This paper presents a strategy for training primary care physicians in the identification, diagnosis and management of Alzheimer's disease and related disorders. The strategy uses evidence-based practice guidelines to establish quality benchmarks and then provides training and other interventions to improve the quality of care received by these patients. The three projects described in this paper assumed that training of primary care physicians alone would not be sufficient to achieve the quality benchmarks derived from guidelines. The projects used creative training strategies supplemented by provider “tool kits”, provider checklists, educational detailing, and endorsement from organizational leadership to reinforce what the primary care providers learned in educational sessions. Each project also implemented a system of dementia care management to “wrap around” traditional primary care to ensure that quality benchmarks would be achieved. Outcomes of two completed studies support the premise that it is possible to improve quality of dementia care through physician education that occurs in association with a coordinated system of dementia care management and in collaboration with community agencies to access guideline-recommended social services.

Objective: To provide a systematic review of selected experimental studies of psychosocial treatments of behavioral disturbances in dementia. Psychosocial treatments are defined here as strategies derived from one of three psychologically oriented paradigms (learning theory, unmet needs and altered stress thresholds).

Method: English language reports published or in press by December 2006 were identified by means of database searches, checks of previous reviews and contact with recognized experts. Papers were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

Results: Only 25 of 118 relevant studies met every specification. Treatment proved more effective than an attention control condition in reducing behavioral symptoms in only 11 of the 25 studies. Effect sizes were mostly small or moderate. Treatments with moderate or large effect sizes included aromatherapy, ability-focused carer education, bed baths, preferred music and muscle relaxation training.

Conclusions: Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were mostly small to moderate with a short duration of action. This limited action means that treatments will work best in specific, time-limited situations. In the few studies that addressed within-group differences, there were marked variations in response. Some participants benefited greatly from a treatment, while others did not. Interventions proved more effective when tailored to individuals' preferences.

Background: Carers who wished to share their experiences with a national working group (the Consumer Group) prepared narratives as a way of identifying areas for discussion.

Methods: The narratives were submitted to one author and subjected to thematic qualitative analysis. The themes were fed back to the Group for discussion.

Results: Five main themes were identified: difficulties in obtaining a diagnosis; acting as an advocate; stresses of caring; practical problems with social care; and emotions experienced by carers.

Conclusions: The narratives provided a means of sharing carers' experiences and creating initiatives for further action by the Group. They have an impact on the people who hear or read them but may also be therapeutic for those who produce them. Narratives can also be a powerful tool in teaching and training, and in identifying areas for service and professional improvement.

The majority of people with dementia develop behavioral and psychological symptoms of dementia (BPSD) at some point during their illness (Jeste et al., 2008). These symptoms, which are especially common among care home residents, are frequently distressing for the patients who experience them (Gilley et al., 2006; Jeste et al., 2008) and problematic for their professional and/or family caregivers. The starting point for our paper “Quality of life for people with dementia living in residential and nursing home care: the impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs” (Ballard et al., 2001) was to try and understand the impact of BPSD, function and language skills on quality of life in care home residents with dementia. Although there were frequent statements in previous work referring to the capacity of psychiatric and behavioral symptoms to reduce quality of life, we had been unable to identify any empirical evidence to support this clinical impression in a thorough literature review. The parallel validation of Dementia Care Mapping (DCM), predominantly a practice development tool, as an observational measure of well-being/quality of life (Kitwood and Bredin, 1997; Fossey et al., 2002) provided an excellent opportunity to examine this issue in a care home setting. The study focused on 209 people with dementia living in residential and nursing home care in north-east England in the U.K., who received a detailed assessment of BPSD, function and cognition. A DCM evaluation was completed for 112 of these individuals, providing a detailed observational measure of well-being, activities and social withdrawal as indices of quality of life over a six-hour daytime period. To our surprise, there was actually no association between well-being, social withdrawal or activities and BPSD. In contrast, there was a significant association between antipsychotic medication and reduced well-being, social withdrawal and activities respectively, even after controlling for the severity of behavioral disturbance. Using an arbitrary definition of “ill-being”, defined as a well-being score of less than zero, 5% of people not taking antipsychotics, 10% of people taking atypical antipsychotics and 22% of people taking typical antipsychotics were defined as having ill-being. Lower levels of functional ability were also associated with significantly lower well-being, less activities and more social withdrawal. At first this latter finding appears to be contrary to one of the central principles of DCM – namely, that the assessment should be independent of dementia severity. Although high levels of well-being and engagement are possible for people with severe dementia, this probably requires higher staff numbers and a workforce with more specialized skills in order to achieve this.

