Delirium is a cognitive disorder characterized by acute onset, fluctuating course and disturbances in consciousness, orientation, memory, thought, perception and behavior (American Psychiatric Association, 2000). It occurs in hyperactive, hypoactive or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006), many with pre-existing dementia (Fick et al., 2002).

Higher rates of cerebrovascular adverse events (CVEs) and mortality for dementia patients taking active drugs were reported during industry-sponsored clinical trials of atypical antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Since then, the use of antipsychotics for BPSD has not been recommended on the basis of advisory warnings issued by regulatory authorities in several countries. Nevertheless, there are currently no demonstrated pharmacologic alternatives. Although early published and unpublished data indicated a risk, few subsequent publications have supported the initial finding. In order to update earlier comments published in International Psychogeriatrics (Shah and Suh, 2005), this editorial briefly introduces subsequent reports, summarizes the discrepant findings of experimental and non-experimental studies, highlights the effect of “Simpson's paradox”, which causes us to throw doubt on conclusions based on meta-analyses or pooled-analyses, explains this discrepancy in the light of current knowledge, and concludes with practical recommendations regarding the use of atypical antipsychotics in dementia.

Background: Dementia is becoming a major public health problem in Latin America (LA), yet epidemiological information on dementia remains scarce in this region. This study analyzes data from epidemiological studies on the prevalence of dementia in LA and compares the prevalence of dementia and its causes across countries in LA and attempts to clarify differences from those of developed regions of the world.

Methods: A database search for population studies on rates of dementia in LA was performed. Abstracts were also included in the search. Authors of the publications were invited to participate in this collaborative study by sharing missing or more recent data analysis with the group.

Results: Eight studies from six countries were included. The global prevalence of dementia in the elderly (≥65 years) was 7.1% (95% CI: 6.8–7.4), mirroring the rates of developed countries. However, prevalence in relatively young subjects (65–69 years) was higher in LA studies The rate of illiteracy among the elderly was 9.3% and the prevalence of dementia in illiterates was two times higher than in literates. Alzheimer's disease was the most common cause of dementia.

Conclusions: Compared with studies from developed countries, the global prevalence of dementia in LA proved similar, although a higher prevalence of dementia in relatively young subjects was evidenced, which may be related to the association between low educational level and lower cognitive reserve, causing earlier emergence of clinical signs of dementia in the LA elderly population.

Background: Increasing efforts are being devoted to the study of early onset dementia (EOD), namely dementia in persons under the age of 65. Until recently, it was assumed that dementia occurs primarily among people aged 65 and over. However, since the number of persons with EOD is increasing, its importance as a clinical and social problem is rising accordingly. The aim of the present paper is to summarize research in this area.

Methods: We reviewed the research published to date on EOD, and divided the current body of knowledge into several main sections.

Results: The first section focuses on clinical aspects and summarizes findings regarding prevalence, causes, symptoms, diagnosis, and management of persons with EOD. The second section focuses on social aspects related to the cost of care for young people with the disease, the challenges faced by individuals and caregivers, and the services available for this population. Finally, conclusions and future directions are suggested.

Conclusions: Research on EOD is still in its early stages. There is an urgent need to expand research that will lead to more effective diagnosis and management of EOD as well as to the allocation of funds and the development of appropriate services suitable for the unique needs of young people with dementia.

Background: Older drivers are at a higher risk of being involved in a motor vehicle accident. However, on-road assessments of all older drivers are impractical, highlighting the need to screen for potentially unsafe drivers. This study undertook a meta-analysis of research examining the cognitive predictors of driving ability in older drivers in order to provide an evidence-based method for screening drivers.

Methods: Comprehensive searches were undertaken of the PubMed, PsycINFO, CINAHL, and Health-Source Nursing electronic databases between 1980 and 2007 in order to identify studies that examined cognitive differences between drivers aged over 55 years who either passed or failed a driving assessment. Twenty-one studies were eligible for inclusion. Weighted Cohen's d effect sizes, percentage overlap statistics, Fail-safe Ns and 95% CIs were calculated for all cognitive tests.

