Background: A recent Cochrane report concluded that more and better quality research is required to investigate the effectiveness of music therapy in reducing problems in behavioral, social, emotional and cognitive domains in patients with dementia. This randomized placebo-controlled trial with blinded observer rater aimed to explore whether music, live or pre-recorded, is effective in the treatment of apathy in subjects with moderate to severe dementia.

Methods: Thirty-two subjects meeting ICD-10 diagnostic criteria for moderate to severe dementia and fulfilling diagnostic criteria for apathy were exposed to live interactive music, passive pre-recorded music or silence for 30 minutes. Each subject was randomized to 30-minute music or silent periods and was video recorded and the muted recording analyzed every 3 minutes using dementia care mapping to assess the quality of engagement to the blinded music intervention.

Results: Compared to low baseline levels of positive engagement (12.5%) in the silent placebo period, the majority of subjects (69%), regardless of dementia severity, showed a significant and positive engagement to live music. Engagement to pre-recorded music was non-significant, with just 25% of all subjects showing positive engagement. No subjects showed any evidence of experiencing a state of ill-being during either the live or pre-recorded music sessions.

Conclusions: During the intervention, live interactive music has immediate and positive engagement effects in dementia subjects with apathy, regardless of the severity of their dementia. Pre-recorded music is non-harmful but less clearly beneficial.

Objective: To examine the current pattern of use of psychotropic medication in Sydney nursing homes and compare this with the pattern noted 5 and 10 years earlier.

Method: Data were recorded from medication cards concerning psychotropic medications prescribed for the 3093 residents in the 51 nursing homes in the Central Sydney Health Area. Documented diagnoses and demographic details were noted from their clinical files.

Results: In late 2003, 47.2% of residents were taking one or more psychotropic drug regularly and another 3.5% had been given “as required” (prn) doses at least once in the preceding 4 weeks. Fewer residents were taking hypnotics (11.3%) and anxiolytics (4.1%) regularly, when compared to 1998, but more were taking antidepressants (20.5%). Selective serotonin reuptake inhibitors were prescribed to 11.4%, venlafaxine to 2.6%, mirtazapine 1.6% and tricyclics to 3.6%. Although the proportion taking antipsychotics had not fallen since 1998, there were over twice as many residents (16.4%) taking atypical neuroleptic medication in 2003 as there were taking conventional neuroleptics (8.1%). Most of them did not have schizophrenia.

Conclusions: There have been further reductions in the use of hypnotics and anxiolytics in Sydney nursing homes, with increased prescription of antidepressants and a striking change towards use of atypical rather than conventional neuroleptic medication.

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).

Background: An increasing number of studies have suggested a link between cholesterol metabolism and Alzheimer's disease (AD), which may be mediated by its effect on amyloid processing. Intracranial cholesterol is primarily eliminated into the bloodstream through conversion into 24-hydroxycholesterol by the enzyme cholesterol 24-hydroxylase (encoded by the CYP46A1 gene). CYP46A1 is an essential gene modulating cholesterol metabolism in the brain.

Method: To investigate whether polymorphisms in the CYP46A1 gene modulate the risk of AD, we studied four common polymorphisms (IVS1-192, IVS2-150, IVS3-128 and IVS4-122) in 182 Chinese AD patients and 179 age-matched healthy Chinese subjects.

Results and conclusion: We found that the IVS3-128 polymorphism was associated with the risk of AD (p < 0.05). Subjects homozygous for the C alleles were protected from AD with an adjusted odds ratio (OR) of 1.53 [95% confidence interval (95% CI) 0.98–2.37, p = 0.047]. However, another minor allele, IVS1-192 C, was more prevalent in the AD group and was associated with an increased risk. Haplotype analysis revealed that two of the eight common haplotypes formed by the four polymorphisms were rarely found in the AD group, suggesting a protective effect of these two haplotypes (GTCA and CCTA). The results supported the involvement of the CYP46A1 gene and cholesterol metabolism in the pathogenesis of AD.

