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Objectives: DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) is designed to address fundamental, and, as yet unanswered, questions about inequalities, outcomes and costs following diagnosis with dementia. These answers are needed to improve the quality of care and equity of access to care, and therefore the quality of life, of people with dementia and their carers.\ud \ud Method: DETERMIND is a programme of research consisting of seven complementary workstreams (WS) exploring various components that may result in unequal dementia care:\ud WS1: Recruitment and follow-up of the DETERMIND cohort - 900 people with dementia and their carers from three geographically and socially diverse sites within six months following diagnosis, and follow them up for three years.\ud WS2: Investigation of the extent of inequalities in access to dementia care\ud WS3: Relationship between use and costs of services and outcomes \ud WS4: Experiences of self-funders of care \ud WS5: Decision-making processes for people with dementia and carers\ud WS6: Effect of diagnostic stage and services on outcomes \ud WS7: Theory of Change informed strategy and actions for applying the research findings\ud \ud Outcomes: During the life of the programme, analysing baseline results and then follow-up of the DETERMIND cohort over 3 years, we will establish evidence on current services and practice. DETERMIND will deliver novel, detailed data on inequalities in dementia care and what drives positive and negative outcomes and costs for people with dementia and carers, and identify factors that help or hinder living well with dementia.

The 10/66 Dementia Research Group has been formed to promote good-quality, internationally comparable research into dementia in developing countries through active research collaboration. In this position paper, we review existing research into dementia prevalence in developing regions of the world. Seven methodologically robust studies were identified. The prevalence of dementia, age-adjusted to the age structure of the Kerala population, ranged from 1.3% to 5.3% for all those aged 60 or over and from 1.7% to 5.2% for all those aged 65 and over. Two studies, from Ibadan, Nigeria and Ballabgarh, India, reported strikingly low prevalence figures. The reported prevalence for most studies was somewhat lower than the consistent figures for Europe reported by the EURODEM concerted action. Based on critical review of the literature, and on the practical research experience of members of the 10/66 group, recommendations have been made for procedure in the following areas: age limits for inclusion in dementia surveys, age ascertainment, sampling, scope for incidence studies, functional assessment and culture- and education-fair dementia diagnosis. Copyright © 2000 John Wiley & Sons, Ltd.

Background The prevalence of neuropsychiatric symptoms (NPS) diminishes the quality of life and increases the care burden in patients with dementia. Despite the clinical importance of dementia-associated NPS, no protocols for treating NPS are already well established. Attention has turned to the effectiveness of nonpharmacological treatments for NPS since their potential safe alternative to pharmacotherapy. Objective This study is aimed to compare the effects in older individuals with dementia living in a residential care, of two intervention programs, the gesture-verbal treatment (GVT), a treatment implemented by us on a previous method for word retrieval in individuals with aphasia, and the better-known doll therapy (DT). The GVT would act on both receptive and expressive language skills, the DT on attachment and emotional connections. Methods We evaluated NPS by the neuropsychiatric inventory in a total of 30 patients divided into 3 groups, the GVT, the DT, and control groups, using a pre-post design. The treatment groups completed 12-week nonpharmacological interventions in addition to standard rehabilitative therapies, while the control group participated only in standard rehabilitative therapies. Results The DT group showed significant improvements in agitation, irritability, apathy, depression, and delusions relative to controls. The GVT group showed significant improvements in apathy and depression with respect to controls. The DT intervention ameliorated symptoms of agitation compared to the GVT intervention whereas the GVT intervention improved apathy compared to the DT intervention. Conclusion Improved understanding of the potential therapeutic benefits of different treatments for neuropsychiatric symptoms is crucial for establishing nonpharmacological interventions in dementia.

Background This paper investigates the potential effects of a policy change in the funding of UK residential care. The White Paper Modernising Social Services (Cm 4169, 1998) outlined plans to change the distribution of the Residential Allowance (RA), payable in support of residents in independent residential or nursing home care, from a component of income support paid direct to establishments to a grant to local authorities. This change was intended to remove the perverse incentive in accessing independent residential care more favourably than local authority care. A further objective was to encourage local authorities to use the grant to support home-based alternatives to residential care. The policy rests on a model in which price signals dictate the choice of care for an older person. By, in effect, raising the price of independent residential and nursing home care, the policy provides an incentive for authorities to seek alternatives to institutional care. Methods Managers from 16 UK social services departments attended a focus group discussion, completed questionnaires and provided information to assist in calculating the potential diversionary effect of the policy. Results Managerial estimates indicated a small diversionary effect of the policy; A potential effect of 0.26 and 0.19 per 1000 older people diverted from residential and nursing care respectively. Conclusions The study indicated that wider organisational factors other than price are likely to play a greater role in deciding whether an older person is admitted to care. Changes in public funding alone do not reflect the complexities involved in decision-making concerning the residential placement of older people. Copyright © 2003 John Wiley & Sons, Ltd.

This short paper attempts to provide a framework to aid the old-age psychiatrist in choosing psychotropic drugs in a way that minimizes the risks of adverse drug reactions. It concentrates on the clinical problems most frequently encountered in old-age psychiatric practice. Older people are at risk of adverse drug interactions because of their higher rate of physical morbidity and increased likelihood of receiving polypharmacy, as well as due to age-related change in drug handling. The strongest evidence for relevant interactions in older people relates to changes in renal excretion (particularly relevant for lithium) and cytochrome P450 (relevant for a wide range of psychotropic and other drugs). Awareness of potential interactions is important in ensuring safe prescribing practice for older people with mental health problems.

