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Filipa Pereira,1,2 Armin von Gunten,3 Joëlle Rosselet Amoussou,4 Isabella De Giorgi Salamun,5 Maria Manuela Martins,2,6 Henk Verloo1,3 1School of Health Sciences, HES-SO Valais-Wallis, Sion, Switzerland; 2Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal; 3Service of Old Age Psychiatry, Lausanne University Hospital, Lausanne, Switzerland; 4Psychiatry Library, Education and Research Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; 5Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland; 6Higher School of Nursing of Porto, Porto, PortugalCorrespondence: Filipa PereiraSchool of Health Sciences, HES-SO Valais-Wallis, Chemin de l’Agasse 5, Sion CH-1950, SwitzerlandTel +41 78 666 17 00Fax +41 27 606 84 00Email filipa.pereira@hevs.chAbstract: Ageing populations with multiple chronic conditions challenge low-, middle-, and high-income countries. Older adults frequently depend on complex medication regimens and polypharmacy, both of which can lead to potentially devastating and debilitating medication-related problems and to subsequent far-reaching public health, social, and economic effects. This perspectives article provides an overview of the current state of medication management, reflects on its relevance among polymedicated home-dwelling older adults living with multiple chronic conditions, and proposes patient-centered approaches for optimizing medication management and preventing medication-related problems.Keywords: multiple chronic conditions, medication-related problems, caregivers, interprofessional collaboration, patient-centered care

The early diagnosis of subjectively perceived or externally anamnestically observed cognitive impairments is essential for proving neurodegenerative diseases or excluding treatable causes such as internal, neurological or psychiatric disorders. Only in this way is early treatment made possible. As part of the project 3.1 of the National Dementia Strategy 2014–2019 («Development and expansion of regional and networked centres of competence for diagnostics»), the association Swiss Memory Clinics (SMC) set itself the goal of developing quality standards for dementia clarification and improving the community-based care in this field. In these recommendations, general guidelines of diagnostics and individual examination possibilities are presented, and standards for the related processes are suggested. Individual areas such as anamnesis, clinical examination, laboratory examination, neuropsychological testing and neuroradiological procedures are discussed in detail as part of standard diagnostics, and supplementary examination methods for differential diagnosis considerations are portrayed. The most important goals of the SMC recommendations for the diagnosis of dementia are to give all those affected access to high-quality diagnostics, if possible, to improve early diagnosis of dementia and to offer the basic service providers and the employees of Memory Clinics a useful instrument for the clarification.

BACKGROUND In randomized controlled trials, Ginkgo biloba extract EGb 761® has been found to be effective in the treatment of behavioral and psychological symptoms of dementia (BPSD). METHODS To assess the effects of EGb 761® on specific BPSD, we analyzed data from all randomized, placebo-controlled, at least 20-week, trials of EGb 761® enrolling patients with dementia (probable Alzheimer's disease (AD), probable vascular dementia or probable AD with cerebrovascular disease) who had clinically significant BPSD (Neuropsychiatric Inventory (NPI) total score at least 6). Data were pooled and joint analyses of NPI single item composite and caregiver distress scores were performed by meta-analysis with a fixed effects model. RESULTS Four trials involving 1628 patients (EGb 761®, 814; placebo, 814) were identified; treatment duration was 22 or 24 weeks; the daily dose of EGb 761® was 240 mg in all trials. Pooled analyses including data from the full analysis sets of all trials (EGb 761®, 796 patients; placebo, 802 patients) revealed significant superiority of EGb 761® over placebo in total scores and 10 single symptom scores. Regarding caregiver distress scores, EGb 761®-treated patients improved significantly more than those receiving placebo in all symptoms except delusions, hallucinations, and elation/euphoria. The benefit of EGb 761® mainly consists of improvement in symptoms present at baseline, but the incidence of some symptoms was also decreased. CONCLUSIONS Twenty two- to twenty four-week treatment with Ginkgo biloba extract EGb 761® improved BPSD (except psychotic-like features) and caregiver distress caused by such symptoms.

With the increase in aging all over the world, and the elderly population nearly tripling from 524 million (8% of the world's population) in 2010 to 1.5 billion (16% of the world's population) in 2050, we will face new challenges and opportunities in providing healthcare. In 2050, it is estimated that Europe will see an increase of 70% in elderly population aged over 65 years, and 170% in those aged over 80 years (World Health Organization (WHO), 2011). It is vital to respond to the needs of this emerging population and the consequent rise in chronic diseases, especially dementia and mental health disorders, which will overload the healthcare system, as well as raise health and social costs, and demand new policies from national governments (World Health Organization, 2012). We urgently need to know how to organize healthcare for elderly people in the years to come