Background: Aggressive behavior (AB) is common in institutional settings. It is an important issue because of its consequences on both the person manifesting such behaviors and their caregivers. Although there are numerous studies assessing non-pharmacologic strategies to manage AB in older adults, no extensive review of the literature is available. This review synthesizes the current knowledge on the effectiveness of non-pharmacological interventions in institutional settings.

Method: Papers describing the assessment of a non-pharmacological intervention to manage AB in which participants were at least 60 years old and living in a long-term care facility were selected mainly by searching various databases.

Results: A total of 41 studies were identified and included in the review. These studies mainly use quasi-experimental designs and include less than 30 participants. Sixty-six percent (27/41) of the studies report either a statistically or behaviorally significant reduction of AB as a result of a non-pharmacological intervention. Staff training programs and environmental modifications appear to be the most effective strategies.

Conclusion: Non-pharmacological interventions seem effective for managing AB. Future studies on the effectiveness of these interventions need to be more rigorous. Development in this field needs to be based on knowledge regarding the determinants of AB in older adults.

Background: Very little is known about the utility of psychiatric day hospitals for elderly adults with mood disorders. The objectives of this study were to evaluate a long-standing day-hospital program and to explore whether demographic and non-demographic patient characteristics were associated with treatment outcomes.

Method: We used t-tests to compare retrospective admission and discharge data for 708 patients over a 16-year period, and multiple regression to examine predictors of improvement.

Results: Depressed patients showed statistically and clinically significant improvements on the Geriatric Depression Scale and the Hamilton Depression Rating Scale. The number and severity of depressive symptoms at admission were strongly related to treatment outcomes. After controlling for initial levels of depression, demographic characteristics did not predict improvement, and axis I and II diagnoses modestly and inconsistently predicted improvement.

Conclusions: A biopsychosocially-focused day-hospital treatment program was associated with improvements in depression in a large sample of elderly adults with mood disorders. Except for depression severity at admission, patient characteristics had very little impact on treatment outcomes, suggesting that day hospital programs are beneficial for a wide range of depressed elderly adults.

Objectives: To assess the attitude of elderly lay people towards the concept and symptoms of dementia.

Methods: A population-based, cross-sectional study of 859 residents without dementia, aged 70 years or older, living in an urban area in Istanbul. Nine questions with yes/no responses were designed to investigate the attitudes of the responders to the concept of dementia and symptoms related to particular aspects of dementia. The χ2-test was used to test for differences between proportions of respondents in different age, sex and education groups.

Results: Dementia was considered as normal by the majority of respondents and age and education did not influence this attitude. Women were significantly less inclined to consider dementia and its associated problems as normal.

Conclusion: The concept of dementia is generally not considered as a medical problem by the elderly Turkish population, independent of age and education. These results are important in guiding policy makers and shaping awareness raising campaigns of local Alzheimer's Associations.

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: Despite the recent dissemination of group homes in Japan for older adults with dementia, the behavioral and psychological features of the residents remain unknown. To clarify the association of such features with the levels of difficulty encountered by caregivers in coping with these symptoms, we have conducted a survey to compare the frequencies of the symptoms among group homes, nursing homes and a long-term care hospital.

Methods: Five hundred and eighty-six older adults aged 65 years or more were sampled. Data were consecutively collected from questionnaires given to the caregivers. The questionnaire included basic activities of daily living, the Mini-mental State Examination, frequencies of behavioral, psychological and physical symptoms, and the levels of difficulty in coping with the symptoms.

Results: In group homes, requests to go home, urinary incontinence and frequent complaining were the most commonly observed symptoms. The symptoms associated with disorientation, anxiety and depression were frequently observed in all three care settings. Most of the symptoms were more frequently observed in group homes than in the other two care settings. However, the levels of difficulty in coping with most of the symptoms were the highest in the long-term care hospital, followed in order by the group homes and nursing homes. In group homes, inappropriate sexual behavior was the symptom creating the most stress for the caregivers, followed by verbal and nonverbal abuse and changeable mood.