Results: The best predictors of on-road driving were the Ergovision and Useful Field of View (UFOV) tests, a complex RT task, Paper Folding task, Dot Counting, WMS Visual Reproduction, and Computerized Visual Attention Task. Simulator driving performance was best predicted by the Benton Line Orientation Task, Clock Drawing, a Driver Scanning task, the UFOV, WAIS Picture Arrangement and MMSE. Finally, the Trail Making Test, Stroop, UFOV, WAIS Block Design, and Automated Psychophysical Test were good predictors of driving problems.

Conclusions: There are a variety of tests that appear suitable for screening older drivers, the exact choice of which depends on the “gold standard” for determining driving ability (on-road driving, driving simulator, driving problems) and whether a computerized or paper-and-pencil task is required.

Background: Normal aging and dementia are characterized by increased prevalence of sleep disorders and alterations of both sleep continuity and architecture. However, little is still known about the nature of sleep in mild cognitive impairment (MCI), which is presumably situated on the continuum from healthy aging to dementia. This unsystematic review summarizes the current literature on the prevalence and severity of sleep disturbances in MCI.

Methods: Eighteen studies addressing sleep/night-time disturbances among other neuropsychiatric symptoms in individuals with MCI were identified through a search of databases and an examination of reference lists of selected papers. Fifteen of those studies reported data on prevalence or severity of sleep/night-time disturbances.

Results: Results indicated that 14–59% of patients with MCI had sleep disturbances. These disturbances were often identified as one of the four most prevalent neuropsychiatric symptoms of MCI and were considered as clinically significant in some studies. In addition, there was some evidence that the prevalence of sleep disturbances in MCI is intermediate between that of normal aging and dementia. Longitudinal data suggest that sleep problems are associated with both incident MCI and dementia.

Conclusions: These findings support the hypothesis that sleep disturbances are one of the core non-cognitive symptoms of MCI. It remains to be known whether sleep problems could help to identify those individuals with MCI who will eventually develop dementia. Studies characterizing sleep more systematically are needed to verify this proposition and to clarify the associations between sleep disturbances and other neuropsychiatric symptoms of MCI.

While working as a staff development coordinator in a long-term care facility during the mid to late 1980s I witnessed agitation in persons with dementia (PWD) and the negative effects that these behaviors had on both the caregiver and the care recipient. Published research findings validated the widespread prevalence of this problem. Management strategies at the time focused primarily on chemical and physical restraints which, in and of themselves, were fraught with adverse effects. Shortly thereafter I enrolled in graduate school where I focused my efforts on exploring this problem with a clear understanding that there was a need for alternative interventions that were relatively inexpensive and could be readily and easily implemented by trained staff. These efforts eventually led to the development of individualized music as an intervention for the management of agitation in PWD. Individualized music is defined as music that has been integrated into the person's life and is based on personal preference (Gerdner, 1992). Extensive clinical experience along with findings from a pilot study (Gerdner, 1992) served as the foundation for the development of intervention guidelines (Gerdner, 1996) and a mid-range theory of individualized music intervention for agitation (IMIA) (Gerdner, 1997). The publication of the original pilot study (Gerdner and Swanson, 1993) generated a considerable amount of interest resulting in further efforts toward testing the effects of individualized music for the management of agitation in PWD (Casby and Holm, 1994; Cohen-Mansfield and Werner, 1997; Devereaux, 1997; Thomas et al., 1997; Clark et al., 1998). The strengths and limitations of these studies were used to design a more rigorous methodology using a larger sample for the purpose of testing the propositions of IMIA and the effects of individualized music when compared to classical “relaxation” music on the frequency of agitation in PWD. The findings of this study were published in International Psychogeriatrics (Gerdner, 2000). As of January 2009, this article has been cited in 91 scholarly publications and was the impetus for additional studies conducted in the U.S.A., Sweden, Japan and Taiwan. These efforts have resulted in an expanding body of research to support the use of this intervention for the management of agitation (Ragneskog et al., 2001; Janelli et al., 2002; Suzuki et al. 2004; Sung et al., 2006; 2008; Park, 2008).

