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The results of clinical trials are often presented in a way that only highlights either the benefits or the risks of the treatment under study. Especially in older age, clinical psychiatric problems are often of complex nature, which requires integrating multiple sources of data to reach clinical decisions. An analytical, decision-making strategy can be of help in arranging the results of various studies in such a way as to aid decision-making. In this paper, we clarify this method using the case of the risks and benefits of using antipsychotics in older people with dementia and behavioural disturbances. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes). Design: An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list. Results: Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done. Conclusions: Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Reports of the extent of working memory (WM) impairment in early Alzheimer's disease (AD) have been inconsistent. Using the model of WM proposed by Baddeley, neuropsychological evidence for the impairment of WM in early AD is evaluated. Method Literature searches were performed using Medline, PsycINFO and Embase databases. Individual papers were then examined for additional references not revealed by computerised searches. Results Phonological loop function is intact at the preclinical and early stages of AD, becoming more impaired as the disease progresses. In mild AD, there is impairment on tasks assessing visuospatial sketchpad (VSS) function; however, these tasks also require executive processing by the central executive system (CES). There is evidence that the CES is impaired in mild AD and may be affected in the earlier preclinical stage of the disease. Episodic buffer function may be impaired but further research is required. Conclusions Future research into central executive functioning at the earliest stages of the disease, combined with further longitudinal studies, needs to be carried out. Tasks to assess the proposed functions of the episodic buffer and specific tests of the VSS suitable for AD subjects need to be developed and validated. Learning more about these processes and how they are affected in AD is important in understanding and managing the cognitive deficits seen in the early stages of AD. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective The objectives of this paper are: (a) to determine Canadian family physicians' attitudes towards cognitive screening, (b) to identify what cognitive screening tools are being used, (c) to investigate how they rate these tools' effectiveness and (d) to identify the attributes of an ideal cognitive screening tool for the primary care setting. Method Postal survey questionnaire of a random sample of 249 practicing members of the College of Family Physicians of Canada. Results Response rate was 52%. The majority of physicians 'Agreed' or 'Strongly Agreed' that cognitive impairment assessment is important in primary care (89%), and 'Disagreed' or 'Strongly Disagreed' that it should be left to specialists (92%). However, 35% were undecided when asked if assessment in primary care would lead to better outcomes. The most frequently used assessment tools were Mini-Mental Status Exam (MMSE), Clock Drawing, Delayed Word Recall, Standardized MMSE and Alternating Sequences, but were mainly rated as only 'Good' in terms of perceived effectiveness. Validity/accuracy was identified as the top attribute of an ideal screening tool. Female physicians were more likely to have a positive attitude towards cognitive assessment. Younger physicians, those in group practices, or those with either <= 20% or 61-80% of elderly patients in their practice indicated a shorter ideal time to administer a cognitive screening tool. Conclusion Despite general agreement that primary care physicians have an important role in cognitive screening, there is less agreement that it leads to better outcomes. The development of a superior screening tool to be used in the primary care setting is needed. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Patients with mild cognitive impairment account for a significant number of referrals to old age psychiatry services and specialist memory clinics. The cognitive evaluation of such patients is commonly restricted to brief dementia screens, with no consideration to their suitability for assessing MCI. Here, we review the utility of such cognitive screens for MCI and provide an overview of validated instruments. Methods We identified papers published after Petersen and colleagues 1999 MCI criteria (Petersen et al., 1999) and examining face-to-face cognitive screening for MCI from publication databases using combinations of the search terms ‘mild cognitive impairment’ and ‘cognitive screening’. We also combined the former search with the names of 39 screening tests recently identified in a relevant review (Cullen et al., 2007). Results Fifteen cognitive screening instruments were identified, 11 cover a restricted range of cognitive domains. High sensitivity and specificity for MCI relative to healthy controls were reported for two comprehensive and two noncomprehensive screening instruments, adequate test-retest and inter-rater reliability for only one of these. With the exception of three studies, sample sizes were universally small (i.e. n ≤ 100), and prognostic values were reported for only two of the identified 15 screening measures. Sensitivities of the full domain measures were universally high, but information about their specificity against psychiatric and non-progressive neurological conditions and predictive validity is lacking. Conclusion Several cognitive screening instruments afford the clinician the ability to detect MCI, early AD, and in some cases non-AD dementia, but they cannot currently be used to make reliable inferences about the course and eventual outcome of MCI. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background This paper analyses the costs and benefits of commissioning memory services for early diagnosis and intervention for dementia. Method A model was developed to examine potential public and private savings associated with delayed admissions to care homes in England as a result of the commissioning of memory services. Findings The new services would cost around £220 million extra per year nationally in England. The estimated savings if 10% of care home admissions were prevented would by year 10 be around £120 million in public expenditure (social care) and £125 million in private expenditure (service users and their families), a total of £245 million. Under a 20% reduction, the annual cost would within around 6 years be offset by the savings to public funds alone. In 10 years all people with dementia will have had the chance to be seen by the new services. A gain of between 0.01 and 0.02 QALYs per person year would be sufficient to render the service cost-effective (in terms of positive net present value). These relatively small improvements seem very likely to be achievable. Interpretation These analyses suggest that the service need only achieve a modest increase in average quality of life of people with dementia, plus a 10% diversion of people with dementia from residential care, to be cost-effective. The net increase in public expenditure would then, on the assumptions discussed and from a societal perspective, be justified by the expected benefits. This modelling presents for debate support for the development of nationwide services for the early identification and treatment of dementia in terms of quality of life and overall cost-effectiveness. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The paper explores the diverse ethical issues in the care of persons with dementia, in the Netherlands and Kerala, India. These cross-cultural data are used to suggest newer ways for addressing the ethical issues in a mutually enhancing manner. Methods A thorough review of the literature focusing on ethical aspects of the care for persons with dementia. Results The medical paradigm is dominant in the Netherlands and awareness of dementia as an organic brain disease is low in Kerala. Institutionalized care is more common in the Netherlands and home-based care is the norm in Kerala. Institutional care is costly, whereas home-based care is stressful for caregivers. The advanced directive plays an influential role in the Netherlands, but this mechanism is yet to evolve in Kerala. The legal and social setting of the Netherlands has a strong influence on physician decision-making concerning end of life issues. In Kerala, discussion of these matters is nearly unknown. Conclusion Limited awareness of dementia in Kerala should be addressed in public forums, which can then be used to garner governmental support. The predominantly institutional model of care-giving in the Netherlands and home-based care-giving in Kerala, each have their strengths; policy makers in both societies can usefully apply the values and merits inherent in both models. A culturally appropriate implementation of the advanced directive will have beneficial medical, social, and economic impacts in Kerala. The remarkable disparity between the Netherlands and Kerala in dealing with end-of-life issues will allow more philosophically and socially informed ways of addressing the ethical questions that arise in those situations. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Limited data are available on how older adults access public mental health systems. This study examines how uninsured or publicly insured older adults with severe mental illness in San Diego County initially accessed the public mental health system, as well as their subsequent use of public mental health services, as compared to younger adults. Methods Data from San Diego County, 2002–2006, were used to examine how older adults initially accessed the public mental health system, and their utilization over the subsequent 90 days. Multivariate regression models were used to control for demographic and clinical characteristics. Results Older adults (age 60 +) were more likely to access the public mental health system through the Psychiatric Emergency Response Team (PERT), a combined law-enforcement and psychiatric service that responds to psychiatric related 911 calls. Older adults were also less likely to receive follow-up care. This lower rate of follow-up was due to both the initial site of service––and an associated lower rate of follow-up among PERT clients––as well as a lower rate of follow-up among older adult clients initiating services in other sectors. Conclusions This paper suggests two areas for intervention that would improve access to care for older adults: improving linkages and referrals between PERT and outpatient providers; and additional efforts to retain older adults at outpatient programs. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Anxiety disorders are highly prevalent in elderly persons, and they are associated with functional impairment, poorer quality of life, and adverse long-term consequences such as cognitive decline. Intervention research in late-life anxiety disorders (LLAD) lags behind where it ought to be. Research in cognitive neuroscience, aging, and stress intersects in LLAD and provides the opportunity to develop innovative interventions to prevent chronic anxiety and its consequences in this age group. Methods This paper evaluates gaps in the evidence base for treatment of LLAD and synthesizes recent research in cognitive neuroscience, basic behavioral science, stress, and aging. Results We examine three intervention issues in LLAD: (1) prevention; (2) acute treatment; and (3) pre-empting adverse consequences. We propose combining randomized controlled trials (RCTs) with mechanistic biobehavioral methodologies as an optimal approach for developing novel, optimized, and personalized treatments. Additionally, we examine three barriers in the field of LLAD research: (1) How do we measure anxiety?; (2) How do we raise awareness?; (3) How will we ensure our research is applicable to underserved populations (particularly minority groups)? Conclusions This prospectus outlines approaches for intervention research that can reduce the morbidity of LLAD. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Given its complexity, there is growing consensus on the need to measure patient-rated broad outcomes like health-related quality of life (HRQL) as well as discrete functions like cognition and behaviour in dementia. This review brings together current data on the distribution, determinants and course of HRQL in dementia to investigate the predictive and explanatory value of measures of HRQL in people with dementia. Design A systematic review of papers in English published up to October 2007 to identify data on the use of disease-specific measures of HRQL in dementia. Results There are no clear or consistent associations between socio-demographic variables and HRQL. There is no convincing evidence that lower cognition or greater activity limitation is associated with lower HRQL. There is a strong suggestion that depression is consistently associated with decreased HRQL in dementia. However, the magnitude of the associations observed is moderate only and the proportion of variance explained is low suggesting that depression and HRQL are different constructs. We currently know almost nothing about the natural history of HRQL in dementia or what attributes or interventions promote or inhibit HRQL life for people with dementia. Conclusions While in other illnesses there may be simple association between HRQL and an easily measurable clinical variable, in dementia this is not so. There are now instruments available with which to measure disease-specific HRQL directly in clinical trials and other studies that can yield informative data. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

BACKGROUND: This paper provides an initial evaluation of the impact of the Single Assessment Process (SAP) in England upon practice regarding multidisciplinary assessment. OBJECTIVES: To investigate changes in recorded health needs of older people and in the number of multidisciplinary assessments undertaken using social care agencies' case files. To examine differences in approaches to the use of multidisciplinary assessment for older people with different health needs. METHODS: An audit of case files of older people living in the community in receipt of social care in three areas carried out at two time periods before and after implementation of the SAP in 2004. Information extracted from files covered a number of domains including evidence of multidisciplinary assessments, and presence of mental and physical health problems. RESULTS: Data from 144 files at Time 1 were compared with 145 files from Time 2. Little evidence emerged that older people at Time 2 were more dependent. However, significantly more multidisciplinary assessments were undertaken following the introduction of the SAP, in particular by occupational therapists and secondary health care teams. Cognitive impairment was a significant predictor of multidisciplinary assessment at both time periods. CONCLUSIONS: The impact of the introduction of the SAP has been mediated by the influence of other policies in England: intermediate care and integrated health and social care provision. Nevertheless, the data suggest that consideration be given to more effective targeting of multidisciplinary assessments on the grounds of both cost and more accurate identification of those who will benefit from the process. [ABSTRACT FROM AUTHOR]

Objective This paper examines possible mechanisms that may explain the bi-directional relationship between vascular disease and depression. Design A literature review was carried out using Medline from 1996 to 2007, using relevant key words including vascular depression, and supplemented by key references to earlier work. Results Several mechanisms were considered including: autonomic dysfunction, platelet activation, hypothalamic pituitary axis activation, endothelial dysfunction, cytokines, omega 3 fatty acids, genetics, homocysteine and effects of treatment. Conclusions The relationship between vascular disease and depression cannot solely be explained by current established risk factors or the effects of treatment for depression. Other mechanisms must apply, and there is some evidence for common genetic factors. Promising future lines of investigation include homocysteine, cytokines and endothelial dysfunction. More longitudinal studies combined with measurements of these biomarkers are needed. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The ‘depression executive dysfunction syndrome’ afflicts a considerable number of depressed elderly patients and may be resistant to conventional pharmacotherapy. Non-pharmacological approaches addressing their behavioral deficits may reduce disability and experienced stress and improve depression. Methods This paper focuses on problem solving therapy (PST) because it targets concrete problems that can be understood by patients with executive dysfunction and trains patients to address them using an easy to comprehend structured approach. Results We suggest that PST is a suitable treatment for patients with the depression-executive dysfunction syndrome because it has been found effective in uncomplicated geriatric major depression and in other psychiatric disorders accompanied by severe executive dysfunction. Furthermore, PST can address specific clinical features of depressed patients with executive dysfunction, especially when modified to address difficulties with affect regulation, initiation and perseveration. Conclusions A preliminary study suggests that appropriately modified PST improves problem solving skills, depression and disability in elderly patients with the depression-executive dysfunction syndrome of late life. If these findings are confirmed, PST may become a therapeutic option for a large group of depressed elderly patients likely to be drug resistant. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The diagnosis of dementia poses difficulties for general practitioners (GPs) particularly when access to specialist diagnostic services is delayed. Ireland is soon to witness an increase in numbers of people presenting with dementia, yet little is known about the service needs of GPs when attempting to diagnose dementia. Objectives To detail the service needs of GPs, especially their training needs, access to diagnostic resources such as CT and MRI brain scans and access to specialist services such as Old Age Psychiatry (OAP), Geriatric Medicine (GM) and Neuropsychology (NP). Methods The paper is based on survey data collected from a sample of GPs (n = 300) registered with the Irish College of General Practitioners (ICGP) and on qualitative data collected from a Focus Group (n = 7). Results GPs were more likely to blame themselves than either the health care system, their patients or family members for the late presentation of dementia in primary care. Stigma was a major obstacle preventing GPs from being more proactive in this area. Rural GPs felt geographically disadvantaged accessing diagnostic services and both rural and urban GPs experienced considerable time delays accessing specialist diagnostic services. Conclusions Findings provide compelling evidence that training and access to diagnostic services are only two of several different structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. Future educational supports for GPs need to be developed which concentrate on these areas.Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Geriatric depression preferentially afflicts individuals with chronic medical illnesses. Disability, hopelessness, lack of acceptance of antidepressant treatment, and limited problem-solving skills contribute to poor treatment adherence, compromised outcomes, and chronically experienced adversity. Methods This paper uses depression comorbid with chronic obstructive pulmonary disease (COPD) as a model entity to develop an approach for integrating treatment components essential for improving treatment adherence and outcomes. Results The behavioral inertia of depression and its coexisting cognitive problems reduce adherence to the sustained and complex demands of the COPD rehabilitation regimen and antidepressant treatment. An intervention identifying reasons for poor treatment adherence and offering direct instructions for addressing them can be combined with problem-solving therapy to target treatment adherence, depressive symptoms, and disability. Conclusions An intervention focusing on treatment adherence and problem-solving skills development may serve as the platform for administering specific treatments to address the interacting problems of depressed medically ill patients. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Although several brain abnormalities have been identified in geriatric depression, their relationship to the pathophysiological mechanisms leading to the development and perpetuation of this syndrome remain unclear. Methods This paper reviews findings on the anterior cingulate cortex (ACC) function and on the relationship of ACC abnormalities to the clinical presentation and the course of geriatric depression in order to elucidate the pathophysiological role of ACC in this disorder. Results The ACC is responsible for conflict detection and emotional evaluation of error and is connected to brain structures that regulate mood, emotional valence of thought and autonomic and visceral responses, which are functions disturbed in depression. Geriatric depression often is accompanied by abnormalities in some executive functions and has a clinical presentation consistent with ACC abnormalities. Indices of ACC dysfunction are associated with adverse outcomes of geriatric depression. Conclusions Converging findings suggest that at least some ACC functions are abnormal in depression and these abnormalities are pathophysiologically meaningful. Indices of ACC dysfunction may be used to identify subgroups of depressed elderly patients with distinct illness course and treatment needs and serve as the theoretical background for novel treatment development. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life. Method We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life. Results The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality. Conclusions Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Approximately 50% of older individuals perceive themselves as being forgetful. Objective The objective of this review is to get an overview of previous research on the relation between perceived forgetfulness (in the absence of objective memory deficit) and quality of life in older individuals. Findings in previous research might be a starting point for further research and possible future interventions. Methods Scientific papers that investigated the relation between subjective memory complaints and quality of life were searched. Two independent raters scored the articles on their methodology. The methodological quality was taken into account when conclusions were drawn. Results The literature search resulted in 682 articles, of which five studies met the inclusion criteria. Although the five studies differed in their methodology, the findings of the methodologically adequate studies show a relation between memory complaints and a diminished quality of life in the elderly. Conclusions The negative impact that subjective memory complaints can have on quality of life makes it important to acknowledge forgetfulness as a serious issue in the life of older individuals. However, more research is needed to explore the relationship between subjective memory complaints and quality of life, also with regard to the influence of depression and objective memory performance. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective This paper describes the development of the Attitudes to Ageing Questionnaire (AAQ) which is a self-report measure with which older people themselves can express their attitudes to the process of ageing. Method The development of the AAQ followed a coherent, logical and empirical process taking full account of relevant gerontological knowledge and modern and classical psychometric analytical methods. Pilot testing with 1,356 participants from 15 centres worldwide refined the scale and provided the basis for a field test. A total of 5,566 participants from 20 centres worldwide contributed to the further development of this new scale with the derivation involving both classical and modern psychometric methods. Results The result is a 24-item cross-cultural attitudes to ageing questionnaire consisting of a three-factor model encompassing psychological growth, psychosocial loss, and physical change. The three-factor model suggests a way of conceptualizing and measuring successful ageing in individuals. Conclusions The AAQ provides researchers, clinicians and policy makers with a unique scale to measure the impact of successful ageing interventions. It also provides a vehicle for the measurement of how individuals age across cultures and under different economic, political and social circumstances. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper reviews and discusses existing barriers to diagnosis and treatment for patients with dementia in Europe as well as approaches to overcome these barriers. The barriers to care are manifold, being present at all levels in each society and between countries in Europe. Multilevel and multifaceted strategies are needed to improve diagnosis and treatments for all patients with cognitive complaints. A multidisciplinary approach based on close collaboration between GPs and specialised memory clinics may be the ideal model for early accurate diagnosis and subsequently early pharmacological and psychosocial interventions. For all healthcare professionals, there should be specialised training in dementia and frequently updated practice guidelines to provide the framework for standards of care. Culture-sensitive strategies to promote public knowledge and destigmatize dementia are essential. Policy makers and authorities should be made aware of the benefits of early access to diagnosis and treatment. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives This paper describes DCM 8 and reports on the initial validation study of DCM 8. Methods Between 2001–2003, a series of international expert working groups were established to examine various aspects of DCM with the intention of revising and refining it. During 2004–2005 the revised tool (DCM 8) was piloted in seven service settings in the UK and validated against DCM 7th edition. Results At a group score level, WIB scores and spread of Behavioural Category Codes were very similar, suggesting that group scores are comparable between DCM 7 and 8. Interviews with mappers and focus groups with staff teams suggested that DCM 8 was preferable to DCM 7th edition because of the clarification and simplification of codes; the addition of new codes relevant to person-centred care; and the replacement of Positive Events with a more structured recording of Personal Enhancers. Conclusions DCM 8 appears comparable with DCM 7th edition in terms of data produced and is well received by mappers and dementia care staff. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background This paper describes the development and validation of the Memory Inventory for Chinese (MIC), for measuring the awareness of memory deficits in the Chinese population with Alzheimer's disease (AD). Methods A combination of qualitative and quantitative approaches was adopted. The MIC was developed with focus group discussion and pilot testing. It has a patient and a caregiver version. A consecutive series of 79 new out-patients with the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorder Association (NINCDS-ADRDA) criteria of probable and possible AD and 20 non-demented elderly subjects were recruited. Results A high internal consistency was found, with Cronbach alpha of 0.89 for the patient version and 0.90 for the caregiver version of MIC. The inter-rater reliability was satisfactory. For validity assessment, the caregiver score of the MIC correlated significantly with cognitive score of the subject as assessed by the Mini-Mental State Examination (rp = -0.37; p < 0.01). The Memory Deficit Awareness Score, calculated by subtracting the patient score from the caregiver score, correlated significantly with clinician ratings of awareness of memory impairment (rs = -0.67; p < 0.01). Conclusions The MIC appears to be a culturally appropriate and valid instrument for the measurement of awareness of memory deficits in Chinese patients with AD. Potential applications of the MIC should be further explored in other subtypes of dementia and in prospective studies. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background There are over 200 000 people in the UK diagnosed with Aspergers Syndrome (AS). Most of these are children and young adults, owing to the fact the disorder was established relatively recently. It can be argued, therefore, that there are many older adults who may have met the criteria for AS as children, but never received such a diagnosis due to the fact it had yet to be established. What happended to these people as they aged? Method This paper examines this issue in detail and presents five case studies of elderly individuals who the authors believe meet the criteria of AS. Results The work illustrates AS presentation in old age, the assessment problems and tools required to assess older people, and the implications of such formulations for clinical practice. Conclusion Older patients with undiagnosed AS may currently be receiving inappropriate treatments. Greater awareness of AS in the older population would enable better management of such patients. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Late-life depression is very common and is associated with high rates of morbidity and mortality. While the field of geriatric psychiatry is focused on depression treatment, prevention is an enticing option. Prevention of late-life depression would decrease both emotional suffering and depression-associated morbidity and mortality and may decrease dependence on non-mental health professionals to detect depression and to initiate a treatment referral. This paper will review current thinking on prevention research with a particular focus on its application to late-life depression. To illustrate these issues, we discuss recent and ongoing clinical trials of interventions to prevent depression in two populations of older persons: those with age-related macular degeneration (AMD) and those with cerebrovascular disease. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background/Objective The Organic Brain Syndrome (OBS) Scale was developed to determine elderly patients' disturbances of awareness and orientation as to time, place and own identity, and assessment of various emotional and behavioural symptoms appearing in delirium, dementia and other organic mental diseases. The aim of the study was to examine the OBS Scale, using the eight criteria and guidelines formulated by the Scientific Advisory Committee of the Medical Outcomes Trust (SAC), and to investigate its relevance and suitability for use in various clinical settings. Method Systematic search and analysis of papers (30) on the OBS Scale were carried out using the criteria suggested by the SAC. Results The OBS Scale in many aspects satisfies the requirements suggested by the SAC: conceptual and measurement model, reliability, validity, responsiveness, interpretability, respondent and administrative burden, alternative forms of administration, and cultural and language adaptations, but there is a need for additional evaluation, especially with regard to different forms of reliability, and the translation and adaptation to other languages. Conclusions The OBS Scale is a sensitive scale which is clinically useful for the description and long-term follow-up of patients showing symptoms of acute confusional state and dementia. Although the OBS Scale has been used in several clinical studies there is need for further evaluation. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The elderly constitute a vulnerable group for psychopathology, yet research on their mental health among both Arab and Jews in Israel remains limited. The same is the case in Arab countries. This paper reports on the contrasting distribution of the mean emotional distress (ED) scores and rates of suspected clinical cases, and their related risk factors, among community residents over the age of 60. Methods Several national agencies conducted a survey on 5,055 elderly individuals to investigate their health status, including ED. The interview included socio-demographic and behavioral health items, as well as a modified 12 item-GHQ as a measure of ED. Total ED scores and prevalence rates for suspected psychopathology were calculated. Their respective risk factors were examined using univariate and multivariate methods. Results The ED scores were highest among Muslim Arabs (4.9), followed by Christian Arabs (4.2), Jews (3.1) and Druzes (2.8). Their estimated prevalence rates were 43.4%, 37.0%, 21.4%, and 17.0%, respectively. The gradient of these results remained unchanged in the multivariate analysis for ED scores adjusting for confounding variables. In contrast, logistic regression analysis controlling for confounding variables did not find a differential risk for suspected psychopathology between Arabs and Jews. Conclusion Conceivably, the higher demoralization scores among elderly Arabs are associated with their minority status affiliation, as well as with the rapid social changes that have taken place in their midst. A cultural response style may be entertained as a possible explanation. However, these factors do not impact the risk for suspected psychopathology where no differential risk was noted after adjustments for confounders. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