Objective The advent of long-term remotely conducted clinical trials requires assessments which can be administered online. This paper considers the utility, reliability, sensitivity and validity of an internet-based system for measuring changes in cognitive function which is being used in one such trial. Methods The Platform for Research Online to investigate Genetics and Cognition in Ageing is a 10-year longitudinal and entirely remote study launched in November 2015. The CogTrackTM System is being used to monitor changes in important aspects of cognitive function using tests of attention, information processing and episodic memory. On study entry, the participants performed CogTrackTM up to three times over seven days, and these data are evaluated in this paper. Results During the first six months of the study, 14 531 individuals aged 50 to 94 years enrolled and performed the CogTrackTM System, 8627 of whom completed three test sessions. On the first administration, 99.4% of the study tasks were successfully completed. Repeated testing showed training/familiarisation effects on four of the ten measures which had largely stabilised by the third test session. The factor structure of the various measures was found to be robust. Evaluation of the influence of age identified clinically relevant declines over the age range of the population on one or more measures from all tasks. Conclusions The results of these analyses identify CogTrackTM to be a practical and valid method to reliably, sensitively, remotely and repeatedly collect cognitive data from large samples of individuals aged 50 and over. Copyright © 2017 John Wiley & Sons, Ltd.

Background. There is limited literature around peer-research in dementia. This study aims to identify the benefits, the risks and the practical challenges and to develop a model of good-practice in peer-research with people with dementia. Methods. We searched on PsycInfo, PubMed and Google Scholar for empirical investigations or discussion papers on peer-research. Given the limited literature in the field of dementia, we included studies with groups who share similar demographics (older people), experience of stigma (mental health service users) and exclusion from research (people with learning disabilities). We applied no restrictions on language and publication date. Analysis. We identified three themes: the potential benefits, the potential risks and the practical challenges of peer-research. We developed a model of good practice. The European Working Group of People With Dementia (EWGPWD) reviewed our paper and added to our findings. Results. We included 7 papers. Potential benefits of peer-research included enriched data and empowering people with dementia. Potential risks included power differentials between researchers and issues of representativeness. The practical issues for good practice included the training of peer-researchers, defining involvement and roles, working with cognitive impairment and considering resource implications. The EWGPWD emphasised the importance of equality issues. Conclusion. Involving people with dementia in peer-research can generate several benefits, including empowerment and opportunities for inclusion for the peer-researchers and the research participants living with dementia, challenging academics’ traditional views on research processes and gathering enhanced research data. There remains a need for further research on the impact of peer-research in dementia studies.

Copyright © 2016 John Wiley & Sons, Ltd. Objectives: Psychotherapy provides a means of helping participants to resolve emotional threats and play an active role in their lives. Consequently, psychotherapy is increasingly used within dementia care. This paper reviews the existing evidence base for individual and group psychotherapy with people affected by dementia. Design: The protocol was registered. We searched electronic databases, relevant websites and reference lists for records of psychotherapy with people affected by Alzheimer's Disease, Vascular dementia, Lewy-body dementia or a mixed condition between 1997 and 2015. We included studies of therapies which met British Association of Counselling and Psychotherapy definitions (e.g. occurs regularly, focuses on talking about life events and facilitates understand of the illness). Art therapy, Cognitive Stimulation and Rehabilitation, Life Review, Reminiscence Therapy and family therapy were excluded. Studies which included people with frontal–temporal dementia and mild cognitive impairment were excluded. Data was extracted using a bespoke form, and risk of bias assessments were carried out independently by both authors. Meta-analysis was not possible because of the heterogeneity of data. Results: A total of 1397 papers were screened with 26 papers using randomised, non-randomised controlled trials or repeated measured designs being included. A broad mix of therapeutic modalities, types, lengths and settings were described, focussing largely on people with mild levels of cognitive impairment living in the community. Conclusions: This study was limited to only those studies published in English. The strongest evidence supported the use of short-term group therapy after diagnosis and an intensive, multi-faceted intervention for Nursing Home residents. Many areas of psychotherapy need further research. Copyright © 2016 John Wiley & Sons, Ltd.

Objective The main objective of this study was to summarize the effects of various individual, caregiver, and system-related factors on the risk of long-term care (LTC) placement for persons with dementia. Methods We searched electronic databases for longitudinal studies reporting on predictors of LTC placement for persons with dementia residing in the community or supportive care settings. We performed meta-analyses with hazard ratios (HRs) of various predictors using random effects models and stratified the HRs with several study variables. Data on predictors not included in the meta-analyses were summarized descriptively. Results Full-text reviews of 360 papers were performed with data from 37 papers used to calculate pooled HRs for LTC placement of select person with dementia (age, sex, race, marital status, type of dementia, living arrangement, and relationship to caregiver) and caregiver (age, sex, and depressive symptoms) characteristics. White race [HR = 1.67, 95% confidence intervals (CI): 1.41–1.99], greater dementia severity (HR = 1.05, 95% CI: 1.03–1.06), and older age (HR = 1.02, 95% CI: 1.01–1.03) increased the risk of LTC placement. Married persons with dementia (HR = 0.38, 95% CI: 0.16–0.86) and living with their caregiver (HR = 0.72, 95% CI: 0.56–0.92) had a lower risk. Behavioral and psychological symptoms of dementia, the degree of functional impairment, and caregiver burden had a consistent effect on the risk of LTC placement in our descriptive review. Conclusion We quantified the predictive effect of several risk factors for LTC placement. These estimates could be used to more precisely categorize the risk of institutionalization and potentially link those at higher risk to appropriate services. Copyright © 2016 John Wiley & Sons, Ltd.

