Let me begin with a declaration of disinterest. The esteemed editor of International Psychogeriatrics commissioned this article after reading my letter to Another Journal (Philpot, 2003) in which I called for a moratorium on all clock-drawing test (CDT) research. It seemed to me that an awful lot of effort was being put into a fairly trivial issue and that researchers' time might be better spent. That much effort is being expended cannot be denied. Using the search words ‘clock drawing’, MEDLINE currently lists 177 publications, 91 since the turn of the century. The first reference to this specific form of drawing test comes in 1983 (Goodglass and Kaplan), and the first paper on validation is that of Shulman et al. (1986).

Few of our regular readers will fail to note the bold new cover of this issue of International Psychogeriatrics or the subtle changes in internal layout. We have changed publishers and the journal is now produced by Cambridge University Press, of Cambridge UK, an independent academic publisher of high repute and venerable traditions which operates under a unique University of Cambridge charter. We have joined a stable of 170 academic journals whose flagship psychiatric journal (Psychological Medicine) is one of the most respected in the world.

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.

The last two decades have seen psychogeriatrics transforming into a fast-moving, science-led specialty. This is particularly so in the field of dementia, spurred on as it so often is, by the findings of high-tech neuroimaging and molecular pathology. Clinicians are required in their daily practice not just to make the traditional diagnostic distinctions between dementia, delirium, pseudodementia and “normal aging,” but are expected in this new world also to recognize a series of different dementia subtypes, including Alzheimer's disease (AD), cognitive vascular impairment (CVI), dementia with Lewy bodies (DLB), fronto-temporal dementia (FTD) and prion disease. The list could go on and on (and sometimes does). We also know from autopsy studies that mixed pathology dementia cases are common and that our clinical diagnoses should take this into account.

There has been longstanding interest in the relationship of depression to vascular disease and this has received renewed interest since the publication of the “vascular depression” hypothesis by Alexopoulos and colleagues (Alexopoulos et al., 1997). They proposed that cerebrovascular disease (CVD) predisposed, precipitated or perpetuated late-life depression by its impact on frontal-subcortical circuits (FSC). However, whilst several lines of research strongly support this proposal, we still have no useful working criteria for vascular depression, assuming such a nosological entity exists.

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.

Objectives: Older people commonly present with memory loss although on assessment are not found to have a full dementia complex. Previous studies have suggested however that people with subjective and objective cognitive loss are at higher risk of dementia. We aimed to determine from the literature the rate of conversion from mild cognitive impairment to dementia.

Methods: Systematic review of MedLine, PsychLit and EmBase.

Results: We identified 19 longitudinal studies published between 1991 and 2001 that addressed conversion of mild cognitive impairment to dementia. Overall the rate of conversion was 10% but with large differences between studies. The single biggest variable accounting for between study heterogeneity was source of subjects, with self-selected clinic attenders having the highest conversion rate. The most important factor accounting for heterogeneity within studies was cognitive testing, with poor performance predicting conversion with a high degree of accuracy.

Conclusions: These data strongly support the notion that subjective and objective evidence of cognitive decline is not normal and predicts conversion to dementia. The more stringent the measures of both variables the better the prediction of conversion. Mild cognitive impairment, appropriately diagnosed, is a good measure with which to select subjects for disease modification studies.

The Luigi Amaducci memorial award was instituted to commemorate the distinguished Florentine neurologist, Luigi Amaducci, who was still at the forefront of research on Alzheimer's disease at the time of his premature death. It honors a living researcher whose work in neuroscience has contributed to notable advances which have led to greater understanding of therapeutics or diagnostic criteria for neurodegenerative disorders. The award is possible because of an unrestricted grant from Novartis Pharma and is awarded every two years.

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.

As chairman of the International Psychogeriatric Association (IPA)'s Research Awards Committee, it is a pleasure and an honor for me to introduce the winners of the IPA's Eighth Biannual Research Awards in Psychogeriatrics competition. These awards are given for the best submitted research in psychogeriatrics. For the 2003 research awards competition, there were 25 submissions from 15 nations on five continents.

Background and Objective: A review of current literature was undertaken in order to summarize some of the possible biopsychosocial contributions to the development of aggressive behavior in elderly people with dementia. It was intended that such a summary would provide a useful clinical aid when assessing patients with behavioral symptoms and a starting point for undertaking research in this area.

Method: Information was gathered from literature searches conducted on several occasions between 1995 and 2001 using 3 databases (Medline, CINHAL and PsycINFO), as well as journals and books available from the libraries of the authors and from Monash University, Melbourne, Australia.

Results: Associations between various conditions and the development of aggressive behavior were found, including the contributions of degrees of cognitive impairment, personality, sensory change, physical illness, language impairment, brain pathology, affective and psychotic disorders. The role of gender, sexuality and disruption of circadian rhythms is also discussed, as is the importance of environmental factors.