Background: The Australian Imaging, Biomarkers and Lifestyle (AIBL) flagship study of aging aimed to recruit 1000 individuals aged over 60 to assist with prospective research into Alzheimer's disease (AD). This paper describes the recruitment of the cohort and gives information about the study methodology, baseline demography, diagnoses, medical comorbidities, medication use, and cognitive function of the participants.

Methods: Volunteers underwent a screening interview, had comprehensive cognitive testing, gave 80 ml of blood, and completed health and lifestyle questionnaires. One quarter of the sample also underwent amyloid PET brain imaging with Pittsburgh compound B (PiB PET) and MRI brain imaging, and a subgroup of 10% had ActiGraph activity monitoring and body composition scanning.

Results: A total of 1166 volunteers were recruited, 54 of whom were excluded from further study due to comorbid disorders which could affect cognition or because of withdrawal of consent. Participants with AD (211) had neuropsychological profiles which were consistent with AD, and were more impaired than participants with mild cognitive impairment (133) or healthy controls (768), who performed within expected norms for age on neuropsychological testing. PiB PET scans were performed on 287 participants, 100 had DEXA scans and 91 participated in ActiGraph monitoring.

Conclusion: The participants comprising the AIBL cohort represent a group of highly motivated and well-characterized individuals who represent a unique resource for the study of AD. They will be reassessed at 18-month intervals in order to determine the predictive utility of various biomarkers, cognitive parameters and lifestyle factors as indicators of AD, and as predictors of future cognitive decline.

Background: The clinical presentations in dementia with Lewy bodies (DLB) and frontotemporal dementia (FTD) overlap considerably with that of Alzheimer's disease (AD) despite different pathological processes. Autopsy studies have also shown that multiple brain pathology occurs frequently, even in cases with a single clinical diagnosis. We aimed to determine the frequency of clinical diagnosis of FTD and DLB and the underlying pathology in a well-characterized cohort of patients with a clinical diagnosis of probable or possible AD.

Methods: We conducted a retrospective analysis of 170 AD patients (probable AD = 83; possible AD = 87) originally enrolled in a case-control study, 27 with postmortem examination, to establish the number of cases meeting probable diagnosis for FTD and DLB, using a checklist of features compiled from their consensus criteria.

Results: 23/83 probable AD cases and 32/87 possible AD cases met probable criteria for another dementia, more commonly DLB than FTD. AD pathology was present in 8/15 probable AD and 8/12 possible AD cases coming to autopsy. DLB pathology was seen in four cases and FTD pathology in eight cases. In the AD cases reaching clinical diagnosis for a second dementia syndrome and coming to autopsy, a minority showed non-AD pathology only.

Conclusions: Presence of core clinical features of non-AD dementia syndromes is common in AD. Concordance between clinical and pathological diagnoses of dementia remains variable. We propose that repeat clinical examinations and structural neuroimaging will improve diagnostic accuracy. In addition, clinical diagnostic criteria for the main dementia syndromes require refinement.

Background: There is limited information describing memory clinics at a national level in Australia. The aim of this study was to gather information about the resourcing, practices and clinical diagnoses of Australian memory clinics.

Methods: A postal survey was sent to all Australian memory clinics identified by key specialists working in dementia assessment services.

