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Henry Handel Richardson's 1929 novel Ultima Thule, the third volume of The fortunes of Richard Mahony, portrays the final years of Mahony's failed 19th century colonial venture and the psychological challenges he faced. The novel graphically describes the onset and evolution of younger onset dementia, modelled on the author's own experiences with her father, who died of general paresis of the insane. The issues on which Richardson focuses, including Mahony's depression and suicidal despair, the difficulties of understanding behavioural change without a diagnosis, the impact of parental dementia on young children and the spouse, and the importance of person-centred care in dementia, remain relevant today. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the prevalence of depression among older Australians with common medical morbidities, and to determine the association between poor physical health and depression in this age group.Design: Cross-sectional, postal questionnaire survey.Setting and Participants: 20 183 community-dwelling adults aged 60 years and over, under the care of 383 general practitioners participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) project (conducted between 2005 and 2008; the data in this article were collected during the baseline phase of the study in 2005).Main Outcome Measures: Depressive symptoms (measured by the nine-item depression scale of the Patient Health Questionnaire), health status (measured by the 12-item Short Form Health Survey and a medical morbidity inventory), social support (measured by the subjective support subscale from the Duke Social Support Index), and demographic and lifestyle information.Results: 18 190 participants (90.1%) reported having at least one chronic physical health condition, while 1493 (7.1%) experienced clinically significant depression (3.1% major depressive syndrome; 4.0% other depressive syndrome). Most chronic physical illnesses were associated with increased odds of depression, and participants with numerous medical morbidities and a high level of functional impairment were three to four times more likely to have a depressive illness.Conclusions: Depression is more the exception than the rule in later life, and among those who are medically unwell, the level of associated impairment may determine their risk of depression more than their acquired physical illness. Many of the factors associated with depression in medically ill patients are amenable to treatment, and GPs are in a unique position to address this important public health issue. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to determine the prevalence and types of young onset dementia (YOD) in New South Wales (NSW), Australia, in 1891 with comparisons to 21st century estimates. Changes might inform future service planning for persons with YOD., Methods: Medical case books of two Hospitals for the Insane were examined at the State Archives and clinical and sociodemographic information extracted of persons who were under the age of 65 in April 1891, when a NSW Census occurred, and were given a dementia diagnosis or had symptoms consistent with dementia. Consensus 21st century 'probable' and 'possible' all cause dementia and major neurocognitive disorder diagnoses were determined by two psychiatrists. Prevalence estimates of moderate-severe dementia were determined and compared with 21st century estimates and dementia types., Results: Of 161 potential dementia cases, 123 were given a consensus 'probable' dementia diagnosis, 28 a 'possible' dementia diagnosis, and ten were given a non-dementia diagnosis, with 'all cause dementia' and 'major neurocognitive disorder' diagnoses identical. Most dementia cases were male (n = 119, 78.8%). 'Unspecified dementia' was the most frequent diagnosis (n = 47, 31.1%), followed by dementia secondary to syphilis (n = 35, 23.2%), epileptic dementia (n = 30, 19.9%), alcohol-related dementia (n = 17, 11.3%), and mixed dementia (n = 16, 10.6%). Epileptic dementia had the youngest average age of admission (34.9 years). Other than epileptic dementia, all other dementia types were more frequent in males. Prominent clinical symptoms included neurological signs (n = 79, 52.3%), psychosis (n = 77, 51.0%), agitation (n = 75, 49.7%), and aggression (n = 45, 29.8%). Most dementia cases either died in hospital (n = 79, 52.3%) or were transferred to a long stay hospital (n = 57, 37.7%). The estimated point prevalence of YOD in persons aged 30-59 in 1891 (86 per 100,000) was higher than current Australian and global estimates in this age group due to the high rates in males (126 per 100,000), but in those aged 60-64, the prevalence in 1891 (159 per 100,000) was much lower than current estimates., Conclusions: This first examination of YOD in the nineteenth century found high rates of dementia in those under the age of 60 compared with current estimates, particularly in men aged between 30 and 59 years old, and largely due to syphilis, alcohol and epilepsy, conditions that are now treatable and thus demonstrating the potential of effective treatments for YOD., (© 2024 The Author(s). International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