Conclusion: Identification of correlates of aggressive behavior may assist clinicians to understand and manage aggressive behavior more effectively.

Senile dementia was the third most common admission diagnosis for New York psychiatric hospitals at the start of the twentieth century and the distinction between vascular and senile dementia was understood by psychiatrists even then. The term Alzheimer's disease (AD) was originally introduced to distinguish a pre-senile dementia from the common general paresis, but Alzheimer raised the possibility that pre-senile AD might not be distinguishable in clinical or histological terms from senile dementia. By the late 1970s it had become clear that the most common disorder producing dementia in elderly people was clinically and pathologically identical to pre-senile AD. AD is malignant, reducing remaining life expectancy by almost half and raising the risk of death over five years threefold (cancer raises it fourfold). Synapse loss associated with beta amyloid oligomers is a strong determinant of cognitive decline in patients with AD. Tau-containing neurofibrillary tangles usefully track disease severity. Unmodifiable risk factors include mutations in three genes which affect the production or metabolism of beta amyloid, the risk factor gene for Apolipoprotein $\epsilon$4 and female gender. The overriding risk factor is age, the prevalence of AD doubling with every five years of age until 90. Low education, head injury and low folate levels are examples of potentially modifiable risk factors. Since a delay of onset of five years would halve the number of patients with the disease, clinical trials for such putative protective factors as estrogens, folic acid, vitamin E, statins, and NSAIDs have begun. Cognitive and leisure activity may be protective against the development of AD but any protective function can only be confirmed by clinical trials.

Objective: To develop and validate a simple method for detecting dementia that is valid across cultures, portable and easily administered by primary health care clinicians.

Design: Culture and Health Advisory Groups were used in Stage 1 to develop culturally fair cognitive items. In Stage 2, clinical testing of 42 items was conducted in a multicultural sample of consecutive new referrals to the geriatric medicine outpatient clinic at Liverpool Hospital, Sydney, Australia (n=166). In Stage 3, the predictive accuracy of items was assessed in a random sample of community-dwelling elderly persons stratified by language background and cognitive diagnosis and matched for sex and age (n=90).

Measurements: A research psychologist administered all cognitive items, using interpreters when needed. Each patient was comprehensively assessed by one of three geriatricians, who ordered relevant investigations, and implemented a standardized assessment of cognitive domains. The geriatricians also collected demographic information, and administered other functional and cognitive measures. DSM-IV criteria were used to assign cognitive diagnoses. Item validity and weights were assessed using frequency and logistic regression analyses. Receiver-operating characteristic (ROC) curve analysis was used to determine overall predictive accuracy of the RUDAS and the best cut-point for detecting cognitive impairment.

Results: The 6-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, drawing and body orientation. It appears not to be affected by gender, years of education, differential performance factors and preferred language. The area under the ROC curve for the RUDAS was 0.94 (95% CI 0.87–0.98). At a cut-point of 23 (maximum score of 30), sensitivity and specificity were 89% and 98%, respectively. Inter-rater (0.99) and test-retest (0.98) reliabilities were very high.

Conclusions: The 6-item RUDAS is portable and tests multiple cognitive domains. It is easily interpreted to other languages, and appears to be culturally fair. However, further validation is needed in other settings, and in longitudinal studies to determine its sensitivity to change in cognitive function over time.

Background and aims: The IQCODE is widely used as a screening test for dementia, particularly where the subject is unable to undergo direct cognitive testing or for screening in populations with low levels of education and literacy. This review draws together research on the psychometric properties and validity of the IQCODE.

Method: A systematic search of the literature was carried out using three databases.

Results: The review shows that the questionnaire has high reliability and measures a single general factor of cognitive decline. It validly reflects past cognitive decline, performs at least as well at screening as conventional cognitive screening tests, predicts incident dementia, and correlates with a wide range of cognitive tests. A particular strength is that the IQCODE is relatively unaffected by education and pre-morbid ability or by proficiency in the culture's dominant language. The disadvantage of the IQCODE is that it is affected by informant characteristics such as depression and anxiety in the informant and the quality of the relationship between the informant and the subject.

Conclusions: Because the IQCODE provides information complementary to brief cognitive tests, harnessing them together can improve screening accuracy.

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.

Objective: To assess the reliability and validity of a brief measure of quality of life recently developed by the World Health Organization, the WHOQOL-BREF, and to examine its association with a variety of clinical and sociodemographic factors in older depressed patients.

Design: Cross-sectional study.

Methods: Older depressed patients (N=41) underwent diagnostic assessment using the Composite International Diagnostic Interview (CIDI) and were independently assessed on a variety of measures including the WHOQOL-BREF (a 26-item self-report questionnaire generating four domain scores), Hamilton Depression Rating Scale (HAM-D); Geriatric Depression Scale (GDS); Mini-mental State Examination (MMSE); Modified Barthel Index (MBI); Instrumental activities of daily living (IADL), and measures of physical health status and social relationships. Estimates of inter-rater and test-retest reliability, and concurrent validity were made.