Results: Of 23 surveys sent out, 14 were returned. Most clinics are located in Victoria where they receive Victorian state funding. The average clinic has 1.67 effective full time clinical staff including 0.42 medical staff, 0.24 allied health staff, 0.53 clinical nursing staff and 0.48 psychologists. Clinics are open on average twice a week and each half-day clinic has two new and three review patients, seeing new patients twice initially then once more over 12 months. Patients wait 10 weeks for initial assessment with 59% referred by general practitioners. The Mini-mental State Examination and clock drawing are utilized universally. The most common diagnoses are Alzheimer's disease (37.8%) and mild cognitive impairment (19.8%) but 6.9% of patients have no cognitive impairment.

Conclusions: This survey has provided useful benchmarking data on Australian memory clinics which can also be used by other countries for comparative analyses.

Background: Short-term residential care (SRC) has proved to be effective in reducing the burden on family caregivers of dementia patients. Nevertheless, little is known about the factors which influence its usage or the expectations of family caregivers regarding quality. In this paper we address the following questions: (i) which variables of the care situation, the caregivers and their attitudes act as predictors for the utilization of SRC facilities? (ii) What are the views of caregivers about the quality of SRC?

Methods: The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in four regions of Germany. With a 20% response it was possible to analyze the quantitative and qualitative data from 404 and 254 family caregivers respectively. Predictors for utilization were evaluated using binary logistic regression analysis. The answers to questions of quality were evaluated using qualitative content analysis.

Results: Significant predictors for the utilization of SRC are the assessment of the helpfulness of SRC and the caregiver's knowledge of the accessibility of SRC facilities. Family caregivers who had already used SRC most frequently expressed the wish for “good care” in SRC facilities, followed by a program of suitable activities for dementia patients.

Conclusions: In order to increase the rate of utilization, family caregivers must be convinced of the relevant advantages of using SRC facilities. The staff should be trained in caring for dementia patients and appropriate activities should be available.

Background: Agitation is common in people with dementia, is distressing to patients and stressful to their carers. Drugs used to treat the condition have the potential to cause particularly severe side effects in older people with dementia and have been associated with an increased death rate. Alternatives to drug treatment for agitation should be sought. The study aimed to assess the effects of bright light therapy on agitation and sleep in people with dementia.

Methods: A single center randomized controlled trial of bright light therapy versus standard light was carried out. The study was completed prior to the mandatory registration of randomized controls on the clinical trials registry database and, owing to delays in writing up, retrospective registration was not completed.

Results: There was limited evidence of reduction in agitation in people on active treatment, sleep was improved and a suggestion of greater efficacy in the winter months.

Conclusions: Bright light therapy is a potential alternative to drug treatment in people with dementia who are agitated.

Background: While the relationship of apolipoprotein E (APOE) to behavioral symptoms of dementia (BSD) has been studied in community-dwelling persons with AD, it has received limited attention within the nursing home (NH) population. The aim of this study was to examine the association between APOE genotype and BSD in NH residents using direct observation.

Methods: Thirty-six participants, aged 71–102 years, were compared using a non-randomized two-group design with continuous measures. APOE genotype was obtained by buccal swab. BSD, including restlessness, escape restraint, tapping and banging, searching and wandering, pacing and walking, and vocalization, were measured using the Modified Agitated Behavior Rating Scale. Participants were observed every 20 minutes for 12 hours per day for five days. Each participant's mean behavior scores were compared according to the presence or absence of the APOE ϵ4 allele.

Results: Resident characteristics included a mean MMSE of 10.44 indicating moderate to severe dementia and a mean of 3.44 medical co-morbidities. Fifty-six percent of the participants had one ϵ4 allele. A significant difference was found between APOE ϵ4+/4− and mean behavioral scores (F1,31 = 4.40, p = 0.04). Restlessness was significantly inversely correlated with MMSE (r = −0.367, p = 0.03), but not APOE genotype. There was no significant correlation between proxy reporting and direct observation (r = 0.257, p = 0.13).

Conclusion: Findings indicate that the presence of the APOE ϵ4+ genotype increases the risk for BSD in NH residents with dementia. Direct observation proved a more accurate estimate of BSD than proxy report.

