Meeting in Lisbon, Portugal on May 3rd 2006, the board of directors of the International Psychogeriatric Association (IPA) endorsed the recommendation of its executive that I be reappointed for a further (and final under the terms of the IPA constitution) four year term to serve as editor of International Psychogeriatrics from 1 January 2007 to 31 December 2010. I accepted this offer with delight, so unless I get fired for misconduct, drop dead or resign early, readers and authors are stuck with me until the end of the decade. As we strive to further develop and improve the journal this is an appropriate moment to reflect on what has changed since I took over at the start of 2003, report how the journal stands at present and indicate what developments may lie ahead.

In March 2005 International Psychogeriatrics published its first “For Debate” section on the topic of “should novel antipsychotics ever be used to treat the behavioral and psychological symptoms of dementia (BPSD)?” (Ames et al., 2005). Following the positive reception of this piece, we have commissioned three further debates, of which this one on mild cognitive impairment (MCI) is the first to be finished. Further For Debate articles on the effectiveness of electroconvulsive therapy in treating the depressed elderly, and the utility of neuroimaging methods in the assessment of dementia are in an advanced stage of preparation and will appear in future issues of the journal. Should any reader have suggestions for other worthwhile debate topics I urge them to contact me at ipaj-ed@unimelb.edu.au as the journal's entire editorial panel is keen to make these debates a regular journal feature.

Mild cognitive impairment (MCI) has become a major issue in the fields of geriatrics, behavioral neurology and geriatric psychiatry. While some have embraced the construct as a step forward in understanding the prodromal stages of dementing disorders, others have assailed the concept as counterproductive and distracting. Perhaps this is appropriate, since any new proposal for the clinical characterization of impaired subjects should undergo strict scrutiny.

Within the spectrum of cognitive disorders Mild Cognitive Impairment (MCI) is a relatively new concept which has become increasingly popular both in clinical practice and in clinical research. Still, the concept of MCI has several shortcomings which limit its utility in clinical practice and research.

The current debate about Mild Cognitive Impairment (MCI) is useful in bringing forward for first-line clinicians, as well as clinical researchers, the importance of paying attention to cognitive complaints in aging individuals. Clearly (and thankfully) not all will progress to dementia. Furthermore, many can be helped by primary care practitioners through a basic clinical assessment and treatment of one of the many conditions potentially associated with mild cognitive complaints, such as depression, hypothyroidism, side-effects of anticholinergic drugs, alcohol abuse, nutritional deficiency, sleep apnea. Many times the cognitive complaints will be reversible. In some cases the symptoms will persist or increase over time, and a yearly follow-up and/or a referral to a specialized setting are appropriate, since there is a higher risk of progression to dementia in such individuals, particularly towards Alzheimer's disease (AD).

In March 2005 International Psychogeriatrics published its first “For Debate” section on the topic of “should novel antipsychotics ever be used to treat the behavioral and psychological symptoms of dementia (BPSD)?” (Ames et al., 2005). Following the positive reception of this piece, we have commissioned three further debates, of which this one on mild cognitive impairment (MCI) is the first to be finished. Further For Debate articles on the effectiveness of electroconvulsive therapy in treating the depressed elderly, and the utility of neuroimaging methods in the assessment of dementia are in an advanced stage of preparation and will appear in future issues of the journal. Should any reader have suggestions for other worthwhile debate topics I urge them to contact me at ipaj-ed@unimelb.edu.au as the journal's entire editorial panel is keen to make these debates a regular journal feature.

Background: Age-related macular degeneration (AMD) affects approximately 10% of persons aged 65–74 years and 30% of those aged 75 and older and is the major cause of blindness in old age. AMD is progressive and irreversible.

<Aim: To review the psychosocial effects of AMD.

Method: OVID data bases (MEDLINE, psycINFO and CINAHL) from 1966 to 2004 were reviewed.

Results: AMD is associated with functional impairment, high rates of depression, anxiety and emotional distress and increased mortality. Risk factors for depression are not well-defined, except for the degree of functional impairment and impending or actual loss of vision in the second eye. Behavioral and self-management programs may be effective in managing depression associated with AMD, but few studies have been performed, and none using drugs or multimodal therapy.

Conclusion: AMD will become even more prevalent as the population ages. Identification of risk factors for psychological consequences and of effective interventions remain to be recognized.

Objective: Cognitive impairment and negative signs are common in patients with schizophrenia. Up to 35% of elderly patients with schizophrenia fulfill the diagnostic criteria of dementia. Donepezil inhibits cholinesterase, thus enhancing cholinergic neurotransmission. We tested the efficacy of donepezil in elderly patients with chronic schizophrenia and severe cognitive impairment.

Method: Following baseline assessment, patients were randomly assigned to receive either donepezil or placebo. The dose was 5 mg daily for the first week and 10 mg for an additional 11 weeks. The procedure was repeated using the crossover compound. The Positive and Negative Symptom Scale (PANSS), Clinical Global Impression Scale (CGI) and Alzheimer Disease Assessment Scale – Cognitive subscale (ADAS-Cog) were used to assess the severity of symptoms, cognitive status and intervention effects.

Results: Twenty subjects were enrolled (15 females, five males), mean age 70.2 years (SD 6.5) and mean duration of disease 38.5 years (SD 9.3). A modest treatment effect was found for both placebo and donepezil treatment periods. No crossover effect was found. No statistical differences were demonstrated between the two treatment groups (CGI p = 0.37, PANSS p = 0.71, ADAS-Cog p = 0.86). Two patients died during the study period due to unrelated causes and one patient discontinued participation due to increased agitation.

Conclusion: Donepezil does not seem to improve negative signs and cognitive impairment in elderly patients with chronic schizophrenia.

Background: Alterations in iron metabolism have been suggested as potential pathological markers in patients with manifest depression. No data on the association between iron and depression exist from population-based studies, in which milder forms of depressive symptoms are much more common. The aim of this study was to analyze the relationship between six parameters of iron metabolism and depressive mood in a population-based cross-sectional study in Germany.

Methods: A total of 374 participants, aged 65–83 years, of the Memory and Morbidity in Augsburg Elderly (MEMO) Study were assessed using the Center for Epidemiologic Studies – Depression Scale (CES-D) for depression. Iron, ferritin, transferrin, soluble transferrin receptor, iron binding capacity, transferrin saturation and C-reactive protein were analyzed with standard laboratory methods. Linear and logistic regression analyses were applied to evaluate the relationship between iron parameters and depressive mood.

Results: The 7-day prevalence of depressive mood was 10.2%, with a higher risk in women compared to men [odds ratio (OR) = 2.04; 95% confidence interval (95% CI) = 1.04–4.0]. Correlation and linear regression analyses adjusted for age, gender, hypertension and smoking yielded no significant relationship between any of the iron parameters and the CES-D scores. In gender-stratified analyses a statistically significant association between serum iron and depressive mood was observed in men only. This finding disappeared after applying a Bonferroni correction for multiple testing.

Conclusions: The lack of association of iron metabolism and depressive mood reported in this population-based study does not support previous findings in patients with major depression. This negative finding in milder forms of depression in elderly people indicates either the absence or a more complex nature of the interactions between iron metabolism, low-grade inflammation and depression.

Background: Cross-sectional studies have shown that late-onset depression is associated with larger deep white matter lesions (WMLs) and subcortical gray matter lesions (GMLs). In a longitudinal analysis, we examined changes in deep WMLs and subcortical GMLs in older depressed and nondepressed subjects over a 4-year period.

Methods: Brain magnetic resonance imaging (MRI) scans were obtained on 164 depressed and 126 healthy subjects aged 60 years or older at baseline, and 2 and 4 years after recruitment. WMLs and GMLs were measured using a semiautomated technique. We used repeated-measures analysis of covariance to determine cross-sectional lesion volume differences, whether lesion volume changes differed between patients and controls, and the effect of lesion volume changes on outcome in late-life depression.

Results: Mean volumes of lesions for the depressive group were 6.51, 8.18 and 7.75 cm2 for WMLs and 0.23, 0.30 and 0.34 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Mean volumes of lesions for the control group were 4.83, 6.22 and 6.45 cm2 for WMLs and 0.17, 0.25 and 0.23 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Cross-sectional between-group mean lesion volumes were significantly different for each measure. However, the pattern of WML and GML volume changes over time was not significantly different between groups. Treatment outcome was associated with changes in total and white matter lesion volume over time.

Conclusions: Lesion volume progression is associated with aging and the pathological condition of late-life depression. The mechanisms that produce these progressive lesion changes remain unclear. Treatments aimed at arresting lesion progression may play a role in the management of late-life depression.

Background: The role of individual differences, including pre-morbid personality, in the development of post-stroke depression, has received relatively little attention. We undertook a cross-sectional study to investigate the relationship between pre-morbid personality and other individual differences, and depression following acute stroke.

Method: We studied 61 consecutive patients admitted to a dedicated stroke inpatient unit. DSM-IV depressive diagnoses were ascertained using the Composite International Diagnostic Interview and depressive symptoms were ascertained on the Hamilton Depression Rating Scale and the Center for Epidemiologic Studies Depression Scale. Informant-rated personality scores were obtained on the full 240-item Neuroticism, Extraversion and Openness Personality Inventory – Revised. Adaptive function was measured on the Modified Barthel Index and the Instrumental Activities of Daily Living scale. Cognitive function was assessed on the Mini-mental State Examination.

Results: An increased risk of post-stroke depression was conferred by both pre-morbid neuroticism [odds ratio (OR) 3.69; 95% confidence interval (95% CI) 1.25–10.92] and a past history of mental disorder (OR 10.26; 95% CI 3.02–34.86). There was no significant relationship demonstrated between lesion location and post-stroke depression.

Conclusions: Informant-rated pre-morbid neuroticism and a past history of mental disorder were important predictors of depression following stroke. Stroke side was not significantly related to risk of depressive symptoms following stroke.

Objective: This cross-sectional study examined the prevalence and characteristics of depression in subjects with mild cognitive impairment (MCI). The data presented here are from the first wave of the longitudinal Personality and Total Health Through Life 60+ (PATH 60+) Project.

Method: A total of 2551 community-dwelling individuals in the age range 60–64 years were recruited randomly through the electoral roll. They were screened using a short cognitive battery and those who screened positive underwent detailed medical and neuropsychological assessments. There were 29 subjects who fulfilled the Mayo Clinic criteria for MCI and these were compared to 520 controls. Subjects were evaluated for depression symptoms and DSM-IV major and minor depression syndromes.

Results: Subjects with MCI had more minor depression and higher scores on a symptom scale. However, a multivariate examination of specific symptoms showed that the differences were confined to only two motivation-related symptoms (“felt slowed up” and “little interest or pleasure”).

Conclusion: Motivation-related depressive symptoms are more relevant in subjects with MCI than mood-related symptoms.

Background: Depression is common in elderly people but physicians may not screen for it because of the length of time required by current screening instruments. We have developed a short screening instrument for depression for use in elderly people with normal cognition, mild cognitive impairment or early dementia.

Methods: Participants were aged 55 years or more, had scored 20 or more on the standardized Mini-mental State Examination (SMMSE) and had been referred to a specialist geriatric outpatient memory clinic. Scores on the 30-item Geriatric Depression Scale (GDS) were analyzed. A composite GDS score, consisting of the top five individual question scores that correlated to depression (GDS ≥ 14), were analyzed using a receiver operating curve analysis.

Results: There were 810 patients with SMMSE scores of 20 or greater, of whom 202 (24.9%) scored 14 or more on the GDS, indicating depression. GDS question 16, “Do you often feel downhearted and blue?,” had the highest correlation with the overall scores of 14 or more on the 30-point instrument (r = 0.64, p < 0.001). The next four questions with the highest correlates were Q10, “Do you often feel helpless?” (r = 0.56, p < 0.001), Q3, “Do you feel that your life is empty?” (r = 0.54, p < 0.001), Q9, “Do you feel happy most of the time?” (r = 0.52, p < 0.001), and Q1, “Are you basically satisfied with your life?” (r = 0.50, p < 0.001). The negative predictive value of “Do you often feel downhearted and blue?” answered negatively for depression was 96%. These five questions were used as a short screening instrument. The positive predictive value of four or five positive responses was 97%. These data were not significantly different whether the patient's SMMSE score was 20–25 or 26–30.

Conclusions: The AB Clinician Depression Screen (ABCDS), comprising five questions, can rapidly identify patients with depression or eliminate that diagnosis. In this population, these five questions may be used instead of the longer 30-question GDS scale.

Background: Two-phase diagnostic surveys are popular in psychiatric epidemiology. The Geriatric Depression Scale (GDS) and the General Health Questionnaire (GHQ) are commonly used to screen in older and younger populations, respectively.

Method: In Phase I, in this Brazilian population-based study, we screened 392 participants aged ≥ 75 years. In Phase II, half of those scoring ≥ 11 in the GDS and ≥ 4 in the GHQ and 20% of others were selected for detailed evaluation with ICD-10 diagnoses assessed by the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (n = 126).

Results: Internal consistencies were good for all scales. At the optimal cut-off points GDS-30 (14/15) yielded 73% sensitivity and 65% specificity, while classical GHQ (4/5), Likert (15/16) and c-GHQ (5/6) yielded 66–75% sensitivity and 57–62% specificity. Receiver operating characteristic (ROC) curve analysis against SCAN indicated only moderate screening potential [area under the ROC curve (AUROC): GDS = 0.76; classical GHQ = 0.74; Likert = 0.76; c-GHQ = 0.73], with no statistically significant differences. All measures were biased by disability and self-reported health.

Conclusions: In this study, neither screen was sufficiently predictive of SCAN ICD-10 diagnosis to recommend their use in two-phase surveys. Despite its theoretical advantages, the GDS-30 performed no better than the GHQ-12, and was biased in similar ways.

Background: Differential item functioning (DIF) exists when test item responses by members of different demographic groups are statistically different when controlling for ability. DIF may indicate item bias. Our objective was to determine whether items from the Italian Mini-mental State Examination (MMSE) had DIF related to educational attainment, age, gender and occupation. We were also interested in exploring the significance of DIF in screening tests.

Methods: In a two-stage study from Granarolo, Italy, residents over age 61 (n = 495) were evaluated with the Italian MMSE. Those with MMSE scores of 28 or lower were further evaluated for dementia. MMSE results were coded in 10 item bundles. We used ordinal logistic regression to determine whether item bundles had DIF.

Results: Six of the 10 MMSE item bundles had DIF in educational attainment subgroups. Four of these six bundles also had DIF related to age. Items that required literacy were much harder for those with lower educational attainment.

Conclusions: DIF related to education appeared at as few as 3 years of formal schooling. These findings suggest cautious interpretation of data from studies using the Italian MMSE in populations with heterogeneous educational backgrounds. DIF is especially troublesome for two-stage studies that use screening tests.

Objective: To examine associations between behavioral and psychological symptoms of dementia (BPSD), cognitive function and clinical deterioration over 2 years.

Methods: One hundred and four Chinese subjects with late-onset Alzheimer's Disease (AD) who presented to psychogeriatric clinics were followed for an average of 22.5 months. BPSD subgroups were categorized by latent class analysis using the Neuropsychiatric Inventory. Comprehensive cognitive profiles were performed with the Mattis Dementia Scale, the Hong Kong List Learning Test (HKLLT) and the Category Verbal Fluency Test. Interactions between cognitive function and behavioral syndromes were evaluated. Potential predictors for clinical deterioration were computed with logistic regression analysis.

Results: Three latent classes of subjects with similar behavioral syndromes were identified: Low BPSD (44%), Affective (32%) and Psychosis (24%) groups. Association between cognitive functions and BPSD was not significant. At follow-up, a higher proportion of subjects in the Affective (70%) and Low BPSD (49%) groups remained stable at the same Clinical Dementia Rating. Baseline scores in the “recognition” test of the HKLLT and age were significant predictors for “deceased” status at 2-year follow-up.

Conclusion: The lack of association between behavioral syndromes and cognitive function suggests that these relatively independent dimensions of dementia should be examined individually for different prognostic significance.

Background and objectives: Until recently, attention and treatment strategies have focused mainly on patients in the early phases of Alzheimer's disease (AD). The objectives of this study were to collect information on moderately severe and severe AD patients (Mini-mental State Examination score < 15) in terms of epidemiological, clinical and economic characteristics and disease change in the later stages of AD, and to compare this specific AD population over 6 months with those in the earlier stages.

Methods: This descriptive analysis recruited institutionalized patients and patients living within the community from the city of London and the South-East region of the U.K. Subgroup analyses at baseline and 6 months were performed using the study population from the London and South-East Region Alzheimer's Disease (LASER-AD) Study. Data from a range of clinical scales, a quality of life (QOL) scale and a resource-utilization questionnaire were analyzed.

Results: People with moderately severe or severe AD are a heterogeneous group with varying QOL, cognitive and functional disabilities, neuropsychological symptoms and relatively low health care resource consumption. This patient group continued to decline but progression of the disease was observed only in some domains.

Conclusion: Even at the later stages of AD, patients show varying rates of decline. Improved knowledge about the characteristics and progression of the disease reveals that moderately severe and severe patients cannot be regarded as beyond help and have the potential to experience varying and even high levels of QoL.

Background: It is generally accepted that Alzheimer's disease (AD) is mainly characterized by memory disorders. Although recent studies also point to an important role of attention deficits early in the disease, this notion has not yet emerged in clinical practice. Our aim was to assess whether attention, quantified by reaction times, can discriminate between patients with mild AD and controls and therefore contribute to clinical diagnosis.

Methods: In a cross-sectional study, 33 patients with mild AD were matched with cognitively healthy elderly controls for age, gender, educational level and depressive mood. Selective attention (SA), alternating attention (AA) and error-rates were measured by a modified reaction time test.

Results: Significant differences between both groups were found for all measures. Logistic regression showed that SA (corrected for individual processing speed) and error-rates could correctly classify subjects with an overall hit ratio of 81%. When attention measures were not corrected for individual processing speed, the overall hit ratio improved to 97%.

Conclusion: SA and AA deteriorate in patients with mild AD and these measures can be used to discriminate between patients and matched controls, independently of depressive mood.

Objective: There are few studies of successful aging in China. This study was designed to investigate the distribution, and related factors, of successful aging in an elderly Chinese population.

Methods: A cross-sectional, community-dwelling elderly population was surveyed in Shanghai, China. We defined successful aging based on a multi-dimensional model. Correlates of successful aging were explored through the Shanghai Successful Aging Project Questionnaire, which includes sociodemographic questions, and a battery of standardized instruments, including the Chinese version of the Mini-mental State Examination, activities of daily living, and the Life Satisfaction Index A (LSIA).

Results: The rate of successful aging was 46.2% [95% confidence interval (CI) 43.6–48.7] among people aged 65 or above, and the rate for males was higher than that for females. The rate was much lower for those aged 85 years or over (9.4%). Logistic regression analysis suggested that female gender and older age were unfavorable factors for successful aging. A higher score on the LSIA, more leisure activities and being currently married related to successful aging.

Conclusion: The rate of successful aging in Shanghai, China is similar to that found in studies from western countries. There are some potentially modifiable factors that may relate to successful aging.