Introduction: People who die by suicide have a higher risk of an alcohol-use disorder (AUD) at the time of death. The present study aims to compare 1) suicide cases with and without AUD, and 2) suicide and sudden-death controls with AUD., Methods: The psychological autopsy method was utilized to investigate suicide and sudden death in Australia (QLD and NSW). Initial information was gathered from coroners' offices. Potential informants were approached and semi-structured interviews were conducted. Univariate and multivariate logistic regression were applied., Results: People with AUD who died by suicide were significantly more likely to have another substance-use disorder, history of suicide attempt, recent serious arguments with spouse/partner and other family members, been unfaithful to partner/spouse, be victims of a crime, and were less likely to be from a non-English speaking background. They were also younger and had higher levels of aggression compared to non-AUD suicides. AUD suicides were more likely to have mood disorders, previous suicide attempt, expressing hopelessness, higher scores in aggression towards self, romantic relationship breakup, and serious arguments with other family members than AUD sudden deaths. Aggressive behavior, having another substance-use disorder, and history of serious arguments with family members remained significant in the final model comparing suicides with and without AUD., Conclusion: Our findings support that aggressive behavior, comorbidity with other psychiatric disorders as predisposing factors, and recent interpersonal conflicts such as breakup and family conflicts can trigger suicide in people with AUD. There is a need for proper diagnosis, risk assessment, and treatment in suicidal people with AUD., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To test the effects of individual, nonfacilitated sessions with PARO (version 9), when compared against a look-alike plush toy and usual care, on the emotional and behavioral symptoms of dementia for people living in long-term care facilities., Design: Parallel, 3-group, cluster-randomized controlled trial conducted between June 14, 2014, and May 16, 2015., Setting: Twenty-eight long-term care facilities operated by 20 care organizations located in South-East Queensland, Australia., Participants: Four hundred fifteen participants aged ≥60 years, with a documented diagnosis of dementia., Intervention: Stratified by private/not-for-profit status and randomized using a computer-generated sequence, 9 facilities were randomized to the PARO group (individual, nonfacilitated, 15-minute sessions 3 times per week for 10 weeks); 10 to plush toy (same, but given PARO with robotic features disabled); and 9 to usual care. Treatment allocation was masked to assessors., Measurements: Primary outcomes were changes in levels of engagement, mood states, and agitation after a 10-week intervention, assessed by coded video observations (baseline, weeks 1, 5, 10, and 15) and Cohen-Mansfield Agitation Inventory-Short Form (baseline, weeks 10 and 15). Analyses followed intention-to-treat, using repeated measures mixed effects models. Australian New Zealand Clinical Trials Registry (ACTRN12614000508673)., Results: Video data showed that participants in the PARO group were more verbally [3.61, 95% confidence interval (CI): 6.40-0.81, P = .011] and visually engaged (13.06, 95% CI: 17.05-9.06, P < .0001) than participants in plush toy. Both PARO (-3.09, 95% CI: -0.45 to -5.72, P = .022) and plush toy (-3.58, 95% CI: -1.26 to -5.91, P = .002) had significantly greater reduced neutral affect compared with usual care, whilst PARO was more effective than usual care in improving pleasure (1.12, 95% CI: 1.94-0.29, P = .008). Videos showed that PARO was more effective than usual care in improving agitation (3.33, 95% CI: 5.79-0.86, P = .008). When measured using the CMAI-SF, there was no difference between groups., Conclusions: Although more effective than usual care in improving mood states and agitation, PARO was only more effective than a plush toy in encouraging engagement., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.

Background: Concerns about suicide risk in people with dementia have been increasing in recent years along with a discourse about rational suicide and assisted suicide., Methods: A systematic narrative literature review of suicidal behavior and assisted suicide in persons with dementia., Results: Most studies that have examined the spectrum of suicidal ideation, attempted suicide and suicide in dementia have methodological limitations but the overall suicide risk does not appear to be increased. When suicidal behavior does occur, common themes include the presence of psychiatric comorbidity, mainly depression; occurrence early in the dementia course with preserved insight and capacity; and an increased risk in younger people. The emerging discourse on rational and assisted suicide has been spurred by early and pre-symptomatic diagnosis and poses a number of ethical challenges for clinicians including the role of proxy decision-makers., Conclusions: Although dementia might not confer a significant overall risk for suicidal behavior, clinicians still need to consider the potential for suicide in vulnerable individuals particularly early in the dementia course.