Objective Inattention is a core feature of delirium, and valid assessment of attention is central to diagnosis. Methods of measuring attention in delirium can be divided into two broad categories: (i) objective neuropsychological testing; and (ii) subjective grading of behaviour during interview and clinical examination. Here, we review and critically evaluate studies of objective neuropsychological testing of attention in delirium. We examine the implications of these studies for delirium detection and monitoring in clinical practice and research, and how these studies inform understanding of the nature of attentional deficits in delirium. Methods Searches of MEDLINE and ISI Web of Knowledge databases were performed to identify studies in which objective tests of attention had been administered to patients with delirium, who had been diagnosed using DSM or ICD criteria. Results Sixteen publications were identified. The attention tests administered in these studies were grouped into the following categories: measures of attention span, vigilance tests, other pen-and-paper tests (e.g. Trail Making Test) and computerised tests of speeded reaction, vigilance and sustained attention. Patients with delirium showed deficits on all tasks, although most tasks were not considered pure measures of attention. Five papers provided data on differential diagnosis from dementia. Cancellation tests, spatial span tests and computerised tests of sustained attention discriminated delirium from dementia. Five studies presented reliability or validity statistics. Conclusions The existing evidence base on objective assessment of attention in delirium is small. Objective testing of attention is underdeveloped but shows considerable promise in clinical practice and research.

†ELS obtained funding devised the project, collected and analysed data and drafted the final paper. MB, MK and LJ supervised the project, data analysis and contributed to the interpretation of results and writing of the paper. BL led data analysis and wrote the paper. Objective: To examine the effect of dementia on longer term survival after hospital admission, and to assess whether dementia is an independent predictor of mortality. This information is vital for the provision of appropriate care. Methods:A prospective cohort study, in a large urban acute general hospital, of 616 people (70 years and older) with unplanned medical admission. The principal exposure was DSM-IV dementia and main outcome mortality risk. Dementia severity was analysed by using the Functional Assessment Staging scale. We examined a range of modifying variables: acute physiological disturbance (Acute Physiology and Chronic Health Evaluation), chronic comorbidity (Charlson Comorbidity Index, CCI) and pressure sore risk (Waterlow score). Results:A total 42.4% of the cohort had dementia. Nearly half (48.3%) had died 12months after admission (median survival time 1.1years compared with 2.7years in people without dementia). Unadjusted hazard ratios for mortality in people with dementia was 1.66 (95% CI 1.35–2.04) and for people with moderately severe/severe dementia 2.01 (95% CI 1.57–2.57). After sequential adjustment (age, gender, Acute Physiology and Chronic Health Evaluation score, Charlson Comorbidity Index and Waterlow score), patients with dementia had a mortality risk of 1.24 (95% CI 0.95–1.60) and those with moderately severe/severe dementia 1.33 (0.97–1.84). Conclusions: People with dementia had half the survival time of those without dementia. The effect of dementia on mortality was reduced after adjustment, particularly by the Waterlow score, a marker of frailty. The median survival of 1year suggests clinicians should consider adopting a supportive approach to the care of older people with moderate/severe dementia who have an emergency hospital admission. Copyright # 2012 John Wiley & Sons, Ltd.

There is limited literature around peer research in dementia. This study aims to identify the benefits, the risks and the practical challenges and to develop a model of good practice in peer research with people with dementia.We searched on PsycInfo, PubMed and Google Scholar for empirical investigations or discussion papers on peer research. Given the limited literature in the field of dementia, we included studies with groups who share similar demographics (older people), experience of stigma (mental health service users) and exclusion from research (people with learning disabilities). We applied no restrictions on language and publication date.We identified three themes: the potential benefits, the potential risks and the practical challenges of peer research. We developed a model of good practice. The European Working Group of People with Dementia reviewed our paper and added to our findings.We included seven papers. Potential benefits of peer research included enriched data and empowering people with dementia. Potential risks included power differentials between researchers and issues of representativeness. The practical issues for good practice included the training of peer researchers, defining involvement and roles, working with cognitive impairment and considering resource implications. The European Working Group of People with Dementia emphasised the importance of equality issues.Involving people with dementia in peer research can generate several benefits, including empowerment and opportunities for inclusion for the peer researchers and the research participants living with dementia, challenging academics' traditional views on research processes and gathering enhanced research data. There remains a need for further research on the impact of peer research in dementia studies. Copyright © 2016 John WileySons, Ltd.

