The past eighteen months have seen a number of new developments for this journal. These include the conclusion of a new contract between the journal's owner, the International Psychogeriatric Association (IPA), and our publisher, Cambridge University Press (CUP); the appointment of a new editor-elect to take over from me as editor-in-chief next year; the addition of three new deputy editors to bring the total of such appointees, who assist the editor in chief, to four; and the development and implementation of an online submission and review system to speed the processing of submissions.

Background: This paper reviews published literature on the pharmacological and non-pharmacological treatment of inappropriate sexual behavior in dementia.

Methods: A literature search of Psychinfo and Cochrane databases was performed and data from case reports and case series were analyzed.

Results: No randomized controlled trials exist for any treatment of sexual disinhibition in dementia and there are no trials comparing different pharmacological agents. Case reports and case series report a wide range of pharmacotherapies as efficacious in the treatment of inappropriate sexual behaviors in dementia. There is only one case report of non-pharmacological strategies to manage inappropriate sexual behavior.

Conclusions: Inappropriate sexual behaviors in dementia can be difficult to treat. Frequently, multiple psychoactive medications are used and many pharmacotherapies are trialed prior to finding an effective agent. More research is needed to clarify the usefulness of these medications and to identify non-pharmacological strategies to prevent unnecessary use of medications.

Background: Older prisoners are a minority within the prison population but their numbers are increasing at a greater rate than any other age group. The mental health of younger prisoners has been well researched but this is not the case for older inmates. The aim of this paper is to provide a review of the existing literature on the mental health of older prisoners.

Methods: Relevant papers were identified through database searches and an examination of cited references in the selected papers. The literature was divided into different sections in order to examine the contributing factors and rates of mental illness in older prisoners.

Results: The first section looks at demographic factors relevant to older prisoners. Subsequent sections examine psychosocial factors, environmental factors and physical health factors that may have a detrimental effect on mental health. The final sections look at the prevalence of mental illness in older offenders before and after sentencing.

Conclusions: Mental illness in older prisoners is a result of complex interactions between numerous individual and environmental factors. It currently remains poorly researched and service provision for older prisoners with mental illness is poorly developed. Further research is needed, with a particular focus on the different groups of older prisoners and the most beneficial service models, because the number of older prisoners, including those with mental illness, is likely to increase in the future.

Background: Differential diagnosis implies identifying shared and divergent characteristics between clinical states. Clinical work with older adults demands not only the knowledge of nosological features associated with differential diagnosis, but also recognition of idiosyncratic factors associated with this population. Several factors can interfere with an accurate diagnosis of specific phobia in older cohorts. The goal of this paper is to review criteria for specific phobia and its differential diagnosis with panic disorder, agoraphobia, post-traumatic stress disorder and obsessive compulsive disorder, while stressing the specific factors associated with aging.

Methods: A literature search regarding specific phobia in older adults was carried out using PubMed. Relevant articles were selected and scanned for further pertinent references. In addition, relevant references related to differential diagnosis and assessment were used.

Results: Etiologic factors, specificity of feared stimulus or situation, fear predictability and the nature of phobic situations are key points to be assessed when implementing a differential diagnosis of specific phobia.

Conclusions: First, age-related sensory impairments are common and interfere both with information processing and communication. Second, medical illnesses create symptoms that might cause, interfere with, or mimic anxiety. Third, cohort effects might result in underreporting, through the inability to communicate or recognize anxiety symptoms, misattributing them to physical conditions. Finally, diagnostic criteria and screening instruments were usually developed using younger samples and are therefore not adapted to the functional and behavioral characteristics of older samples.

Background: Although studies indicate that community-dwelling elderly have a lower prevalence of major depression compared with younger age groups, prevalence estimates in Brazil show that clinically significant depressive symptoms (CSDS) and depression are frequent in the older population. However, a systematic review and meta-analysis of prevalence of and factors associated with depressive disorders and symptoms in elderly Brazilians has not previously been reported. The aims were (i) to perform a survey of studies dating from 1991 to 2009 on the prevalence of depressive disorders and CSDS in elderly Brazilians residing in the community; (ii) to determine depression prevalence and identify associated factors; and (iii) develop a meta-analysis to indicate the combined prevalence and the influence of gender on depressive morbidity in this population.

Methods: Studies were selected from articles dated between January 1991 and May 2009, extracted from Medline, LILACS and SciELO databases.