Despite a general decline in late life suicide rates over the last 30 years, older people have the highest rates of suicide in most countries. In contrast, non-fatal suicidal behaviour declines with age and more closely resembles suicide than in younger age groups. There are difficulties in the detection and determination of pathological suicidal ideation in older people. Multiple factors increase suicide risk ranging from distal early and mid-life issues such as child abuse, parental death, substance misuse and traumatic life experiences to proximal precipitants in late life such as social isolation and health-related concerns. Clinical depression is the most frequently identified proximal mental health concern and in many cases is a first episode of major depression. Recent studies have identified changes on neuroimaging and neurocognitive factors that might distinguish suicidal from non-suicidal depression in older people. Strategies for suicide prevention need to be 'whole of life' and, as no single prevention strategy is likely to be successful alone, a multi-faceted, multi-layered approach is required. This should include optimal detection and management of depression and of high risk individuals as available evidence indicates that this can reduce suicidal behaviour. How best to improve the quality of depression management in primary and secondary care requires further research., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Psychological effects of supporting someone with mild cognitive impairment (MCI) are often overlooked. We aimed to establish correlates of psychological distress in study partners of individuals with and without nonclinical MCI., Methods: Demographic, psychosocial and health measures were obtained cross-sectionally from 714 participants (39% MCI) and study partners of a longitudinal community-based study on cognitive aging. Study partners (i.e. family members/friends) were categorized as providing support with instrumental everyday activities or not. Psychological distress was measured by the Kessler psychological distress scale. Multiple hierarchical regressions examined determinants of psychological distress within Pearlin's stress process model., Results: Psychological distress was generally low and not associated with MCI or whether study partners provided support or not. Instead, distress was greater if participants were male irrespective of study partners' sex and if study partners reported negative reactions to participants' behavioral symptoms, felt burdened by providing support and showed worse coping abilities; overall explaining 37% variance. Self-rated disability and aspects of health-related quality of life explained additional 7%., Conclusion: Objective impairment measures were not associated with distress in partners or supporters. However, study partners' appraisals of functional and behavioral symptoms were linked to increased distress even in this very mildly affected community cohort.