Background: Vocally disruptive behavior (VDB) in the elderly is a common condition, especially in people with dementia, but difficult to treat. It may occur in as many as 40% of nursing home residents. This study is a review of the existing literature on this condition. Method: The literature review was conducted using PubMed (particularly Medline and the Cochrane database) and reference lists from relevant publications in English, French, and German. Results: Most studies are small and no conclusive prevalence data are available. Many biological and psychosocial treatments have been advocated, but most studies are little more than anecdotal case reports. It is evident that VDB can have deleterious consequences on others and the patients themselves, although no studies specifically examine the range or the pervasiveness of VDB. Etiopathogenic research on VDB is still in its infancy. Conclusions: Most aspects surrounding VDB are insufficiently understood. The heterogeneity and multiple contributive factors regarding VDB suggest quite convincingly that a panoply of different interventions tailored to the individual's needs will be required to overcome VDB and the suffering related to it

Background: Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and dementia. In many cases, MCI represents an early stage of developing cognitive impairment. Patients diagnosed with MCI do not meet the criteria for dementia as their general intellect and everyday activities are preserved, although minor changes in instrumental activities of daily living (ADL) may occur. However, they may exhibit significant behavioral and psychological signs and symptoms (BPS), also frequently observed in patients with Alzheimer's disease (AD). Hence, we wondered to what extent specific BPS are associated with cognitive decline in participants with MCI or AD. Methods: Our sample consisted of 164 participants, including 46 patients with amnestic (single or multi-domain) MCI and 54 patients with AD, as well as 64 control participants without cognitive disorders. Global cognitive performance, BPS, and ADL were assessed using validated clinical methods at baseline and at two-year follow-up. Results: The BPS variability over the follow-up period was more pronounced in the MCI group than in patients with AD: some BPS improve, others occur newly or worsen, while others still remain unchanged. Moreover, specific changes in BPS were associated with a rapid deterioration of the global cognitive level in MCI patients. In particular, an increase of euphoria, eating disorders, and aberrant motor behavior, as well as worsened sleep quality, predicted a decline in cognitive functioning. Conclusions: Our findings confirm a higher variability of BPS over time in the MCI group than in AD patients. Moreover, our results provide evidence of associations between specific BPS and cognitive decline in the MCI group that might suggest a risk of conversion of individuals with amnestic MCI to AD

Behavioural and psychological symptoms of dementia (BPSD) occur in most patients with dementia. They cause great suffering in patients and caregivers, sometimes more so than the cognitive and functional decline inherent to dementia. The clinical features of BPSD include a wide variety of affective, psychotic and behavioural symptoms and signs. The causes and risk factors for BPSD are multiple and include biological, psychological and environmental variables. Frequently, their combination, rather than any specific factor, explains the occurrence of BPSD in an individual patient. Thus, a sound etiopathogenetic investigation including the patient and the family or care team is essential. The aim is to develop an individualized treatment plan using a therapeutic decision tree modified by the individual and environmental risk profile. Still, treatment may be difficult and challenging. Clinical empiricism often steps in where evidence from controlled studies is lacking. Psychosocial treatment approaches are pivotal for successful treatment of BPSD. Often a combination of different non-pharmacological approaches precedes drug treatment (most of which is off-label). Regular assessments of the treatment plan and any prescriptions must be carried out to detect signs of relapse and to stop any medicines that may have become inappropriate. Even with optimal management, BPSD will not disappear completely in some cases and will remain challenging for all involved parties. This article is a narrative review based closely on the interprofessional Swiss recommendations for the treatment of BPSD. To establish the recommendations, a thorough research of the literature has been carried out. Evidence-based data were provided through searches of Medline, Embase, ISI and Cochrane-Database research. Evidence categories of the World Federation of Biological Societies were used. Additionally, the clinical experience of Swiss medical experts was considered.

Henk Verloo,1 Céline Goulet,2 Diane Morin,3,4 Armin von Gunten51Department Nursing Sciences, University of Applied Sciences, Lausanne, Switzerland; 2Faculty of Nursing Science, University of Montreal, Montreal, QC, Canada; 3Institut Universitaire de Formation et Recherche en Soins (IUFRS), Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland; 4Faculty of Nursing Science, Université Laval, Québec, Canada; 5Department of Psychiatry, Service Universitaire de Psychiatrie de l’Age Avancé (SUPAA), Lausanne University Hospital, Prilly, SwitzerlandBackground: Delirium and frailty – both potentially reversible geriatric syndromes – are seldom studied together, although they often occur jointly in older patients discharged from hospitals. This study aimed to explore the relationship between delirium and frailty in older adults discharged from hospitals.Methods: Of the 221 patients aged >65 years, who were invited to participate, only 114 gave their consent to participate in this study. Delirium was assessed using the confusion assessment method, in which patients were classified dichotomously as delirious or nondelirious according to its algorithm. Frailty was assessed using the Edmonton Frailty Scale, which classifies patients dichotomously as frail or nonfrail. In addition to the sociodemographic characteristics, covariates such as scores from the Mini-Mental State Examination, Instrumental Activities of Daily Living scale, and Cumulative Illness Rating Scale for Geriatrics and details regarding polymedication were collected. A multidimensional linear regression model was used for analysis.Results: Almost 20% of participants had delirium (n=22), and 76.3% were classified as frail (n=87); 31.5% of the variance in the delirium score was explained by frailty (R2=0.315). Age; polymedication; scores of the Confusion Assessment