Background: Mental capacity has been little studied among older general hospital inpatients.

Methods: A retrospective analysis was undertaken of routinely collected data (age, gender, ethnicity, admission diagnosis, psychiatric diagnosis, Mini-mental State Examination score, whether capacity was assessed, the outcome of that assessment, and discharge destination) on referrals to a liaison psychiatry service for older people (2003–2006) from medical and surgical teams at a large London teaching hospital.

Results: 1267 patients were referred to the service, of whom 379 (30%) were assessed for capacity. The most common mental capacity issues were placement (303 assessed of whom 54% lacked capacity), treatment (86 assessed, 59% lacking capacity) and finances (70 assessed, 79% lacking capacity). Cognitive impairment, dementia and delirium, rather than mental disorders were associated with incapacity. Those assessed and deemed to lack capacity for placement decisions were twice as likely to be placed in a care home, and four times as likely to be placed in an elderly mentally ill (EMI) facility, independent of dementia diagnosis and cognitive functioning.

Conclusion: Referrals to a liaison psychiatry service for older people for assessment of mental capacity are common. The main mental capacity issues in older people were those linked to discharge planning. The relatively high proportion of those found to have capacity when capacity had been queried by referring clinicians attests to the important role of specialist liaison teams, particularly in complex cases, in protecting the autonomy of vulnerable older people, and avoiding institutionalization.

Background: This study investigates discrepancies between the confidence expressed by Korean elders in their balance and their actual physical performances according to sex and age. It also attempts to identify the factors responsible for such gaps or discrepancies.

Methods: The Korean Longitudinal Study on Health and Aging (KLoSHA) was designed as a population-based prospective cohort study on the health and aging of Korean adults aged 65 years and over. We evaluated 1000 of 1118 randomly selected subjects in terms of activities-specific balance confidence (ABC) and performance in regard to balance and gait (POMA). Activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed to measure disability. Pain-related dysfunctions, depression and cognitive functions were assessed. Next, we assessed the relationship between balance confidence and physical performance and functioning by sex and age.

Results: The balance confidence of elderly women was lower than that of elderly men, although the physical performances of men and women under the age of 80 were similar. Women showed increased functional disability related to lower extremity pain and closely associated with balance confidence. However, psychological variables such as depression and cognitive functioning did not affect balance confidence.

Conclusion: We found a discrepancy between balance confidence and physical performance according to sex and age among Koreans elders. Low balance confidence among women elders was correlated with pain-related dysfunctions other than those reflected in POMA scores. Therefore, enhancing confidence and controlling pain as a means of preventing disability should be emphasized when developing models for maintaining and promoting health in elders.

Background: The effects of traumatization among the elderly is a neglected topic in research and clinical settings. Forced displacement of civilians is one of the main traumatic features of modern armed conflict. Roughly 12 million German people were displaced in World War II (WWII) and to our knowledge there has been no representative study investigating the mental health outcomes of such trauma in the elderly population. The survey assessed whether current depression, anxiety, resilience and life satisfaction were significantly associated with forced displacement in WWII.

Methods: A nationwide representative face-to-face household survey was conducted in Germany. A representative sample of the German population aged 61 years or older (N = 1513 participants, N = 239 displaced in WWII) was approached using 258 sample points. Measurements included depressive symptoms (PHQ-2), anxiety (GAD-7), resilience (RS-11), general and domain-specific life satisfaction (FLZM) and sociodemographic variables.

Results: Forced displacement in WWII is significantly associated with higher levels of anxiety and lower levels of resilience and life satisfaction 60 years later. In regression analyses, forced displacement in WWII significantly predicted current anxiety (β 0.07; p < 0.01), life satisfaction (β −0.06; p < 0.05) and resilience (β −0.07; p < 0.01).