Results: A total of 17 studies were found, 13 with CSDS, 1 with major depression alone and 3 with major depression and dysthymia, involving the evaluation of 15,491 elderly people. The average age of participants varied between 66.5 and 84.0 years. Prevalence rates of 7.0% for major depression, 26.0% for CSDS, and 3.3% for dysthymia were found. The odds ratios for major depression and CSDS were greater among women. There was a significant association between major depression or CSDS and cardiovascular diseases.

Conclusion: The review indicates greater prevalence of both major depression and CSDS compared to rates reported in the international literature, while the prevalence of dysthymia was found to be similar. The high prevalence of CSDS and its significant association with cardiovascular diseases reinforces the importance of evaluating subthreshold depressive symptoms in the elderly in the community.

Background: A recent cross-national study demonstrated a curvilinear (inverted U-shaped curve) between elderly male suicide rates and the Human Development Index (HDI) fitting the quadratic equation y = a + bx − cx2 where y is the elderly male suicide rate, x is the HDI and a, b and c are constants). This study used only one-year cross-sectional data on suicide rates, and suicide rates can randomly fluctuate year on year.

Methods: A study designed to replicate this curvilinear relationship between elderly suicide rates and the HDI was undertaken by: (i) using one-year average of five years data on suicide rates; and (ii) using more recent data on both elderly suicide rates than used in the previous study. Data were ascertained from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (inverted U-shaped curve) relationship between suicide rates in males aged 65–74 years, males aged 75+ years, females aged 65–74 years and the HDI fitting the quadratic equation y = a + bx − cx2. A similar curvilinear relationship was observed in females aged 75+ years, but the significance level only approached 0.05 level.

Conclusions: The replication of the curvilinear (inverted U-shaped curve) relationship between elderly suicide rates and the HDI by using one-year average of five years data on suicide rates suggests that the observed relationship is robust and accurate.

Background: The difficulty in identifying and distinguishing Major Depressive Disorder (MDD) in primary care is well known. The main objective of this study is to determine the frequency of MDD in persons aged 65 years and older using the Detection of Depression in the Elderly Scale (DDES). A second objective is to determine the convergent validity of the DDES with the Geriatric Depression Scale (GDS).

Methods: A cross-sectional, observational study was carried out of 1,387 subjects aged 65 years and older. The variables considered were: affective state (GDS and DDES), physical and cognitive functional state, health problems and sociodemographic characteristics.

Results: Using the DDES we identified MDD in 50 subjects (4.3%). There was a moderate correlation (r = 0.570; p < 0.001) between the DDES and the GDS scores (p < 0.001). According to logistic regression analysis, the variables associated with a probable MDD (DDES +) were: dependence in activities of daily living (OR: 3.3), female gender (OR: 2.3), marital status single/widowed/divorced (OR: 2.0), and the presence of four of more health problems (OR: 2.1).

Conclusions: Using the DDES scale we found a 4.3% prevalence of MDD in a representative sample of older adults. Compared to the GDS, the most commonly used scale, the DDES may be considered a more sensitive screening tool for the identification of MDD in primary care.

Background: This study aimed to characterize healthcare and human services utilization among mentally distressed and non-distressed clients receiving in-home care management assessment by aging services provider network (ASPN) agencies in the U.S.A.

Methods: A two-hour research interview was administered to 378 English-speaking ASPN clients aged 60+ years in Monroe County, NY. A modified Cornell Services Index measured service utilization for the 90 days prior to the ASPN assessment. Clients with clinically significant anxiety or depressive symptoms were considered distressed.

Results: ASPN clients utilized a mean of 2.93 healthcare and 1.54 human services. The 42% of subjects who were distressed accessed more healthcare services (e.g. mental health, intensive medical services) and had more outpatient visits and days hospitalized than the non-distressed group. Contrary to expectations, distressed clients did not receive more human services. Among those who were distressed, over half had discussed their mental health with a medical professional in the past year, and half were currently taking a medication for their emotional state. A far smaller proportion had seen a mental health professional.

Conclusions: In the U.S.A., aging services providers serve a population with high medical illness burden and medical service utilization. Many clients also suffer from anxiety and depression, which they often have discussed with a medical professional and for which they are receiving medications. Few, however, have seen a mental health specialist preceding intake by the ASPN agency. Optimal care for this vulnerable, service intensive group would integrate primary medical and mental healthcare with delivery of community-based social services for older adults.