OBJECT: The aim is to describe the development of the scientific literature on dementia. METHODS: We present a quantitative, bibliometric study of the literature on dementia, based on Medline, covering 36 years (1974-2009). Two samples of references to dementia papers were retrieved: The main sample based on the MeSH term Dementia holds more than 88 500 references. We have compared the annual additions of references on dementia with the addition to total Medline. Changes of 'the Dementia to Medline ratio' (%) give the best information on the development. RESULTS: Publications on dementia increased 5.6 times faster than Medline. Most of this relative acceleration took place during 1980-1997, when the references on dementia increased from 0.17 to 0.78%. During the recent 12 years, the publications on dementia have been keeping pace with Medline and have stabilized around 0.8%. CONCLUSIONS: We have shown a large increase of the literature on dementia, relative both to the development of all medical research and to all psychiatric research. The bibliometric approach may be questioned as quantitative methods treat articles as being of equal value, what is not true. If, for example, during a certain period, the research output is 'inflated' by a great number of repetitive papers, the quantitative method will give an unfair picture of the development. Our relative method, however, will give relevant results as, at each point of time, the proportion of 'valuable research' ought to be about the same in the dementia group as in total Medline. Copyright © 2012 John Wiley & Sons, Ltd.

Psychotherapy provides a means of helping participants to resolve emotional threats and play an active role in their lives. Consequently, psychotherapy is increasingly used within dementia care. This paper reviews the existing evidence base for individual and group psychotherapy with people affected by dementia.The protocol was registered. We searched electronic databases, relevant websites and reference lists for records of psychotherapy with people affected by Alzheimer's Disease, Vascular dementia, Lewy-body dementia or a mixed condition between 1997 and 2015. We included studies of therapies which met British Association of Counselling and Psychotherapy definitions (e.g. occurs regularly, focuses on talking about life events and facilitates understand of the illness). Art therapy, Cognitive Stimulation and Rehabilitation, Life Review, Reminiscence Therapy and family therapy were excluded. Studies which included people with frontal-temporal dementia and mild cognitive impairment were excluded. Data was extracted using a bespoke form, and risk of bias assessments were carried out independently by both authors. Meta-analysis was not possible because of the heterogeneity of data.A total of 1397 papers were screened with 26 papers using randomised, non-randomised controlled trials or repeated measured designs being included. A broad mix of therapeutic modalities, types, lengths and settings were described, focussing largely on people with mild levels of cognitive impairment living in the community.This study was limited to only those studies published in English. The strongest evidence supported the use of short-term group therapy after diagnosis and an intensive, multi-faceted intervention for Nursing Home residents. Many areas of psychotherapy need further research. Copyright © 2016 John WileySons, Ltd.

Background Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late-life anxiety disorders. Methods This paper reviews the unique features of anxiety in later life and synthesizes the work of the Advisory Committee. Results Suggestions are offered for refining our understanding of the effects of aging on anxiety and other disorders (e.g., mood disorders) and changes to the DSM5 criteria and text that could facilitate more accurate recognition and diagnosis of anxiety disorders in older adults. Several of the recommendations are not limited to the study of anxiety but rather are applicable across the broader field of geriatric mental health. Conclusions DSM5 should provide guidelines for the thorough assessment of avoidance, excessiveness, and comorbid conditions (e.g., depression, medical illness, cognitive impairment) in anxious older adults. Copyright © 2011 John Wiley & Sons, Ltd.

Background Depression is common in older people with dementia. Physical activity is effective in reducing depression in adults but there is limited evidence about its effectiveness in people with dementia. Design and Methods A systematic review and partial meta-analysis of physical activity interventions in people with dementia is reported. We searched eight databases for English language papers and reference lists of relevant papers. Included studies reported a physical activity intervention lasting at least 12 weeks in which participants were older and had a diagnosis of dementia. Studies compared the intervention with a non-active or a no-intervention control and reported at least one outcome related to physical function, quality of life or depression. At least two authors independently assessed each paper for inclusion and for study quality and extracted data. Results We included 13 randomised controlled trials with 896 participants. Three of six trials that reported walking as an outcome found an improvement, as did four of the five trials reporting timed get up and go tests. Only one of the four trials that reported depression as an outcome found a positive effect. Both trials that reported quality of life found an improvement. Conclusions There is some evidence that physical activity interventions improve physical function in older people with dementia. Evidence for an effect on depression and quality of life is limited. Copyright © 2011 John Wiley & Sons, Ltd.

We thank Wei Xing Noah Toh and colleagues1 for their interest in our paper on bilingualism and cognitive decline.2 We agree with the authors who say verbal measures of executive function, which we used in our paper, may bias results against those for whom English is not a first language. We have discussed this as a limitation in the paper. The authors also point out that MMSE score is likely to be affected by education, which is why we adjusted for education in our linear regression model investigating the effect of bilingualism on MMSE score and found no significant difference of bilingualism once education was taken into account. This is not surprising as our analysis was of decline and therefore baseline function on the MMSE was taken into account. We also checked for collinearity between MMSE and education‐related variables before fitting our models. The MMSE does not, as the authors point out, measure Executive Function (EF), but it is still a well‐validated measure of cognitive decline which is why it was suited for our primary analysis and why we included tests of EF that were available in this cohort, in a separate analysis. We agree that the measure of bilingualism was coarse‐grained in this cohort, but it is rare for cohort studies to measure bilingual status at all. Our circumspect conclusion takes this into account and states that “bilingualism is complex and that simply speaking two languages does not protect from cognitive decline or enhance executive function. The precise pattern of language use in bilingual speakers may be critical and certainly such information is necessary to more fully disentangle the longer‐term neuroprotective effect of bilingualism.” Mukadam et al further investigated this topic in their systematic review of bilingualism and cognitive decline and again concluded that bilingualism itself is not protective against cognitive decline when analyses from cohort studies are appropriately adjusted for education and socioeconomic status.3 We would welcome future research that could measure the more fine‐grained effects of bilingualism, comparing, for example, bilinguals who frequently switch between different languages and those who use their languages in separate environments.