Results: 39 subjects completed the study. The majority of subjects (94.9%) received a diagnosis of DSM-IV Major Depressive Disorder. Levels of comorbidity were high. Three of the four domains of the WHOQOL-BREF (Physical, Psychological and Environment domains) demonstrated satisfactory reliability and validity. However, the Social Relationships domain exhibited poor validity. Quality of life scores were strongly correlated with severity of depression, number of self-reported physical symptoms and self-assessed general health status. There was no relationship between diagnostic comorbidity and quality of life scores.

Conclusions: The WHOQOL-BREF was successfully administered to older depressed patients although the concurrent validity of one of its four domains was poor. Quality of life scores were strongly correlated with severity of depression, raising the issue of measurement redundancy.

Objective: To investigate the risk factors for delirium in the elderly during the post-operative period of coronary artery bypass graft surgery (CABG).

Methods: A total of 220 inpatients submitted to CABG were evaluated prior to and after surgery. In order to investigate the possible risk factors, data were collected from pre-intra- and post-operative periods.

Instruments: The patients were assessed using the Mini-mental State Examination and to the Geriatric Depression Scale. The diagnosis of delirium was determined according to DSM-IV criteria.

Results: Delirium was detected in 74 (33.6%) patients. Increasing age, blood urea level, cardio-thoracic index, hypertension, smoking habits, blood replacement during bypass, atrial fibrillation (AF), pneumonia and blood balance in the post-operative period were the risk factors for delirium selected by the logistic regression analysis. No specific factor associated with the CABG (perfusion pressure, number of grafts) was correlated with an increased risk for delirium post-operatively. The length of stay was twice as long in the delirious group (p<0,001).

Conclusions: Delirium in the elderly after CABG is a multifactorial disorder. Nine factors taken together can identify patients at great risk for delirium. No specific factor associated with bypass procedure could be identified as a risk factor for delirium. The control of the risk factors should bring a decrease in delirium morbidity and mortality.

Background: To date, no firm conclusions can be reached regarding the effectiveness of reminiscence for dementia. Researchers have emphasized that there is an urgent need for more systematic research in the area.

Objective and Method: A single-blinded, parallel-groups (one intervention, one comparison, and one no-intervention group) randomized controlled trial (RCT) was adopted to investigate whether a specific reminiscence program leads to higher levels of psychosocial well-being in nursing home residents with dementia. The intervention adopted a life-story approach, while the comparison group provided friendly discussions to control for any changes in outcome as a result of social contacts and attention. The Social Engagement Scale (SES) and Well-being/Ill-being Scale (WIB) were the outcome measures used. The outcomes of the groups were examined with reference to the baseline (T0), immediately (T1), and six weeks (T2) after intervention. The final sample had 101 subjects (control group: n=30; comparison group: n=35; intervention group: n=36). Using multivariate analysis with repeated measures, no significant differences in outcome were found between groups at either T1 or T2. Wilcoxon signed rank tests were performed for each group comparing outcomes between T1 and T0, T2 and T1, and T2 and T0. Significant differences were observed in the intervention group when comparing T1 and T0 WIB (p=.014), but not for the other groups.

Conclusion: Although the intervention did not lead to significant differences between the three groups over time, there was a significant improvement in psychosocial well-being for the intervention group.

Background: Several reports have indicated that the Behavioral and Psychological Symptoms of Dementia (BPSD) are associated with increased burden of care, carer depression and increased rates of institutionalization of patients. The present study aims to review the association between these variables in cross-sectional as well as longitudinal studies.

Methods: Systematic review and meta-analysis of all available information published in English between January 1990 and December 2001 was made. Case-reports, case-series and studies with 20 or fewer subjects were excluded from the analyses.

Results: Thirty articles are included in the review of cross-sectional data and 12 in the systematic review of longitudinal data. Pooled correlation coefficients were generated for the relationship between BPSD and caregiver burden (rpooled=0.57; 95% CI=0.52 to 0.62), caregiver psychological distress (rpooled=0.41; 95% CI=0.32 to 0.49) and caregiver depression (rpooled=0.30; 95% CI=0.21 to 0.39), suggesting that these concepts have a moderately strong association. Multivariate data, on the whole, further supported the notion that BPSD are a predictor of burden of care and of psychological distress and depression. Limited longitudinal data made clarifying the temporal relationahip between BPSD and the psychological sequelae of care (PSC) difficult. The limited data pertaining to the relationship between BPSD and institutionalization suggest that caregiver variables may be more important in predicting institutionalization than BPSD. Methodological issues and limitations associated with this type of investigation were also considered.

Conclusion: The results of this review support, but do not conclusively establish, the association between BPSD and PSC. We propose that the concept of burden of care be abandoned in favor of more clinically relevant outcomes such as caregiver depression.

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.