Conclusions: The symptomatic traits of residents in group homes were clarified in the present study. These findings could be helpful in considering desirable placement or the improvement of eligible service provision for older adults with dementia in care facilities.

Background: To determine the prevalence of dementia among the residents of geriatric institutions in the greater Jerusalem area.

Methods: A population-based, cross-sectional survey of a representative sample, weighted according to the level of care, of 11 of the 88 long-term care (LTC) wards in 34 LTC institutions providing care for the elderly residents in the greater Jerusalem area in 1999. A single physician interviewed 311 residents. The presence of dementia was determined from medical records and by performance on the Modified Mini-mental State Examination (3MS) instrument (with a score less than 78/100 indicating significant cognitive impairment or suspected dementia), and professional care providers were interviewed for their opinion regarding the presence of dementia in each subject.

Results: The mean age of the patients was 83.9 years and 75% were women. Overall, 180 residents, representing 49.9% of the weighted sample in Jerusalem LTC facilities, were determined to have dementia according to medical records, ranging from 22.9% in independent and frail care units to 97.7% in skilled nursing care wards. However, based on their performance on the 3MS, the prevalence of cognitive impairment with suspected dementia among the subjects was substantially greater, with the staff being unaware of this diagnosis in about one-quarter of the subjects.

Conclusions: There is a high prevalence of dementia in geriatric institutions in the Jerusalem area, particularly in those providing greater care. Moreover, significant cognitive impairment is probably under-reported in the medical records.

Background: A carer-held record (CHR) was developed to enable carers to contribute to care plans for their relatives with dementia, alongside other professionals. The aim of this study was to establish whether CHRs provide any measurable benefits for carers, in the areas of health, stress, knowledge of dementia and locus of control.

Methods: This was a controlled parallel-group trial involving 84 carer/patient pairs, drawn from all new referrals to two community mental health teams (CMHTs). Subjects from one CMHT were given CHRs. The control group from the other CMHT were not offered the initiative. Carers in both groups completed instruments measuring knowledge of dementia, carer stress and strain, carer health, and locus of control (internal, external, chance, shared care) at three time points: baseline, 6 months and 1 year.

Results: Findings are reported for outcome at 6 months and 1 year on 51 carer/patient pairs. Having a CHR was associated with significantly reduced scores on the Carer Strain Index at 1 year (mean between-group difference: −1.34, 95% CI −2.67 to −0.02). Regarding locus of control, external control scores were significantly lower in the intervention group, by 2.5 points at 6 months (95% CI −4.82 to −0.18) and 3.43 points at 1 year (95% CI −5.57 to −1.29) (p = 0.01). There was a significant group by time interaction in chance control, with the difference in chance control between groups widening between 6 and 12 months. In the shared care dimension of locus of control, there was no difference at 6 months, but a significant group by time interaction, with the intervention group maintaining a higher level of internal control between 6 and 12 months, while the control group reduced. No significant differences were identified in the domains of carer health or knowledge of dementia.

Conclusions: Although not a randomized controlled trial, and limited by smaller sample size than planned, this study indicates that use of CHRs provides some benefits for carers in the domains of carer strain and locus of control.

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: Differential patterns of brain lesions in patients with Alzheimer's disease (AD) or vascular dementia (VaD) can result in differing clinical courses and presentations.

Method: Thirty patients with AD were compared with 29 patients with VaD for differences in behavioral symptoms using the Behavioral Pathology in Alzheimer's Disease (BEHAV-AD) rating scale.

Results: Patients with AD had significantly more delusions, hallucinations, anxieties and phobias and caregiver distress than patients with VaD.