OBJECTIVE Delirium is a very common and serious disorder with high morbidity and mortality. Despite symptomatic treatment the outcome can be poor for some especially when no underlying cause is identified. As a result, various strategies for delirium prevention have been assessed. Pharmacological agents such as antipsychotics, acetylcholinesterase inhibitors, sleep-wake cycle regulators, anti-inflammatories and others have been advocated for a potential role in delirium prevention. The aim of this paper is to review the available evidence for their use in the prevention of delirium. METHODS An electronic search was carried out using Medline, EMBASE and Cochrane for randomised controlled trials (RCTs) and other studies. The words delirium, prevention, intervention, pharmacological, prophylactic, antipsychotics, acetylcholinesterase inhibitors, sleep and anti-inflammatories were used. References from selected papers were also searched. RESULTS No multi-centre RCT has been identified. Few trials and other studies have been published so far assessing the prophylactic role of antipsychotics, acetylcholinesterase inhibitors, hypnotics, melatonin, and gabapentin. As these studies tested different drugs, regimes and protocols in diverse populations no meaningful comparison can be made. CONCLUSION To date there is conflicting and inconsistent data regarding the efficacy of pharmacological treatment for delirium prevention. Positive reports in few of the studies justify further assessment of the potential for some pharmacological agents in the prevention of delirium. Well designed and appropriately powered RCTs are now needed. However, based on available evidence so far, no recommendation can be made to justify the routine clinical prophylactic use of any pharmacological agent in the prevention of delirium.

Aim This introductory paper offers a critical review of current models and measures of quality of life, and describes a choices and choosing (c-c) process as a new model of quality of life. Method Criteria are proposed for judging the relative merits of models of quality of life with preference being given to explicit mechanisms, linkages to a science base, a means of identifying deficits amenable to rational restorative interventions, and with embedded values of the whole person. Result A conjectured model, based on the processes of gaining access to choices and choosing among them, matches the proposed criteria. The c-c process is an evolved adaptive mechanism dedicated to the pursuit of quality of life, driven by specific biological and psychological systems, and influenced by social and environmental forces. Conclusions This model strengthens the science base for the field of quality of life, unifies approaches to concept and measurement, and guides the evaluation of impairments of quality of life. Corresponding interventions can be aimed at relieving restrictions or distortions of the c-c process; thus helping people to preserve and improve their quality of life. RELATED WORK: Companion papers detail relevant aspects of the science base, present methods of identifying deficits and distortions of the c-c model so as to open opportunities for rational restorative interventions, and explore empirical analyses of the relationship between health imposed restrictions of c-c and conventional indicators of diminished quality of life. [corrected]

Objective Based on research staff observations during several studies in nursing homes and the findings of other studies, we propose a nomenclature of components of care for the elderly in nursing homes. The paper seeks thereby to operationalize those aspects of the nursing home practice style that can be improved. Methods This operationalization examines two main components (staff and institutional components) of practice style of care in nursing homes. Four domains characterize staff conduct (knowledge, practice style proficiency, flexibility and individualization of care and communication) and three domains define institutional conduct (staff support, resources and flexibility/rigidity of policies). Results The paper addresses critical aspects of staff conduct, and by extension, key features that require training, monitoring, and systemic change. Examples for each domain of practice style are provided. Conclusions After systematically reviewing the observations and findings it was concluded that enhancing practice styles in the nursing home requires knowledge, communication, flexibility, understanding, and genuine concern on the part of nursing home staff and administrators at all levels. We acknowledge and understand, of course, that changing practice styles in nursing homes is a difficult and time-consuming process. Copyright © 2007 John Wiley & Sons, Ltd.

The main objective of this study was to summarize the effects of various individual, caregiver, and system-related factors on the risk of long-term care (LTC) placement for persons with dementia.We searched electronic databases for longitudinal studies reporting on predictors of LTC placement for persons with dementia residing in the community or supportive care settings. We performed meta-analyses with hazard ratios (HRs) of various predictors using random effects models and stratified the HRs with several study variables. Data on predictors not included in the meta-analyses were summarized descriptively.Full-text reviews of 360 papers were performed with data from 37 papers used to calculate pooled HRs for LTC placement of select person with dementia (age, sex, race, marital status, type of dementia, living arrangement, and relationship to caregiver) and caregiver (age, sex, and depressive symptoms) characteristics. White race [HR = 1.67, 95% confidence intervals (CI): 1.41-1.99], greater dementia severity (HR = 1.05, 95% CI: 1.03-1.06), and older age (HR = 1.02, 95% CI: 1.01-1.03) increased the risk of LTC placement. Married persons with dementia (HR = 0.38, 95% CI: 0.16-0.86) and living with their caregiver (HR = 0.72, 95% CI: 0.56-0.92) had a lower risk. Behavioral and psychological symptoms of dementia, the degree of functional impairment, and caregiver burden had a consistent effect on the risk of LTC placement in our descriptive review.We quantified the predictive effect of several risk factors for LTC placement. These estimates could be used to more precisely categorize the risk of institutionalization and potentially link those at higher risk to appropriate services. Copyright © 2016 John WileySons, Ltd.