Aim: This study aims to examine contacts with different health professionals in the three months prior to death in suicide cases compared to sudden death controls; and, to analyse contacts with health professionals among people who died by suicide having a diagnosable mental health disorder at the time of suicide compared to those who did not have such a diagnosis within four major groups of conditions., Methods: The psychological autopsy method was utilised to investigate suicides of individuals over the age of 35years. A case-control study design was applied using sudden death cases as controls. Odds ratios with a 95% confidence interval were calculated., Results: In total, 261 suicides and 182 sudden deaths were involved. In terms of contacts during the last three months prior to death, 76.9% of suicides and 81.9% of sudden deaths visited a general practitioner (GP). Persons who died by suicide had significantly more frequently contacts with mental health professionals than sudden death controls did. People with a diagnosable mental health disorder at the time of suicide attended GP surgeries with approximately the same frequency of people without a diagnosis at GP level., Conclusion: Similarly, approximately 90% of people who die by suicide and by sudden death seek for help from health care system, mainly from GPs in three months prior to their death. With reference to health care contacts, people who had or did not have a diagnosable psychiatric disorder are not distinguishable at the GP surgery level., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aim: The present study aims to analyse predicting factors of suicide among older adults compared to sudden death controls and middle-aged suicides., Methods: During the period 2006-2008, at two Australian sites, the psychological autopsy method was utilised to investigate suicides of individuals over the age of 35 by interviewing next-of-kin and healthcare professionals. A case-control study design was applied using sudden death cases as controls. Initial information was gathered from coroner's offices. Potential informants were approached and interviews were conducted using a semi-structured format., Results: In total, 261 suicides (73 aged 60+) and 182 sudden deaths (79 aged 60+) were involved. Older adult suicides showed a significantly lower prevalence of psychiatric diagnoses (62%) when compared to middle-aged suicide cases (80%). In both age groups, subjects who died by suicide were significantly more likely to present a psychiatric diagnosis, compared to controls; however, diagnosis did not remain in the final prediction model for older adults. Hopelessness and past suicide attempts remained in the final model for both age groups. In addition, living alone was an important predictor of suicide in older adults., Conclusion: Although mood disorders represent an important target for suicide prevention in old age, there should be increased attention for other risk factors including psychosocial, environmental, and general health aspects of late life., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: To describe the needs of patients aged 50 years and over with chronic mental illness being case managed within a public mental health service, and to determine factors that influence these needs., Method: Patients were recruited from community-based Adult Mental Health (AMH) teams and Specialist Mental Health Services for Older People (SMHSOP) teams. Eligibility criteria included a diagnosis of schizophrenia or mood disorder. Patient, carer and key worker interviews were carried out using the Camberwell Assessment of Need for the Elderly (CANE)., Results: Of 183 eligible patients, 97 (mean age of 66.4 years) participated, of whom 63 were managed by AMH teams and 34 by SMHSOP teams. The majority (52%) had a diagnosis of schizophrenia, particularly those managed by AMH (71%). Patients self-rated fewer needs overall on the CANE than their key workers or the researcher, and also rated a higher proportion of their needs being met (83%) than the key worker (77%) or researcher (76%). From each perspective, over 80% of psychiatric and around 95% of identified medical needs were being met. The majority of social needs were unmet, with patients reporting only 42%, and key workers only 33%, met needs. The key unmet social needs were company, daily activities and having a close confidant. Key workers, patients and researchers rated SMHSOP service delivery to have significantly less unmet needs., Conclusions: The social needs of older patients with chronic mental illness require greater attention by public mental health services.

People with dementia usually experience behavioural and psychological symptoms of dementia (BPSD) during the course of their illness. Currently, in Australia, there is a lack of comprehensive planning for managing and preventing BPSD, and the resources required for optimal care are inadequate and unevenly distributed. We propose a seven-tiered model of service delivery based on severity and prevalence of BPSD, ranging from no dementia through tiers of increasingly severe behavioural disturbance to the propensity for extreme violence in a small number of individuals. Each tier is associated with a different model of intervention. People with dementia may move up or down between tiers depending on their condition, their care and the intervention provided. Lower-level interventions may prevent the need for the more intensive interventions needed when disturbance becomes more severe.

Objective: To compare the outcomes of 3 interventions for the management of dementia complicated by depression or psychosis: psychogeriatric case management, general practitioners with specialist psychogeriatric consultation, and standard care for nursing home residents., Method: The sample for this 12-week randomized controlled trial consisted of 86 subjects with dementia from 11 Sydney, Australia, nursing homes, of whom 34 had depression, 33 had depression and psychosis, and 19 had psychosis. All participants received full psychiatric assessments and physical examinations. Information was obtained from the residents' families and nursing home staff. Depression measures included the Even Briefer Assessment Scale for Depression, Hamilton Rating Scale for Depression, Cornell Scale for Depression in Dementia, and Geriatric Depression Scale. Psychosis measures included the Behavioral Pathology in Alzheimer's Disease Rating Scale, Neuropsychiatric Inventory, and Scale for the Assessment of Positive Symptoms. Data were obtained from nursing home records on prescription of psychotropic medication and demographic information. Management plans were formulated by a multidisciplinary team before random assignment to interventions., Results: All 3 groups improved from pretreatment to posttreatment on depression scales for depression groups and psychosis scales for psychosis groups. Mode of management appeared to make no difference in rate or amount of improvement; neither of the treatment group-by-time interactions were significant. Neither use of antidepressants nor use of antipsychotics predicted depression or psychosis outcomes., Conclusion: Participation in the study was associated with improvement in depression and psychosis, perhaps because of the presence of a psychogeriatric team, the increased attention focused on residents, or the generalization of active intervention techniques to control subjects. A formula-driven psychogeriatric team case management approach was not significantly more effective than a consultative approach or standard care. This study demonstrates the difficulties and feasibility of conducting service-oriented research in nursing homes.