Background: Subjective Memory Complaints (SMCs) are common among middle-aged and older adults and are often a source of distress and worry. However, rates of help-seeking are low. Investigating perceptions of SMCs may help us better to understand psychological reactions to SMCs and help-seeking behavior. The present study had two aims: (i) to investigate whether the dimensions drawn from the Common Sense Model of Illness Perception (Leventhal et al., 1984) provide a valid model of perceptions held by patients with SMCs; and (ii) to develop a questionnaire to measure these perceptions.

Methods: Qualitative interviews to explore perceptions of SMCs were conducted with 32 participants recruited from a memory clinic and community groups. Information from these interviews was utilized to adapt the Illness Perception Questionnaire – Revised (IPQ-R) for use with patients with SMCs. Ninety-eight such patients then completed the adapted questionnaire along with measures of cognition, depression and subjective memory function.

Results: The dimensions of illness perception measured by the IPQ-R were present in participant accounts of SMCs with the exception of Timeline Cyclical. The adapted measure (IPQ-M) showed good validity and reliability.

Conclusions: The development of the IPQ-M provides opportunities for further investigation of illness perceptions and their relationship to psychological distress and help-seeking behavior in SMCs. Furthermore, investigation of these relationships may provide a basis from which to develop interventions to improve well-being and help-seeking in older adults with SMCs.

Background: Despite the magnitude of dementia, little research on survival duration and prognosis of dementia has been reported in developing countries. This study was conducted to investigate survival times, identify related prognostic factors and construct a prognostic index (PI) for community-based dementia patients in Beijing, China.

Methods: This study is part of the 10/66 Dementia Research Group study in China. One hundred and thirty-seven dementia patients identified by 10/66 dementia criteria among 2162 participants and 137 referent subjects matched by age and sex were followed up for five years.

Results: Ninety-one (66.4%) dementia patients and 51 (37.2%) referent subjects died during the 5-year follow-up (p < 0.01). The median survival time of dementia patients was 4.2 years (95% CI: 3.8–4.6). Severity of dementia (severe/mild, HR: 8.765, 95% CI: 4.436–17.163), substantial disability (HR: 5.503, 95% CI: 3.017–8.135), co-morbidity (HR: 4.149, 95% CI: 2.254–7.736) and age (HR: 1.079, 95% CI: 1.048–1.110) were independent predictors of survival for patients with dementia. Using the PI calculated for each dementia patient, all dementia patients were classified into three groups: low, medium and high risk groups. The median survival times of each group were 5.2 years, 4.4 years and 1.5 years (p < 0.01), respectively.

Conclusions: Survival times of community-based dementia patients were significantly shorter than those of referent subjects. Severity of dementia, substantial disability, co-morbidity and age were independent predictors of survival. The PI derived from the four predictors can stratify the mortality risk and predict life expectancy for community-dwelled dementia patients, although further validation is needed.

Background: Despite the high consistency of evidence in favor of person-centered care, little information is available on how person-centered and family-centered interventions are actually provided. The aim of this study is to gain insight into the provision of the effective New York University Caregiver Intervention (NYUCI) in order to enhance its implementation.

Methods: This is a qualitative study using a grounded theory approach. Group interviews were carried out with three purposefully sampled counselors who had provided the NYUCI.

Results: Six themes were identified: (1) family problems, (2) ways to deal with these family problems, (3) barriers encountered by counselors,(4) ways to deal with these barriers, (5) facilitators or rewards of being a counselor, and (6) perceived effectiveness.

The problem categories were (a) conflicts within families; (b) past experiences and personality; and (c) daily living with dementia. Ways of helping caregivers deal with these problems included problem clarification from the perspectives of the key players. An important barrier was reluctance to be helped. This was dealt with by acknowledging caregivers’ need for control over situations. Additional effects of participation in the NYUCI observed by the counselors were reduction of anger and awareness of more and new options for dealing with dementia.

Conclusions: Person- or family-centered care offers new perspectives on problems that are seemingly unmanageable. We hypothesize that seeing new and more options is a direct effect of this person-centered counseling. This might be an important outcome to be measured in future studies.

Background: Approximately 25% of individuals with dementia live alone, yet little is known about the cognitive and functional factors that impact detection of impairment.

Methods: Subjects with dementia (n = 349) from a community study of dementia management were administered the Mini-mental State Examination (MMSE) and were asked to rate their cognitive status. Each participant's knowledgeable informant (KI) was interviewed to provide information about the subject's mental health and levels of cognitive and functional impairment. Subjects with dementia living alone (n = 97, 27.8%) were compared to subjects living with others (n = 252, 72.2%) regarding functional impairment, psychiatric symptoms, cognitive functioning, and dementia recognition.