Background: wandering occurs in 15–60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices. Objective: to determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia. Design: a systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought. Results: (i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable. Conclusions: in order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials

Background No previous attempt has been made to synthesise information on mortality and neurosis in older people. Our objective was to estimate the influence on mortality of various types of neurosis in the older population. Methods Data sources were: Medline; Embase; and personal files. Studies were considered if they included a majority of persons aged 65 and over at baseline either drawn from a total community sample or drawn from a random sample from the community. Studies which sampled from a larger age range were also included if it was possible to retrieve results about those aged 65 and over. Samples from health care facilities were excluded. Effect sizes were extracted from the papers and if they were not included in the published papers effect sizes were calculated if possible. No attempt was made to contact authors for missing data. Results We found seven reports (six of which used a neurosis diagnosis and one which used a symptom scale). Using Fisher's method we found an increase in mortality which was not significant (p = 0.08). Conclusion There have been few studies, and the evidence is weakly in favour of an increased mortality risk. Copyright © 2004 John Wiley & Sons, Ltd.

Background: the issue of diagnostic disclosure in dementia has been debated extensively in professional journals, but empirical data concerning disclosure in dementia has not previously been systematically reviewed. Objective: to review empirical data regarding diagnostic disclosure in dementia. Methods: five electronic databases were searched up to September 2003 (Medline, Embase, Cinahl, Sociological Abstracts, Web of Science). Additional references were identified through hand searches of selected journals and bibliographies of relevant articles and books. The title and abstract of each identified paper were reviewed independently by two reviewers against pre-determined inclusion criteria: original data about disclosure were presented and the paper was in English. Any disagreements were resolved by discussion until consensus was reached. Data were extracted independently by two reviewers using a structured abstraction form. Data quality were not formally assessed although each study was critically reviewed in terms of methodology, sampling criteria, response rates and appropriateness of analysis. Results: fifty-nine papers met the inclusion criteria for detailed review. Many of the studies had methodological shortcomings. The studies reported wide variability in all areas of beliefs and attitudes to diagnostic disclosure and reported practice. Studies of the impact of disclosure indicate both negative and positive consequences of diagnostic disclosure for people with dementia and their carers. Conclusions: existing evidence regarding diagnostic disclosure in dementia is both inconsistent and limited with the perspectives of people with dementia being largely neglected. This state of knowledge seems at variance with current guidance about disclosure

Background There has been little information about depression in Chinese elderly people. In order to investigate whether or not there is an excess of depression among the Chinese elderly, we have performed a meta-analysis of the published epidemiological studies. Methods Papers published in the literature from The People's Republic of China included in the Chinese medical databases were obtained. Some additional papers collected from other sources were also included. The fixed/random effects model and Poisson model were employed for data analysis. Results There were 10 cross-sectional studies (23 samples divided according to men/women and urban/rural subjects) giving sufficient prevalence data on depression (13 565 subjects) or depressive mood (8476 subjects). The pooled prevalence of depression was 3.86% (95%CI 3.37–4.42%), while that of depressive mood was 14.81% (14.20–15.64%). The risk of depression in the rural communities (5.07%, 3.61–7.13%) was higher than in the urban (2.61%, 2.22–3.08%). The same trends were observed for depressive mood. The patterns of risk factors were similar to those in western countries. Conclusions Chinese tradition and culture may be explanatory factors for the low prevalence, provided the methodological issues have not seriously biased the results. Copyright © 1999 John Wiley & Sons, Ltd.

Social care research has moved gradually in recent years to include the subjective perspective. Dementia care, which in many ways is still in its infancy, has lagged behind in this development, and much research has been informed by the carer rather than the person with dementia. As a young subject area, it is right that dementia care should look around for lessons that can be learned from other disciplines. This paper will consider how research with people with learning difficulties has developed a culture for hearing the views of service users. It will outline various methodologies, with considerations of their strengths and weaknesses. The paper will then review research in dementia care which features the subjective experience, and will finally draw out lessons and identify possible ways forward.

Background The characteristics of this pandemic increase the potential psychological impact on care homes workers (CHWs). The aims of this study were to analyse the mental health and health‐related quality of life (HRQoL) of a broad sample of CHWs in Spain and to identify potential factors that have a significant effect on their mental health and HRQoL. Method This descriptive study comprised 210 CHWs who completed the Generalized Anxiety Disorder 7‐item Scale, the Patient Health Questionnaire‐9, the Impact Event Scale‐Revised, the Insomnia Severity Index, and the Health‐related Quality of Life Questionnaire. Sociodemographic and clinical data in relation to COVID‐19 were also recorded. Descriptive statistics, univariable analysis and multivariable linear regression models were applied to identify factors associated with mental health and HRQoL. Results Of total, 86.19% of participants were female; 86.67% were aged under 55 years; 11% were physicians and 64.19% were nurses or auxiliaries; 77.62% have themselves tested positive for Covid‐19; and 67.94% of CHWs have directly treated patients with Covid‐19. 49.28% had clinical depression; over half (58.57%) had clinical anxiety; 70.95% had clinical stress; and 28.57% had clinical insomnia. Increased use of tranquilizers/sedatives appears to be an explanatory variable of suffering greater anxiety, depression, stress and insomnia, and of having a worse HRQoL amongst our CHWs. Conclusions Our study confirms that symptomatology of anxiety, depression, stress, insomnia and HRQoL were affected amongst CHWs during the Covid‐19 pandemic., Key points Despite the enormous burden of distress and potentially traumatic events experienced by care home workers, almost no studies have yet been carried out documenting the prevalence of mental health problems amongst this population group.Symptomatology of anxiety, depression, stress, insomnia and health‐related quality of life were affected amongst care homes workers during the COVID‐19 pandemic. Why do this paper matter? It will be necessary to monitor care homes workers—particularly those most at risk—and our data, together with other current studies, can help to establish screening, support and treatment strategies for improving their mental health.

This is a series in which key papers in old age psychiatry are presented with an introduction, commentary by the original author and current update by someone working in the field. A full introduction is given in volume 10, no 10. These papers are a milestone in the psychiatry of old age and in the link between pathological brain changes and clinical features of dementia during life. These two companion papers represent the pathological descriptions of the patients concerned. The summaries of the two papers, together with the associated commentaries by Professor Tomlinson and Dr Mann, underscore the immortality of the work.

Inattention is a core feature of delirium, and valid assessment of attention is central to diagnosis. Methods of measuring attention in delirium can be divided into two broad categories: (i) objective neuropsychological testing; and (ii) subjective grading of behaviour during interview and clinical examination. Here, we review and critically evaluate studies of objective neuropsychological testing of attention in delirium. We examine the implications of these studies for delirium detection and monitoring in clinical practice and research, and how these studies inform understanding of the nature of attentional deficits in delirium.Searches of MEDLINE and ISI Web of Knowledge databases were performed to identify studies in which objective tests of attention had been administered to patients with delirium, who had been diagnosed using DSM or ICD criteria.Sixteen publications were identified. The attention tests administered in these studies were grouped into the following categories: measures of attention span, vigilance tests, other pen-and-paper tests (e.g. Trail Making Test) and computerised tests of speeded reaction, vigilance and sustained attention. Patients with delirium showed deficits on all tasks, although most tasks were not considered pure measures of attention. Five papers provided data on differential diagnosis from dementia. Cancellation tests, spatial span tests and computerised tests of sustained attention discriminated delirium from dementia. Five studies presented reliability or validity statistics.The existing evidence base on objective assessment of attention in delirium is small. Objective testing of attention is underdeveloped but shows considerable promise in clinical practice and research.

Biobanks for research and genetic research are important opportunities to create new understanding of complex disorders, such as psychiatric disorders and dementia. The management of biobanks for subjects with psychiatric disorders or dementia raises additional challenges because of the ethical issues regarding the potentially impaired decision-making capacities of the subjects. The aim of this paper is to study (i) how guidelines address the matter and (ii) how they can be implemented in real research situations with patients suffering from psychiatric disorders and dementia.We collected and analysed all the relevant guidelines and position papers from national and international organizations dealing with research on biological materials and selected documents mentioning the participation of incapacitated adults in genetic research and biobanks.Eighteen of the 30 analysed documents contain explicit references to adults who are unable to give consent. The main topics addressed by the guidelines are the following: (i) informed consent; (ii) principles of non-therapeutic research; and (iii) ethics committee review.In biomedical research, guidelines are an important instrument for facilitating research while promoting subjects' rights and well-being. Compared with legally binding documents, guidelines are more flexible and can be more easily revised according to evolving research situations and for adaptation to real persons and research settings. We suggest measures to implement the analysed guidelines taking into consideration the case for the participation of patients with neuropsychiatric disorders, who can have impairment of decision-making capacities without being obviously incompetent, in genetic research and biobanks.

General practitioners (GPs) and the primary care team are uniquely situated to play a central role both in the diagnosis and ongoing care of dementia. Anecdotal reports and empirical work suggest that GPs face several challenges in fulfilling this role. This paper describes the various roles GPs and the primary care team could play in diagnosis and ongoing management. It then discusses the legitimate anxieties and difficulties faced in fulfilling these roles. The paper concludes with suggestions for how GPs and the primary care team might be supported to maximize their role in dementia diagnosis and management.

Subtle cognitive changes have been described that may predate the onset of clinically recognizable Alzheimer's disease (AD) and may reflect pathological changes in the brain that are detectable up to 10 years before the onset of AD. Early screening for cognitive status can have benefits in terms of early management and prevention strategies for cognitive decline.A novel computerized cognitive screening tool, the Cognitive Function Test (CFT), was compared with established paper tests of episodic memory, executive function and processing speed, domains previously shown to be predictive of AD, with 50 normal participants, Mini Mental State Examination ≥24, mean age 58.1, SD 5.6 years (range 50-65). An online version, self-administered by 195 eligible respondents without significant memory complaints or dementia, was assessed.Significant correlations (r = 0.75, p 0.0001) were found between the CFT and paper tests in a pilot study, showing concurrent validity. The pilot computerized tests were compared with the online version, and no differences were found in mean scores on the total test and domain-specific scores using an algorithm derived from the pilot CFT scores, thus showing internal consistency and reliability of the online format. Norms and 1.5 SD cut-offs for the CFT are presented.The online CFT was shown to be suitable for self-administration in online format (with a mouse response mode) for this midlife age group. Individuals may wish to monitor their cognitive performance before memory concerns are sufficient to warrant visiting a GP or memory clinic.