Objective: The objective of this study is to determine the 1998 rates, types, regional variation and Medicare expenditure of private psychiatry services for older people in Australia, as compared with younger adults and with 1985-1986 data., Method: Medicare Benefits Schedule Item Statistics for the psychiatric item numbers 300-352 and item 14224 were obtained from the Health Insurance Commission for each State and Territory. The items were examined in the age groups 15-64 years, 65 years and over and 75 years and over. Main outcome measures were per capita service provision by age group, State and Territory and Medicare expenditure by age group., Results: During 1998, 6.4% (5765.6 per 100 000) of private psychiatric services were to patients aged > 64 years. Patients aged 15-64 received 2.7 times the number of psychiatric services per capita than patients > 64 and 3.6 times that of patients aged > 74 years. Patients aged > 64 received more hospital and nursing home consultations, home visits and electroconvulsive therapy per capita, while younger adults used more office-based consultations, longer consultations, and group therapy. Victoria had the highest per capita rate (7659.2 per 100 000) and the Northern Territory the lowest (540.4 per 100 000), although the highest proportion of services to older patients was in Western Australia. Per capita the proportion of Medicare expenditure allocated to adults aged less than 65 years was 4.1 times that for adults over 64 years., Conclusions: Private psychiatric service provision to older people is inequitable when compared with younger adults. The proportion of Medicare private psychiatry expenditure on older adults has declined since 1985-1986.

We describe the interface between general practice and psychogeriatrics in Australia. While aged care services are complex and there are serious deficiencies in the management of the elderly, several initiatives appear set to improve the level of care. Economic considerations, mutual education of general practitioners and psychogeriatricians, and social factors are strong determinants of good primary care of the mental health needs of older people.

The prevention of suicide in old age has received little attention, despite suicide rates being highest in older men. About 90% of older people who attempt or complete suicide have a mental disorder, usually depression, which often has been inadequately treated. Other treatable contributing factors include pain, grief, loneliness, alcoholism and carer stress. Few suicides in older people occur in the context of terminal illness or can be regarded as "rational". Educational programs are required to improve the recognition and treatment of depression in primary care.

Objective: To compare elderly co-resident caregivers of stroke and dementia patients on measures of burden and psychological morbidity., Design: Cohort study., Setting: Caregivers interviewed at home., Subjects: Convenience sample, 99 co-resident caregivers of dementia and stroke patients registered with a community rehabilitation and geriatric service and who were 60 years or over., Main Outcome Measures: Caregiver burden as measured by self-administered questionnaire and subsequent interview, using the Relatives Stress Scale (RSS) and psychological morbidity as measured on the General Health Questionnaire (GHQ)., Results: Forty-six percent of caregivers had significant psychological morbidity (GHQ greater than 4). Mean RSS score was 12.2 (SD 5.4). No significant differences were found between stroke and dementia caregivers on these measures. Caregiver burden was significantly correlated with psychological morbidity in both caregiver groups. Behavior and mood disturbance in the patient was significantly correlated with burden (dementia caregivers r = 0.66; stroke caregivers r = 0.49, P less than 0.0001) and psychological morbidity (dementia caregivers r = 0.44, P less than 0.01; stroke caregivers r = 0.30, P less than 0.05). Caregiver's dissatisfaction with participation in life activities was correlated with burden (dementia caregivers r = 0.58; stroke caregivers r = 0.63, P less than 0.0001) and psychological morbidity (dementia caregivers r = 0.67, stroke caregivers r = 0.56, P, 0.0001)., Conclusion: Elderly co-resident caregivers for stroke and dementia patients experience similar degrees of burden and high levels of psychological morbidity. Psychiatric aspects of chronic disability, rather than physical aspects, were found to be more stressful to caregivers. All assessments of the disabled elderly should include measures of caregiver burden and psychological distress.