Results: While subjects with dementia living alone had significantly fewer ADL impairments (p < 0.0001) and less cognitive impairment (p < 0.0001) than subjects with dementia who were living with others, nearly half of subjects living alone had two or more IADL impairments. Both knowledgeable informants (p < 0.001) and primary care physicians (p < 0.009) were less likely to detect dementia in subjects living alone, while 77.3% of subjects with dementia living alone rated their cognitive abilities as “good” or “a little worse”. Subjects with dementia living alone and those living with others had similar rates of psychosis (p = 0.2792) and depressive symptoms (p = 0.2076).

Conclusions: Lack of awareness of cognitive impairment by individuals with dementia living alone as well as their knowledgeable informants and physicians, combined with frequent functional impairment and psychiatric symptoms, heightens risk for adverse outcomes. These findings underscore the need for increased targeted screening for dementia and functional impairment among older persons living alone.

Background: There is increasing interest in identifying novel cognitive paradigms to help detect preclinical dementia. Promising results have been found in clinical settings using the Semantic Interference Test (SIT), a modification of an existing episodic memory test (Fuld Object Memory Evaluation) that exploits vulnerability to semantic interference in Alzheimer's disease. It is not yet known how broadly this work will generalize to the community at large.

Methods: Participants aged ≥65 years from the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) were administered the SIT at study entry. Independent of neuropsychological assessment, participants were rated on the Clinical Dementia Rating (CDR) scale, based on reported loss of cognitively driven everyday functioning. In individuals free of dementia (CDR <1), the concurrent validity of the SIT was assessed by determining its association with CDR using multiple logistic regression models, with CDR 0 (no dementia) vs. 0.5 (possible dementia) as the outcome and the SIT test variables as predictors.

Results: Poorer performance on all SIT variables but one was associated with higher CDR reflecting possible dementia (Odds Ratios 2.24–4.79). Younger age and female gender also conferred a performance advantage. Years of education and reading ability (a proxy for quality of education) evidenced a very weak association with SIT performance.

Conclusions: The SIT shows promise as a valid, novel measure to identify early preclinical dementia in a community setting. It has potential utility for assessment of persons who may be illiterate or of low education. Finally, we provide normative SIT data stratified by age which may be utilized by clinicians or researchers in future investigations.

Background: Computerized cognitive assessment tools have been developed to make precise neuropsychological assessment readily available to clinicians. Mindstreams batteries for mild impairment have been validated previously. We examined the validity of a Mindstreams battery designed specifically for evaluating those with moderate cognitive impairment.

Methods: 170 participants over the age of 60 years performed the computerized battery in addition to standard clinical evaluation. The battery consists of six technician-administered tests and one patient-administered interactive test sampling the cognitive domains of orientation (to time and place), memory, executive function, visual spatial processing, and verbal function. Staging was according to the Clinical Dementia Rating Scale (CDR) on the basis of clinical data but independent of computerized cognitive testing results, thus serving as the gold standard for evaluating the discriminant validity of the computerized measures.

Results: Seven participants received a global CDR score of 0 (not impaired), 76 were staged as CDR 0.5 (very mildly impaired), 58 as CDR 1 (mildly impaired), 26 as CDR 2 (moderately impaired), and 3 as CDR 3 (severely impaired). Mindstreams Global Score performance was significantly different across CDR groups (p < 0.001), reflecting poorer overall battery performance for those with greater impairment. This was also true for the domain summary scores, with Executive Function (d = 0.67) and Memory (d = 0.65) distinguishing best between CDR 0.5 and 1, and Orientation best differentiating among CDR 1 and 2 (d = 1.20).

Conclusions: The Mindstreams battery for moderate impairment differentiates among varying degrees of cognitive impairment in older adults, providing detailed and distinct cognitive profiles.

Background: Plasma homocysteine has been associated with reduced brain volumes in cross-sectional studies. We aimed to investigate if homocysteine is associated with ongoing atrophy, and if so, if this is localized to gray or white matter.

Methods: In a group of 80 hypertensive subjects aged 70–90 years (from the SCOPE study) MRI images were obtained at two time points two years apart. Rates of gray and white matter and hippocampal atrophy were determined by calculating the difference in segmentation probability maps using SPM5. Plasma homocysteine, folate, B12 and creatinine were measured at study end.

Results: Homocysteine levels correlated with white matter atrophy rate (p = 0.006) hippocampal baseline volume (p = 0.011) and hippocampal atrophy rate (p = 0.004) but not global gray matter atrophy or baseline gray or white matter volumes. The correlations remained significant (p < 0.05) after controlling for subject age, blood pressure, folate levels and white matter lesion volume.

Conclusion: In older hypertensives, plasma homocysteine levels are associated with increased rates of progressive white matter and hippocampal atrophy.

Background: Delirium is common in the elderly and is associated with high mortality and negative health outcomes. Reduced activity in the cholinergic system has been implicated in the pathogenesis of delirium. Cholinesterase inhibitors, which increase cholinergic activity, may therefore be beneficial in the treatment of delirium.

Methods: This is a double-blind, placebo-controlled randomized pilot study of the treatment of delirium with a cholinesterase inhibitor of patients admitted to hospital medical wards. Patients over the age of 65 years were identified as having delirium by the Confusion Assessment Method (CAM). Patients with delirium were randomized to receive rivastigmine 1.5 mg once a day increasing to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days).

Results: Fifteen patients entered the trial; eight received rivastigmine and seven received placebo. All of the rivastigmine group, but only three of the placebo group, were negative for delirium on the CAM when they left the study and eventually discharged home. There was no significant difference in the duration of delirium between the two groups (rivastigmine group 6.3 days versus placebo group 9.9 days, p = 0.5, 95% confidence interval −15.6–8.4).

Conclusions: The numbers of patients who screened positive for delirium was very small and as a result the sample size was too small to make any meaningful inferences about treatment of delirium. Despite the small numbers included in the study, there are some indicators that rivastigmine may be safe and effective in treating delirium.

Background: Apathy, a complex neuropsychiatric syndrome, commonly affects patients with Alzheimer's disease. Prevalence estimates for apathy range widely and are based on cross-sectional data and/or clinic samples. This study examines the relationships between apathy and cognitive and functional declines in non-depressed community-based older adults.

Methods: Data on 1,136 community-dwelling adults aged 50 years and older from the Baltimore Epidemiologic Catchment Area (ECA) study, with 1 and 13 years of follow-up, were used. Apathy was assessed with a subscale of items from the General Health Questionnaire. Logistic regression, t-tests, χ2 and Generalized Estimating Equations were used to accomplish the study's objectives.

Results: The prevalence of apathy at Wave 1 was 23.7%. Compared to those without, individuals with apathy were on average older, more likely to be female, and have lower Mini-mental State Examination (MMSE) scores and impairments in basic and instrumental functioning at baseline. Apathy was significantly associated with cognitive decline (OR = 1.65, 95% CI = 1.06, 2.60) and declines in instrumental (OR = 4.42; 95% CI = 2.65, 7.38) and basic (OR = 2.74; 95%CI = 1.35, 5.57) function at 1-year follow-up, even after adjustment for baseline age, level of education, race, and depression at follow-up. At 13 years of follow-up, apathetic individuals were not at greater risk for cognitive decline but were twice as likely to have functional decline. Incidence of apathy at 1-year follow up and 13-year follow-up was 22.6% and 29.4%, respectively.

Conclusions: These results underline the public health importance of apathy and the need for further population-based studies in this area.

An 81-year-old female with no previous psychiatric history presented with late-onset obsessive compulsive disorder following an acute right macular hemorrhage and loss of vision. Following a thorough organic screen to exclude a physical cause, various high doses of selective serotonin reuptake inhibitors were tried with no therapeutic benefit. The patient had significant remission of her symptoms following a course of electroconvulsive therapy.

We describe an 81-year old female patient who was seen at our outpatient clinic with a history of falls. The clinical diagnosis was concurrent with depressive symptoms, but an arachnoid cyst turned out to be the cause of her problems. The patient recovered completely after surgery.

We report a case of a 63-year-old man who experienced his first manic episode, and then, one year later, experienced a second episode which was associated with a significant loss of brain parenchyma. Two computed tomography (CT) brain scans were performed at each manic episode to observe brain structure. Significant loss of brain parenchyma was shown using CT scans. A Mini-mental State Examination (MMSE) score of 29 was observed after the first manic episode and a score of 23 was obtained after the second manic episode. This case report supports the idea that an increased risk of developing dementia exists in patients with major affective disorders.