Conclusions: Behavioral symptoms in both AD and VaD exhibit specific longitudinal patterns. An understanding of the pattern can aid the treating physician in giving appropriate advice to caregivers regarding the course of the illness and also help them in planning appropriate interventions.

Background: Assessing function is a crucial element in the diagnosis of dementia. This information is usually obtained from key informants. However, reliable informants are not always available.

Methods: A 10-item semi-structured home interview (the CHIF, or Clinician Home-based Interview to assess Function) to assess function primarily by measuring instrumental activities of daily living directly was developed and tested for inter-rater reliability and validity as part of the Indianapolis–Ibadan dementia project. The primary validity measurements were correlations between scores on the CHIF and independently gathered scores on the Blessed Dementia Scale (from informants) and the Mini-mental State Examination (MMSE). Sensitivities and specificities of scores on the CHIF and receiver operator characteristic (ROC) curves were constructed with dementia as the dependent variable.

Results: Inter-rater reliability for the CHIF was high (Pearson's correlation coefficient 0.99 in Indianapolis and 0.87 in Ibadan). Internal consistency, in both samples, was good (Cronbach's α 0.95 in Indianapolis and 0.83 in Ibadan). Scores on the CHIF correlated well with the Blessed Dementia scores at both sites (−0.71, p < 0.0001 for Indianapolis and −0.56, p < 0.0001 for Ibadan) and with the MMSE (0.75, p < 0.0001 for Indianapolis and 0.44, p < 0.0001 for Ibadan). For all items at both sites, the subjects without dementia performed significantly better than those with dementia. The area under the ROC curve for dementia diagnosis was 0.965 for Indianapolis and 0.925 for Ibadan.

Conclusion: The CHIF is a useful instrument to assess function directly in elderly participants in international studies, particularly in the absence of reliable informants.

Background: Indigenous Australians have a unique cultural heritage dating back many thousands of years. Unfortunately, there is no validated tool to assess cognition in older indigenous Australians. This study was designed to address this deficiency. The Kimberley Indigenous Cognitive Assessment (KICA) was developed with Indigenous health and aged care organizations, and comprises cognitive, informant and functional sections. The psychometric properties of the cognitive assessment section (KICA-Cog) are described in this paper.

Methods: The KICA-Cog was tested in 70 indigenous subjects, of varying cognitive abilities and diagnoses, over 45 years of age. Subjects were interviewed using the KICA-Cog and then independently assessed by expert clinical raters using DSM-IV and ICD-10 criteria. Interrater and internal reliability were determined.

Results: The KICA-Cog score showed no systematic interrater difference; the mean was −0.07 (SD = 1.83). Interrater reliability for 16 individual questions from the cognitive section revealed a κ-value ≥ 0.6 and intraclass correlations for 12 questions. Internal consistency, as assessed by Cronbach's α, was 0.88. Three items on the cognitive score (pension week, recall and free recall) effectively discriminated 85–7% of dementia cases. Sensitivity and specificity were 90.6% and 92.6%, respectively, using a cut-off score of 31/32.

Conclusions: The KICA-Cog appears to be a reliable assessment tool for cognitive impairment in an Australian older traditionally living indigenous population.

Objective: To develop an instrument that measures observable problematic behaviors in patients with dementia.

Methodology: We used focus group interviews to identify the problematic behaviors of patients with dementia. Eighty-two behaviors grouped into 12 domains were generated from the data collected from five different focus groups. After conducting a content validation process, a 72-item Dementia Behavior Disturbance Inventory (DBDI) rated by a frequency and a disturbance scale was formed. The DBDI was administered to 200 institutionalized elderly patients with dementia by formal caregivers for psychometric evaluation.