The aim is to describe the development of the scientific literature on dementia.We present a quantitative, bibliometric study of the literature on dementia, based on Medline, covering 36 years (1974-2009). Two samples of references to dementia papers were retrieved: The main sample based on the MeSH term Dementia holds more than 88,500 references. We have compared the annual additions of references on dementia with the addition to total Medline. Changes of 'the Dementia to Medline ratio' (%) give the best information on the development.Publications on dementia increased 5.6 times faster than Medline. Most of this relative acceleration took place during 1980-1997, when the references on dementia increased from 0.17 to 0.78%. During the recent 12 years, the publications on dementia have been keeping pace with Medline and have stabilized around 0.8%.We have shown a large increase of the literature on dementia, relative both to the development of all medical research and to all psychiatric research. The bibliometric approach may be questioned as quantitative methods treat articles as being of equal value, what is not true. If, for example, during a certain period, the research output is 'inflated' by a great number of repetitive papers, the quantitative method will give an unfair picture of the development. Our relative method, however, will give relevant results as, at each point of time, the proportion of 'valuable research' ought to be about the same in the dementia group as in total Medline.

OBJECTIVES: Suicide in later life is a public health concern. Given the need for practical guidance and policy implementation, this paper aims to provide a critical interpretive synthesis approach to prioritize the likely relevance of publications and the contribution that they make to understanding of the problem. METHODS: A selective review of the English language literature focusing on the epidemiology of suicide among older people was conducted; the search strategy built on that of a previous review. Papers were selected for their ability to shed light on the potential for prevention and practice from public health perspectives. RESULTS: Whilst the majority of older people who commit suicide have major depression, suicide seems to be due to a combination of personality factors and co-morbidities, including chronic pain and disablement. Complex multi-component public health studies are underway and are likely to provide useful knowledge to guide practice more precisely, but there is remarkably little information about the involvement of older people in risk reduction or about harm minimization approaches at patient and public participation levels. CONCLUSIONS: For lack of sufficient evidence from intervention trials that are specific to older people, practitioners need to extrapolate from studies of younger adults and be aware of risk factors for suicide in later life. Public health approaches combined with practitioners' experiences of older people at risk may help minimize the risks of suicide in later life. These are fruitful areas for collaborative practice development, service initiatives, evaluation, and research. Language: en

Background A previous paper began with a critical review of current models and measures of quality of life and then proposed criteria for judging the relative merits of alternative models: preference was given to finding a model with explicit mechanisms, linkages to a science base, a means of identifying deficits amenable to rational restorative interventions, and with embedded values of the whole person. A conjectured model, based on the processes of accessing choices and choosing among them, matched the proposed criteria. The choices and choosing (c–c) process is an evolved adaptive mechanism dedicated to the pursuit of quality of life, driven by specific biological and psychological systems, and influenced also by social and environmental forces. Objective In this paper the c-c model is examined for its potential to strengthen the science base for the field of quality of life and thus to unify many approaches to concept and measurement. Conclusions A third paper in this set will lay out a guide to applying the c–c model in evaluating impairments of quality of life and will tie this evaluation to corresponding interventions aimed at relieving restrictions or distortions of the c–c process; thus helping people to preserve and improve their quality of life. The fourth paper will demonstrate empirical analyses of the relationship between health imposed restrictions of options for living and conventional indicators of diminished quality of life. Copyright © 2008 John Wiley & Sons, Ltd.

Background The intense focus on major psychiatric disorders in both contemporary psychiatric research and clinical practice has resulted in the relative neglect of less definable constructs such as loneliness and how such entities might impact on health outcomes. The purpose of this review is to raise awareness among physicians and psychiatrists of the medical impact and biological effects of loneliness as well as making the argument that loneliness should be a legitimate therepeutic target. Methods Using Pubmed we searched the literature for research and review papers looking at loneliness as a construct, how it is measured and its health effects. We reviewed the relevant papers and have summarized their main findings. Results Loneliness has strong associations with depression and may in fact be an independent risk factor for depression. Furthermore loneliness appears to have a significant impact on physical health being linked detrimentally to higher blood pressure, worse sleep, immune stress responses and worse cognition over time in the elderly. There is a relative deficiency in adequate evidence based treatments for loneliness. Conclusion Loneliness is common in older people an is associated with adverse health consequences both from a mental and physical health point of view. There needs to be an increased focus on initiating intervention strategies targeting loneliness to determine if decreasing loneliness can improve quality of life and functioning in the elderly. Copyright © 2008 John Wiley & Sons, Ltd.

Since April 2003 the UK government has been phasing out paper pension books. Previously, many older people received their pension benefits by using paper slips which were exchanged for cash at the Post Office. Now, the state pension is transferred directly into a bank account and cash obtained by using a bank card, keypad and a four digit personal identification (PIN) number. The system is believed to be more secure and mirrors wider changes in the UK retail sector. People with dementia or early memory problems are likely to have difficulty remembering their four-digit PIN number, however, there has been little research into the level of cognitive ability a person requires to be able to manage their financial affairs. This cross-sectional study was conducted on 35 consecutive attendees at a medical day hospital, and 15 from a local community centre. All were community dwelling, aged over 65 with no acute medical or psychiatric illness, gave consent and were fluent in English. Ethical committee approval was obtained. Our main hypothesis was that cognitive impairment could be associated with difficulty in using a PIN number and keypad.