity.