Our knowledge of how the brain functions has markedly improved in recent years, but this improvement has largely been constrained to simpler levels of processing such as those involved in sensory or motor systems. In contrast, the neural bases of higher functions such as consciousness, will, long-term planning, complex problem- solving, etc., are still under investigation, although everyone agrees that the frontal lobes (FL) play an important role in such processes. The importance of understanding these neural bases of higher functions becomes even more evident in the study of aging, since a decrease of frontal lobe perfusion is reported during aging, and because this age-related frontal lobe dysfunction has been proposed to explain part of the cognitive disorders (attention disorders, decreased mental flexibility and abstraction) and behavioral changes (mainly apathy or indifference) associated with aging.

Background: At the request of the Editor of International Psychogeriatrics, a statistical audit of all papers published in the journal during 2003 was undertaken by the statistical advisor to International Psychogeriatrics.

Method: Only research papers using inferential statistical techniques were assessed and only the statistical elements of these papers were evaluated. The following issues were addressed: did the authors report a power calculation or address power issues? Did the authors report an appropriate effect size indicator? When multiple univariate statistical tests were used was a correction for type 1 error employed? Did authors demonstrate the adequacy of the data analyzed for the statistical tests employed? Were sufficient details reported to enable an evaluation of the statistical analyses and reported results?

Results: Twenty papers published during 2003 were suitable for analysis. None addressed power issues. About half reported an effect size indicator and about half adjusted the statistical analysis for the effects of multiple univariate statistical comparisons. Few demonstrated the adequacy of the data being analyzed and few provided sufficient detail to evaluate the statistical analyses and reported results. Most papers used the right statistic in the right way.

Conclusion: The statistical quality of articles published in International Psychogeriatrics could be improved by attention to a few relatively fundamental issues.

Objective: The main objective of this article is to evaluate and describe instruments for assessing decision-making capacity in psychiatry and psychogeriatrics, and to evaluate them for use in daily practice.

Methods: The instruments were selected in Medline articles. We focus on the relationship between these instruments and the concept of competence, represented in the following elements: context in which an instrument is developed, disclosure of information, standards to assess decision-making capacity, the scale or threshold model, and validity and reliability.

Results: The developmental context influences how information is provided and standards defined. Although it is not clear how decision-making capacity relates to competency judgments, most instruments provide good reliability.

Conclusions: Comparison of the different instruments opens directions for future research. Although instruments can never replace a physician's judgment, they may provide a clear starting point for a discussion on competence. In daily practice assessments, attention should be given to information disclosure, the influence of our own normative values in evaluating standards of decision-making capacity, and the relation between decision-making capacity and competence.

Background: This issue of whether or not, how and when patients should be told of the diagnosis of dementia remains a matter for discussion. Recent data confirm that the patient is told of the diagnosis in only 40 to 55% of cases. We therefore studied the performance of Flemish general practitioners (GPs) in this area.

Method: A postal questionnaire, based on that prepared by Johnson et al., was sent to a random sample of 1000 Flemish GPs, out of a total of 7000.

Results: A total of 647 answers were returned, of which 521 were eligible for analysis (response rate 60%). Thirty-six percent of these 521 GPs always or usually disclose the diagnosis, while 37% provide information about the prognosis. Most doctors (75%) see benefits in disclosure, particularly as regards planning care, providing treatment and encouraging a good doctor-patient relationship. Only 61% of respondents present an appropriate differential diagnosis.

Discussion: The results obtained from the Flemish GPs are similar to those of other known studies. A detailed analysis of the reasons for and the benefits of disclosing the diagnosis reveal a less reluctant attitude than could be inferred from the rough data. GPs pay a great deal of attention to the patient's feelings, experiences and ability to cope and to the proper timing of their information. However, intensive educational projects have to be set up in order to stimulate a more etiologically-oriented diagnosis and to improve the quality of the process of disclosing the diagnosis of dementia.

Background: This study investigated which concepts regarding “the good life” are used in mission statements of nursing homes providing care for demented patients.

Method: All 317 Dutch nursing homes caring for demented patients were asked to participate; of these, 69% responded. Their mission statements were qualitatively analyzed on content. Whether different types of nursing home differed significantly in the content of their mission statements was investigated by means of χ2 analyses.

Results: Six main concepts were found that are considered important for a good life: 1) autonomy and freedom, 2) individuality and lifestyle, 3) relationships and social networks, 4) warmth and safety and familiarity, 5) developing capacities and giving meaning to life and 6) subjective experience and feelings of well-being. It was found that mission statements specifically developed for demented patients attach less importance to the concepts 1) autonomy and freedom and 2) individuality and lifestyle, than mission statements which are also aimed at non-demented residents. Most mission statements turned out to be highly eclectic in content.

Conclusion: Nursing homes with a separate statement for demented residents seem to acknowledge the special position of demented residents and the tension between dementia and the ideal of autonomy. Although the eclecticism found in mission statements is understandable, a coherent view on the good life for demented residents should aim for a sound internal structure, and make choices between values. Only then can mission statements provide real guidance for everyday care.

Background: Little is known about the prevalence of, or associations with behavioral and psychological symptoms of dementia (BPSD) in developing countries.

Methods: Individuals diagnosed as having dementia according to DSM-IV criteria (mild and moderate cases as defined by the Clinical Dementia Rating scale only), together with their main caregiver, were recruited from 21 centers in 17 developing countries. People with dementia were directly assessed with the Community Screening Interview for Dementia and the Geriatric Mental State Schedule (GMS); GMS data were processed by the AGECAT computer program to yield diagnostic information on 8 psychiatric syndromes. Caregivers answered direct questions about behavioral symptoms of dementia (BSD) and completed the Zarit Burden Inventory.

Results: At least one BSD was reported in 70.9% of the 555 participants. At least one case-level AGECAT psychiatric syndrome (not including the organic syndrome) was exhibited by 49.5% of people with dementia. Depression syndromes (43.8%) were most common followed by anxiety neurosis (14.2%) and schizophreniform/paranoid psychosis (10.9%). Caregivers were more likely to report BSD in people with dementia who were married, younger and better educated. More advanced dementia, poorer functioning and the presence of depression or anxiety were each associated with BSD. BSD, and psychiatric syndromes (anxiety neurosis and schizophreniform/paranoid psychosis) predicted caregiver strain after controlling for cognitive impairment. BPSD are poorly understood, leading to shame and blame.

Conclusions: BPSD are common among people with dementia in developing countries, though we found marked regional variations. Representative population studies are needed to clarify prevalence and impact, but our research suggests considerable unmet need, with much scope for intervention. Raising awareness of the problem should be the first step.

In the following book review, which appeared on page 247 of the June 2004 issue of International Psychogeriatrics (Volume 16, Part 2), the year of publication was incorrectly given as 200X. The correct year of publication for this book is 2002.

Background: The aim of this epidemiological study is to examine the prevalence and correlates of psychotropic drug use in the very old and to evaluate the appropriateness of psychotropic drug use in very old age.

Methods: Data from the Berlin Aging Study (BASE), a multidisciplinary study of an age- and gender-stratified, randomly selected sample of elderly people living in Berlin are presented. Over-sampling, especially very old men, allows for powerful analyses of this population. All participants went through extensive psychiatric and somatic examinations. Medication intake was assessed by different data sources (interviewing patients and their family physicians, drug inspection at home). Results were brought together in a consensus-conference and research physicians gave operationalized ratings of medication appropriateness.

Results: The prevalence of elderly people who were taking at least one psychotropic medication within the 14 days immediately preceding investigation was 29.8%. Of these medications, 68.4% had been taken for longer than one year. There was no effect of age or gender on the scope of psychotropic drug use. Benzodiazepines were taken by 19.8% of the elderly. Antidepressants, neuroleptics and anti-dementia drugs were taken by about 3–4% each. People taking psychotropic drugs had significantly higher levels of psychiatric morbidity, as measured by syndromes and specified diagnoses. Psychotropic drugs were significantly less often judged to be indicated than somatic medications. This is mostly due to benzodiazepines.

Conclusions: Psychotropic drug use is common in old age, but there is no additional increase in usage beyond the age of 70. Intake of psychotropics is mostly oriented at symptoms or syndromes, which explains why benzodiazepines are still the most commonly prescribed psychotropics

Background: Apathy has been shown to be an important feature of degenerative, vascular or traumatic brain disorder. Its presence is associated with high depression scores, higher age, low performance on frontal tasks, and more severe deep white matter hyperintensities. In late-life depression, lack of interest or motivation are often more prominent than depressed mood, especially in the late-onset type. It was hypothesized that in a heterogeneous sample of elderly depressed patients, apathy is associated with late-onset type of depression, cognitive dysfunction or vascular risk factors.

Method: The Apathy Evaluation Scale (AES) was administered to twenty-nine elderly (≥60 years) inpatients with a DSM-IV major depression or dysthymic disorder. The severity of the depression was measured with the Montgomery-Åsberg Depression Rating Scale (MADRS) and cognitive function with the Mini-mental State Examination (MMSE). The presence of vascular risk factors was traced in the patient's medical records.

Results: Apathy was found in 86% of the patients. The AES-score was correlated with the negative symptom score, but not with total MADRS or MMSE-score. No difference in AES-score between early-onset depressed (n = 16) and late-onset depressed (n = 13) patients was found, and between patients with or without vascular risk.

Conclusion: Apathy is a main feature of moderate to severe depressive illness in elderly patients and related to the negative symptoms of the disorder. Further studies should include less severely depressed patients and investigate the relation between depression severity and apathy.