Results: Inter-item correlation of items in each domain was performed for item reduction. Forty-eight items remained after this procedure. Exploratory factor analysis obtained nine factors that explained 59.2% and 59.6% of the total variance in the frequency and disturbance scales, respectively. Cronbach's α of the entire 48-item frequency and disturbance scales was 0.88 and 0.91, respectively. Most of the factors had acceptable internal consistency reliability. Test–re-test reliability coefficients of the frequency and disturbance scales were 0.78 and 0.64, respectively. The DBDI was weakly but positively related to functions of daily activities and ambulation.

Conclusion: The DBDI demonstrates promising psychometrical properties as an instrument to assess problematic behaviors in elderly people with dementia.

Objectives: To describe and classify individual trajectories of 15-day changes in delirium severity.

Methods: A longitudinal hospital-based study was carried out with 230 medical inpatients aged 65 and over admitted to St Mary's Hospital in Montreal, Canada, between 1996 and 1999, diagnosed with delirium at enrollment, and who had at least four measurements of delirium severity during the next 15 days. Delirium severity was assessed using the Delirium Index (DI). To classify patients' individual trajectories, we applied a new method that relies on principal factor analysis and cluster analysis. We used multiple linear regression to investigate if clusters were associated with DI scores measured at an 8-week follow-up. Multivariable Cox's proportional hazards regression was used to assess whether the clusters were associated with survival over the next 12 months.

Results: Individual patterns were classified into five clusters: Steady (n = 89, 38.9%), Fluctuating (n = 36, 15.7%), Worsening (n = 15, 6.6%), Fast Improve-ment (n = 26, 11.3%), and Slow Improvement (n = 63, 27.5%). The Fast Improvement cluster had much lower prevalence of dementia (38.5% vs. 55.6% to 77.8% in other clusters, p = 0.003). Subjects whose 2-week patterns were classified as Fast or Slow Improvement had a significantly lower DI at 8 weeks than those in the Steady or Fluctuating clusters. The Worsening cluster had the largest percentage of deaths. The Fast Improvement and Worsening clusters initially had a high risk of death in the first 2 weeks (adjusted relative risks of approximately 3 and 6, respectively) but that risk decreased rapidly thereafter.

Conclusion: Two-week trajectories of delirium severity were associated with short-term mortality and delirium severity at 8-week follow-up.

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 and objectives: Cognitive screening is a “first step” in detecting dementia and other neuropsychiatric syndromes and hence represents an important public health and clinical initiative. A plethora of cognitive screening instruments has been advocated in recent years, but the extent to which these instruments are used or their effectiveness is not well known. An International Psychogeriatric Association (IPA) survey was designed to determine which cognitive screening instruments were used most frequently by clinicians with special expertise in the neuropsychiatric aspects of old age and also to determine the ones considered most useful by these specialists.

Method: Under the auspices of the IPA, the survey was mailed in the fall of 2004 to all IPA members as well as members of the American and Canadian Associations of Geriatric Psychiatry. The survey inquired about demographic information, the frequency of use of cognitive screening instruments, and the value attributed to the cognitive screening instruments. Participants also had an opportunity to provide written commentary.

Results: A total of 334 completed surveys were processed. The majority of respondents were geriatric psychiatrists (58%). Of the 20 different instruments that were listed on the survey, only six were selected as “routinely” or “often used” by the survey respondents. These instruments in declining order were: (1) the Folstein Mini-mental State Examination; (2) the Clock Drawing Test; (3) Delayed Word Recall; (4) the Verbal Fluency Test; (5) Similarities; and (6) the Trail Making Test. “Effectiveness” and “ease of administration” were the test characteristics most highly predictive of frequency of use. Open-ended comments highlighted patient factors that continue to provide challenges, including ethnicity/culture, language, education/literacy, and sensory impairment. Respondents concluded that “no single test is adequate.”

Conclusions: Psychogeriatricians worldwide routinely use a relatively small number of brief cognitive screening instruments. Further evaluation is necessary as the need increases for cognitive screening guidelines that inform public health initiatives related to dementia and neuropsychiatric syndromes.