Conclusion: To our knowledge this is the first nationwide representative survey to examine the late-life effects of forced displacement, particularly of persons displaced during WWII in Germany. Further research is needed to identify mediating variables and to evaluate psychotherapeutic interventions in elderly trauma survivors.

Background: The objective of this study was to examine the prevalence and short-term course of depression and anxiety in a sample of hospitalized, medically unwell older adults, using both a symptom measure and a diagnostic instrument.

Methods: One hundred participants were recruited from in-patients in a geriatric hospital in Melbourne, Australia. Anxiety and depression were assessed shortly after admission, and again two months later, using the Hospital Anxiety and Depression Scale (HADS) and the Geriatric Mental Status Schedule/ AGECAT diagnostic system.

Results: At Time 1, 60% of the sample exhibited anxiety symptoms at a sub-case level, while 16% had anxiety symptoms at a syndrome case level, whereas 48% of the participants had depression at syndrome level. The HADS and AGECAT were concordant with respect to anxiety for 78% of participants, but agreement was lower for depression; AGECAT identified a further 36 syndrome cases of depression not deemed depressed by the HADS. There was a significant decrease in overall rates of both depression and anxiety symptoms and syndromes from Time 1 to Time 2.

Conclusion: This study confirms the findings of previous research with respect to the high prevalence of depression in physically unwell older adults, and extends knowledge about anxiety in this group. Symptoms of anxiety are even more common than symptoms of depression in this group, especially around the time of admission to hospital. Over a relatively short time period, there is a marked reduction in symptoms, but levels of anxiety and depression remain high.

Background: This retrospective chart review evaluated a comparison of the clinical profiles of older outpatients having mania and those with unipolar depression.

Methods: The charts of elderly outpatients with mania and unipolar depression in tertiary care settings were reviewed and relevant information incorporated regarding clinical presentation, past and family history of affective disorder, treatment history and previous psychiatric and neurological history.

Results: Charts for 30 patients with mania (23 men and 7 women with mean (±SD) age of 68.5(± 5.75 years) and 92 with depression (47 men and 45 women with mean (±SD) age of 68.18 (±6.0 years) were evaluated. Fifteen patients (50%) with manic episodes had psychotic symptoms in the form of delusions and hallucinations while only 33 (35.8%) depressed patients had psychotic symptoms. One-third of manic patients received mood stabilizers at index visit. More than half (n = 16; 53.3%) of the patients in the mania group were prescribed antipsychotic medications. On cognitive functions, patients with manic episodes scored poorly compared with those with depression.

Conclusions: These findings suggest that mania in the elderly is a severe form of affective disorder with respect to psychotic and cognitive symptoms. Conclusions from this study are limited due to its retrospective design. Further studies in this area are warranted.

Background: The reported decline in elderly suicide rates in England may have been, in part, due to prompt and successful resuscitation of those who attempt suicide. This study examines the impact of prompt and successful resuscitation of those who attempt suicide on elderly suicide rates in England.

Methods: Possible changes in rates of attempted suicides in elderly age-bands over a nine-year period and the correlation between rates of attempted suicide and suicide in elderly age-bands in England were examined using nationally collected data.

Results: There was a significant increase in the rates of attempted suicide over the study period in the age-band 60–74 years, but not in the age-band 75+ years. There was a positive correlation between rates of attempted suicide and suicide in the age-band 75+ years, but not in the age-band 60–74 years.

Conclusions: The findings of this study were unable to confirm conclusively that prompt and successful medical resuscitation of those who attempt suicide makes a contribution to the decline in elderly suicide rates and requires further study. Public health initiatives should be designed to reduce not only suicide rates but also rates of attempted suicide; otherwise they are failing in the prevention of mental illness and suicidal behavior, early identification and treatment of those with mental illness and those at risk of suicide, and systematic follow-up of those recovering and recovered from mental illness.

Background: A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse.

Methods: We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel.

Results: Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse.

Conclusions: The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.