ObjectiveThe objective of the study was to provide observational clinical data on psychotropic drugs used in older people with mental illness. MethodsThis was an observational, single-centre, one-week prevalence study of psychiatric symptoms, disorders and psychotropic drug use in older with mental illness cared for by the South West people Yorkshire Mental Health NHS Trust (Wakefield Locality), UK. The clinical assessment included completion of the Psychosis Evaluation Tool for Common use by Caregivers. ResultsA total of 593/660 older patients with mental illness (mean ± SD age, 76 ± 8.1 years were assessed. 44.5% had dementia (excluding vascular dementia) and 33.7% had a mood disorder. Of the total, 20.4% did not receive CNS active medication. Of those receiving CNS active medication approximately half (51.3%) took antipsychotics and 46.2% antidepressants. Of 304 patients taking antipsychotics, 87% took only one medication. However, patients with schizophrenia and related disorders were significantly more likely to be prescribed two or more antipsychotics (p < 0.001). Risperidone was the most frequently prescribed antipsychotic (n = 136, 44.7%). Risperidone doses were significantly lower for patients with dementia and mood disorders than with schizophrenia (p < 0.002). Side-effects from antipsychotics were significantly greater in patients with schizophrenia, suggesting a dose-related effect. Risperidone appeared to be well tolerated in all patients with no evidence of cerebrovascular side-effects in patients taking it. ConclusionsPsychotropic drugs were commonly used by older people in contact with mental health services. The doses of antipsychotics used in dementia and affective disorders were significantly lower than in schizophrenia. Risperidone was the most commonly used drug in all diagnostic groups including dementia. Despite a relatively large numbers of patients receiving risperidone in this naturalistic study, no serious side-effects were reported or identified. In this paper we focus our findings on antipsychotics in the light of recent advice from the Committee on Safety of Medicines (UK). Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Rates of suicide remain high among older people and those who deliberately self harm are believed to be at an increased risk of killing themselves in the future. If older people who deliberately harm themselves are to be helped by developments in services we need to understand what currently happens to them in terms of service provision and outcome. Methods A retrospective paper and electronic case note survey was carried out on all older people living in the London Borough of Barnet who presented to Accident & Emergency Departments with DSH over a two-year period. Ensuing actions and events were then tracked. Results Forty-three older people with DSH were identified. 18/43 (42%) had previous contact with local psychiatric services. The main method of DSH was overdose of medication (36/43 or 84%). Compared to the general population there were more women and widows. There were similar levels of physical ill-health. Thirty-seven of 43 (86%) received documented psychiatric input outside of hospital following the DSH. The mean follow-up period was 789.0 days (SD 419.8) and during this time 8/43 (19%) had a further documented episode of DSH, and 18/43 (40%) died from natural causes. Conclusions This study confirms the need for improved documentation of DSH and its coding; this needs to be reviewed at local and national level. The vast majority of older people who attempt suicide do have subsequent contact with psychiatric services. There is a strong likelihood of repeat DSH and a higher risk of death by natural causes, emphasising the need to conceptualise DSH as a risk factor relevant to all medical specialities. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: 'Depression of Alzheimer's Disease' (dAD) is a common complication of Alzheimer's disease and is increasingly recognized as a syndrome with a clinical presentation differing from major depression. Criteria for the diagnosis of dAD have been proposed previously. METHODS: This paper presents these criteria in operationalized format designed to be accessible for clinical use. Four cases are discussed that demonstrate the use of these criteria and illustrate important differences between dAD and major depression. RESULTS: The dAD criteria are broader than DSM-IV criteria for Major Depressive Episode and incorporate caregiver input. CONCLUSIONS: Given the differences between dAD and major depression diagnoses, it is important to assess the efficacy of treatments for dAD. Depression in Alzheimer's Disease-2 (DIADS-2) is a controlled trial of dAD treatments that will also assess the validity of these criteria. [ABSTRACT FROM AUTHOR]

Background In Hong Kong, the aged population will be increased rapidly in the coming three decades and the oldest-old (aged 80 and above) is the fastest growing age group. In this paper, we examined the prevalence rate and the correlates of depression for the oldest-old. Method This article analyzes cross-sectional data collected from a representative community sample of 1 903 Chinese elderly people aged 60 or above in Hong Kong. Respondents were interviewed in face-to-face format with structural questionnaire. Result Using 8 as the cut-off point for the 15-item Geriatric Depression Scale, we found that the prevalence rate was greater for the oldest-old (31.1% ± 9.7%) than for the young-old (aged between 60 and 69; 19.1% ± 2.8%) and the old-old (aged 70 and 79; 22.4% ± 4.2%) groups. Logistic regression analyses revealed that financial strain, poor self-rated health, loneliness, and heart disease were significantly and positively related to depression in the oldest-old after gender, marital status, education, living arrangement, functional disability, sensory impairment, cognitive ability, and the presence of eight medical conditions were controlled. Interestingly, financial strain, self-rated health, and loneliness were found to be significant correlates of depression in the young-old and the old-old groups, too. Conclusion Depression is a serious problem for the oldest-old but a number of correlates are consistently identified in the oldest-old, as well as the two other age groups in the elderly population. Therefore, aged care service practitioners must take these correlates into consideration in their prevention and treatment for depression for all different age groups in the aged. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective In this paper we investigated the question, how do older women who drink moderate amounts of alcohol differ from those who do not drink on measurements of cognitive function, memory, affect and health? Methods The nonprobability sample of female participants (n = 182) averaged 75 years of age and had a Mini Mental State Examination scores of 28. The participants were asked to indicate whether they drank alcohol or abstained (yes/no) and if they indicated that they did drink, to describe how many drinks they consumed in a given period of time (day/week/month). Results None of the participants acknowledged drinking more than 2 drinks a day. Caucasian women had the largest number of moderate drinkers (53% vs 47%), while the majority of African–American and Hispanic women reported not drinking. The moderate drinkers reported less depression, had higher self-reported health, performed better on instrumental everyday tasks, had stronger memory self-efficacy, and used more strategies to improve memory performance. In addition, these women had higher performance on tests of executive function: attention, concentration, psychomotor skills, verbal-associative capacities, and oral fluency. Conclusions The circumstances under which people drink are complex and were not evaluated in this study. Therefore, rather than endorsing drinking behavior, these findings suggest that future research might examine why elders make the decision to drink, the circumstances that predispose women to drink (alone/with others), and other qualities that characterize female drinkers over the age of 65. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Effective screening instruments are needed for the detection of alcohol use disorders (AUDs) in the elderly, in view of the significant physical, psychological and social problems associated with this phenomenon. Methods This paper provides details on the different self-report alcohol screening instruments that have been studied in the elderly, describing both the instruments themselves and their effectiveness as screening instruments for AUDs in different elderly populations. Results The vast majority of studies reviewed were carried out in the US, and a high proportion of these were carried out in Veterans Administrations institutions, thus limiting the generalizability of results. The CAGE was the most widely studied screening instrument, followed by the MAST or variations of the MAST, the AUDIT and variations of the AUDIT, and other screening instruments. Sensitivity and specificity of these instruments varied widely, depending on the prevalence of AUDs in the population being studied, the clinical characteristics of the population and the type of AUD being detected. The CAGE performed poorly in psychiatric populations but a newer instrument, the AUDIT-5, has had promising results to date. No studies focussed on elderly people with cognitive impairment, and there is a need for research in this area. Conclusions Ease of use, patient acceptability, sensitivity and specificity must all be considered when selecting a self-report alcohol screening instrument for use in the elderly. Furthermore, the prevalence of AUDs in the population and the clinical characteristics of that population must also be taken into account. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Methods This paper reports a case series of ten patients collected over a 12-year period of clinical work in old age psychiatry in the UK by the author. Results The core features of the syndrome are: apparent cognitive impairment, regression and increasing physical dependency beginning in late middle or early old age, without evidence for an organic dementia from investigations or from taking into account the course of the illness. The syndrome is more common in women from a higher socio-economic background with past psychiatric histories dominated by depressive symptoms. The syndrome usually progresses to the point where long term institutional care is needed although the mean survival from onset is 13 years. Conclusions The author suggests that conversion pseudodementia in older people is caused by a catastrophic reaction to cumulative loss in later life in individuals who have predisposing borderline and narcissistic personality traits. Treatment using psychotherapeutic approaches may limit the progression of the syndrome if it is recognised at an early stage. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression. Methods Paper-and-pencil administration of the CES-D to 318 elders (55–85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (MINI), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore the characteristics of true versus false positives were analyzed. Results For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes. Conclusions The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi-clinical sample of elders. Subjects scoring ≥25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective The objective of this paper is to investigate the prevalence of and risk factors associated with cognitive impairment in a community-dwelling elderly population. Methods 1000 community residents aged 65–74 years were recruited in the cross-sectional survey of associated factors of cognitive impairment in southern Taiwan. We employed a multilevel stratified sampling strategy and conducted this interview survey from April to June 2001. The survey questionnaire included background information and the Short Portable Mental Status Questionnaire. The relationship between cognitive impairment and each individual variable in personal attributes and social participation were explored. Results Eight hundred and ninety-four (89.4%) subjects completed the interview and questionnaires. The cognitive impairment rate among all subjects was 4.92%. Of those surveyed, 54.98% were male and 45.02% were female, and the average age was 69.37 (SD 2.73) years. Most survey respondents (72.05%) were married, and 68.90% of the subjects did not participate in any social activities in the last 6 months. Females, those who were illiterate or did not attend school, those who had an average family income below US$860 per month, and persons who did not participate in any social activities had a significantly higher rate of cognitive impairment. Conclusion The educational level and participation in social activities were associated with the cognitive impairment among the aged community dwellers. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Debate persists about whether people of different ages react similarly to traumatic events, and whether elderly people are more vulnerable to such events, or better able to cope with them. The first aim of this paper was to shed light on this debate by comparing the post-traumatic responses of young, middle-aged and elderly community residents who had been exposed to technological disasters. The second aim was to differentiate between these three age groups in terms of coping strategies. Methods One hundred and forty-eight community residents, who were exposed to two technological disasters, participated in the study. They were assessed using the Impact of Event Scale (IES), the General Health Questionnaire (GHQ-28) and the Ways of Coping Checklists (WOC). Results The results showed that in terms of IES, GHQ and WOC scores, no significant differences were found across the three age groups. However, main effects were found according to type of disaster and intensity of exposure to disaster. One significant interaction effect was that residents exposed to the aircraft crash used significantly more confrontive coping than those exposed to the train collision, in all three age groups. Correlation coefficients results showed that for all three age groups, on the whole, the more they experienced intrusive thoughts and avoidance behaviour, the more they experienced general health problems. Conclusions Following exposure to technological disasters, young, middle-aged and elderly community residents could display similar post-traumatic responses and employ similar coping strategies, which contradicts the vulnerability hypothesis and the inoculation hypothesis. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background The public health impact of cognitive decline and dementia is increasing as the population ages. Studies exploring therapies or risk factors for cognitive impairment require understanding of expected age-related decline. Objective To establish the rate of age-related cognitive decline in the general elderly population. Design Systematic review of studies of cognitive decline in the general elderly population. Medline, Embase and PsycINFO databases were searched using an adapted version of McMaster's aetiology, causation and harm strategies and the Cochrane Dementia and Cognitive Impairment Group strategy. Grey literature was explored and experts contacted. A second observer was involved at all stages and quality appraisal of included studies was performed. Included studies were representative, community-based, cohort studies of people aged over 60, incorporating individuals with dementia. Results Identification of 5990 abstracts and retrieval of 163 full texts led to inclusion of 19 papers. Heterogeneity made narrative review the appropriate method of data synthesis. Some degree of cognitive impairment with increasing age was found in all studies, although the extent varied. The prevalence of cognitive impairment and the rate of decline increased with age. Studies were of variable quality. Conclusions Cognitive decline is almost universal in the general elderly population and increases with age. Improved communication between researchers and between clinicians to identify a core minimum data set of neuropsychological tests that could be used in different populations would support consistent study design and meta-analysis, helping to quantify the true rate of cognitive decline in the elderly and assisting diagnosis in clinical practice. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The objective of this paper is to ascertain estimates of the prevalence, and associated risk factors for, suicidal ideation among community-dwelling older adults in Hong Kong. The study was conducted as part of the General Household Survey (GHS), using face to face interviews of ethnic Chinese people aged 60 or above living in the community. Elders living in institutions or elderly homes were excluded from the study. Six percent of the sample was found to have ever had suicide ideation. The results showed that poor physical health, including poor vision, hearing problems, and a greater number of diseases; and poor mental health, especially in the form of depression, are predictors of suicidal ideation in the elderly population. Also, statistical analysis by linking individual factors to depression showed that financial and relationship problems are significant risk factors as well. Older adults who engaged in active coping, that is, those who actively seek to manage or control the negative events in their lives, fare better with lower levels of suicidal ideation than those who use passive coping styles. The prevalence of suicidal ideation is similar among elders in Hong Kong and western countries. Factors that contribute to risk for suicidal ideation span physical and mental health, social, and psychological domains. Although the association of suicidal ideation to self-destructive acts remains to be determined, these findings indicate a variety of potential foci for late life suicide prevention efforts. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper seeks to address whether integrated structures are associated with more integrated forms of service. Northern Ireland has one of the most structurally integrated and comprehensive models of health and personal social services in Europe. Social and health services are jointly administered and this arrangement should, in theory, promote collaborative working and interdisciplinary arrangements. The study employed a cross-sectional survey of consultants in old age psychiatry in England and Northern Ireland. Potential respondents were sourced from the UK Royal College of Psychiatrists membership list and locally collected information. A self-administered postal questionnaire. Along with general service arrangements, the domains measured reflect core policy issues for older people''s services. Under particular scrutiny in this study were the degree of integration of health and social service provision, as well as inter-professional team working. The integrated health and social care services in Northern Ireland do appear to provide more integrated patterns of working, primarily in managerial arrangements and in the location of staff. There was no evidence of the impact of integration on practice in areas such as: assessment, referral and medical screening. The factors found to be associated with greater integration of health and social care in the prediction model fell into three categories: provision of specialist services; provision of outreach activities; and shared policies by which the whole team worked. Health and personal social services in Northern Ireland have a distinct advantage over their counterparts in comparable areas of England. The results indicate that integrated structures in old age psychiatry services are associated more with integrated management systems and less with integrated practice-related activities. Further research is required on the effectiveness and cost effectiveness of integrating services in general. It is important that future intervention studies systematically measure the component parts, nature and extent of integration and their individual and joint contribution to the effectiveness and efficacy of services. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Nine years after the initial approval of a cholinergic drug for the treatment of Alzheimer's Disease in the USA, a compound with a different pharmacological approach, namely the NMDA antagonist memantine, has been approved for the first time in Europe in 2002. This event led to an enhanced perception of a decade of basic research work on its mode of action. At the same time, additional preclinical data, e.g. on memantine's effects on the hyperphosphorylation of tau, and clinical trial results, e.g. on the glutamatergic–cholinergic combination therapy, are being reported. The present paper attempts to provide an update on the currently available pharmacological and clinical evidence on memantine, including earlier clincial data, e.g. in vascular dementia. As the clinical database broadens, and various additional conditions are being tested in ongoing controlled clinical trials, we are approaching an ever more precise profile of memantine's spectrum of safety and tolerability, and also varied efficacy—hopefully resulting in another useful tool in the clinician's hands to fight previously untreatable neurodegenerative disease. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Aim The somatoform disorders have long been ignored by old age psychiatry. The main aim of this paper is to identify and examine possible reasons for this neglect. Method A selective review of the general literature on somatoform disorders. Results Significant conceptual, diagnostic and classificatory problems have impeded the consideration of somatoform disorders in older people. There is a perception that somatoform disorders are infrequent and have not been validated as independent clinical disorders. However, we present evidence that the more broadly defined somatoform disorders are common in all age groups in primary care and meet criteria for the determination of clinical validity. General difficulties in the assessment of psychiatric disorders in primary care, the setting in which somatoform disorders are most common, are compounded by a lack of support from old age psychiatry services. Effective psychological therapies may not be readily available to sufferers. Conclusion There is a need for change in the conceptualisation and nosology of the somatoform disorders. The formulation of age appropriate diagnostic criteria and presentations is a prerequisite for determining the clinical validity of these disorders in older people. This can be followed by study of their frequency, associated risk factors and treatment. A system of education that enhances the management of these disorders within primary care and old age psychiatry services is needed. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Performance measurement and benchmarking are common concerns in the delivery of long term care. It is common to measure the performance of providers and to publicly report these data. This paper examines selected technical challenges facing those who design, implement and disseminate health care quality performance measures. Method Review of the application of measures of performance in the US nursing home sector. Results Using examples drawn from the skilled nursing home arena, problems ranging from data reliability and validity, the multi-dimensional nature of quality measures and selection bias as well as differential measurement abilities are discussed. Conclusions Benchmarking of performance is an inherently complex issue. However, to ensure that such comparisons are both fair and valid requires measures to be more technically sophisticated and sensitive to real changes attributable to changes in care. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Dutch nursing homes employ physicians who have completed a two year specialist training programme to become a qualified nursing home physician. This paper describes the origin of the profession of nursing home medicine in the context of Dutch nursing homes. Method Review of the history and development of the need for specialist physicians in care of residents in nursing homes. Examination of the competencies required and training available for physicians and the benefits of this arrangement in improving quality of care. Results Relevant skills and competencies of the specialist physician in nursing homes are discussed. The role and tasks, and the nursing home physician's method of working and providing care are explained, as well as the benefits and disadvantages of organizing medical care in this way. Conclusions The benefits of a specialist physician are considered greater than the disadvantages. Specialist training for this role is considered to be highly desirable. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The needs of individuals with dementia and other psychiatric problems of old age have received increased attention in Australia over the last decade. This paper reports on the role of Aged Care Assessment Teams (ACATs) in managing these clients, and the extent to which they are differentiated from other clients in the assessment process and outcomes recommended. Data on some 26,500 clients seen by ACATs in Victoria in the second half of 1999 are analysed to show (1) the relationship between a diagnosis of dementia and reporting of disability in orientation, (2) characteristics of clients with and without a diagnosis of dementia and (3) outcomes for groups of clients defined on the basis of a diagnosis of dementia and disability in orientation. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Empirical evaluation of the agreement between different diagnostic approaches is crucial for the understanding of epidemiological results in geriatric psychiatry. In this paper, we analyse differences between widely used diagnostic approaches of dementia and depression and offer evidence that diagnostic thresholds vary substantially on quantitative dimensions, but that conceptual and other differences between approaches must also been taken into account. In an epidemiological study of n = 516 persons, aged 70-103 years, we compared psychiatric diagnoses of dementia and depression obtained by GMS-A/HAS-AGECAT, DSM-III-R and clinician's diagnoses of subthreshold depression (SD). For depression, cumulative prevalence of clinician's diagnosis (including SD, GMS-A/HAS-AGECAT and DSM-III-R defined forms) was highest, followed by GMS-A/HAS-AGECAT-diagnosis and DSM-III-R, while for dementia DSM-III-R was followed by GMS-A/HAS-AGECAT. Overall agreement between DSM-III-R and GMS-A/HAS-AGECAT was moderate. Adapting thresholds for AGECAT resulted in slightly better diagnostic efficiency. Diagnostic disagreement was found predominantly for cases with intermediate symptom severity, supporting the hypothesis of differing thresholds between DSM-III-R and GMS-A/HAS-AGECAT, while cases with lower or higher symptom severity were similarly seen as cases or non-cases. Disagreement is not only caused by conceptual differences, but also different thresholds of diagnostic algorithms. Adaptation of threshold levels should be feasible, depending on the purpose of the analysis. [ABSTRACT FROM AUTHOR]

Objectives This paper reports on a bibliometric analysis of keywords in the literature on ethics and dementia during the period 1980–2000. Methods Keywords were drawn from titles, abstracts and keyword fields of 14 bibliographic databases and clustered in to 19 categories. These categories were then examined for their frequency and co-occurrences. The strength of relationships between these categories is mapped using the metaphor of the ‘night sky’ showing constellations of issues and changes over time. Results Four categories appear consistently and frequently in the literature: professional care, end-of-life issues, decision-making and treatment. Other issues come and go (such as quality-of-life issues) while others appear to respond to outside events (e.g. feeding issues). The research literature is based predominantly on surveys or studies soliciting responses to predefined issues. Little research has been undertaken to establish the range of ethical issues for either family members or professionals. Discussion We discuss the domination of the literature by four categories of ethical issues, the new and emerging areas of ethical interest and those areas that are triggered by external events such as legal cases. We also discuss some of the limitations of the study and note some omissions in the literature. Conclusion During the period 1980–2000 the research literature has been dominated by surveys and studies soliciting views on predefined issues with relatively few in-depth, open-ended qualitative studies. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Recent research suggests there are clinical and biological differences between late onset depression (LOD) and early-onset depression (EOD). Objectives In this paper we review clinical, epidemiological, structural neuroimaging and genetic investigations of late life depression that have been performed over the past two decades and offer evidence that LOD is often a prodromal disorder for dementia. Results LOD patients are more likely to have cognitive impairment and to have more deep white matter lesions (DWMLs). Evidence concerning cortical and temporal lobe atrophy is conflicting, while the ApoE 4 allele is not associated with LOD. Conclusions It is likely that LOD is not a prodrome for a particular type of dementia, but the majority of patients who do develop dementia will acquire Alzheimer's disease (AD) or a vascular dementia, as these are by far the most common causes of dementia. This issue requires further clarification with follow-up of patients over the long term. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Increasing attention has been paid to the needs of family members caring for a person with dementia but little has been written about the impact on the wider family. This paper was intended to see whether the need for information would stretch to those relatives living far from the patient. Method A case-control study comparing two sets of relatives of community-dwelling probands in contact with secondary services and having a clinical diagnosis of dementia: one set of relatives living less than an hour away and another set living further away. The reported need for and source of information obtained by relatives was questioned using a specially designed questionnaire. Mini Mental State Examination (MMSE) and Clinical Dementia Ratings Scale were used with probands. Results Relatives living distantly from the person with dementia reported similar rates of subjective distress but were more often dissatisfied with information received. Distant relatives were also less likely to access information from books or lay societies. Conclusion The impact of having a relative with dementia does not lessen with distance. The wider family need support and information as well as ‘primary carers’. If the whole family is to be supported in their caring role, then clinicians and the lay societies need to widen their supportive net. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Suicidality is constituted by all those phenomena that are apparently positioned along a continuum, with the two extremes represented by death wishes and completed suicide. Objectives The aim of this paper is to show the one-year prevalence of the phenomena constituting this possible continuum in the elderly population (aged 65 years and over) of a northern Italian city and to evaluate the relationship between some of these phenomena with psychological suffering. Method Emotional feelings and suicidal thoughts have been investigated by an epidemiological survey conducted in a central quarter of that city. Data on attempted and completed suicide derived from the data bank of the Padua's WHO Collaborating Centre for Research and Training in Suicide Prevention that monitors these phenomena since 1989. Results and Conclusions Results suggest the existence of some continuity in suicidal phenomena, where prevalence decreases from those of emotional/ideational nature to most extreme behaviour. Subjects presenting with more severe suicidal ideation were those also obtaining highest scores in a number of sub-scales of the Brief Symptom Inventory. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background It has been reported that 10% of all patients with bipolar disorder develop their illness after the age of 50, with bipolar disorder accounting for 5–19% of mood disorder presentations in the elderly. There has been a growing awareness regarding the manifestation of bipolar disorder among older adults due to both changes in national demographics, and developing sophistication in the treatment of bipolar illness. A persistent problem in our understanding of management of late life bipolar disorder is the paucity of research and rigorous published studies on the psychopharmacology of this condition. Objective This paper reviews medication treatments, non-medication biological therapies, and psychosocial interventions for bipolar disorder in late life with a particular emphasis on age related modifiers of treatment. Methods Findings are based upon review of the current literature. Results There are multiple, significant gaps in our knowledge of bipolar disorder in late life which have important implications in the optimum treatment of elderly individuals with bipolar illness. Conclusion There are a number of areas of needed future research in late life bipolar disorder. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]