We were delighted, but surprised, by the publication success of our first pilot trial on the efficacy of repetitive transcranial magnetic stimulation (rTMS) to treat late life depression (LLD) (Manes et al., 2001). This preliminary study had major limitations – for example, the small sample size and the use of both a non-therapeutic dose of rTMS and a defective method of sham stimulation. However, it addressed an important clinical problem for which we still do not have a satisfactory solution: how do we treat LLD that has been resistant to the usual therapeutic approaches in a safe and efficient way?

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.

Background: There is no consensus on the monitoring for rare but potentially serious cardiac adverse events associated with cholinesterase inhibitor drugs in the treatment of dementia. Different protocols have been proposed, with and without ECG examination. We surveyed an urban old age psychiatry service to investigate the variables that may influence the implementation of such protocols.

Methods: Case notes of 45 consecutive patients assessed for dementia were scrutinized, to establish how many underwent an ECG or other cardiac examination prior to drug treatments. Data were collected on demographics, medical conditions and drug treatments. Patient files were searched for indications of investigations and any outcomes.

Results: Half of all patients treated with a cholinesterase inhibitor (11/22) had an ECG before treatment. In five cases no pulse or cardiac symptoms were recorded in the absence of an ECG. Medical history, findings on examination, seniority of the clinician, and patient cooperation all may have influenced whether patients had an ECG. In three cases treatment was not prescribed due to concerns over cardiac effects, and with five ECGs new diagnoses were made. A protocol based on pulse monitoring would only have indicated ECGs in two out of 22 cases.

Conclusions: Several factors may influence decisions on cardiac monitoring. Fewer ECGs could be done if only pulse and cardiac symptoms were monitored before cholinesterase inhibitor prescription, but new cardiac diagnoses might then be missed. Protocols can be devised to incorporate both cardiac investigation and cholinesterase inhibitor monitoring.

Background: Filipino home care workers provide the majority of around-the-clock personal care to frail individuals in Israel. To date, the working conditions as well as exposure to work-related abuse of Filipino home care workers in Israel have not been evaluated.

Methods: A survey of 245 Filipino home care workers was conducted to evaluate their working conditions and exposure to abuse as well as their clinical correlates (e.g. burnout as measures by the Maslach Burnout Inventory). This was integrated with findings from interviews with Filipino home care workers, social workers, and family members of care recipients cared by Filipino home care workers.

Results: A majority of the workers (88%) reported paying large amounts of money in order to work in the country. Overall, 43% reported being asked to do more than was specified in their job description, 41% reported being verbally abused, and 40% reported not receiving adequate food. Almost half reported work-related injuries. The most consistent predictor of burnout (as measured by the Emotional Exhaustion and Depersonalization scales) was exposure to work-related abuse. Interview data identified system and societal barriers that prevent workers from using the legal system for their protection.

Conclusions: The present study calls for further supervision of this caregiving arrangement. Psychoeducational programs directed towards all stakeholders (e.g. social workers, home care workers, care recipients, and family members of care recipients) are needed.

Dementia has been identified as a national health priority in Australia. National programs in the areas of research, education and training have been established. The Dementia Care Skills for Aged Care Workers program is a three-year project that commenced in 2006. It has the goal of providing training in the essentials of dementia care to 17,000 staff of aged care services across Australia. Successful completion of the training results in the award of a nationally recognized qualification. Although the delivery of the training has been difficult in some areas – because of the long distances to be covered by trainers and trainees, a wide range of cultural backgrounds, and difficulties in finding staff to cover for people attending the training – the seven training organizations providing this training are on target to meet the goal. The project is being evaluated independently. The anecdotal reports available to date strongly suggest that the training is being well received and is making a difference to practice.

A surprisingly large proportion of attendees (9%) have been registered nurses, which demonstrates the need among this group of staff for training in the care of people with dementia.

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: This paper provides a systematic review of selected experimental studies of the effectiveness of psychosocial treatments in reducing psychological symptoms in dementia (e.g. anxiety, depression, irritability and social withdrawal).

Method: English language reports published or in press by February 2008 were identified by means of database searches and checks of previous reviews. Reports were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

Results: Only 12 of 48 relevant papers met every specification. Treatments proved more effective in reducing psychological symptoms than an attention control condition or another treatment in only six of the 12 selected studies. Interventions with moderate effect sizes included music and recreation therapy.

Conclusions: Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were generally modest with an unknown duration of action. This limited efficacy suggests that treatments will work best in specific, time-limited situations, tailored to individuals' requirements. There is no preferred method to rate psychological symptoms.

The behavioral and psychological symptoms of dementia (BPSD) are common and serious problems that affect the quality of life of the patients who experience such symptoms as well as their caregivers (Matsui et al., 2006). BPSD present a major challenge in the medical management of cognitively impaired patients. Our paper entitled “Behavioral disorders and caregivers’ reaction in Taiwanese patients with Alzheimer's disease” (hereafter referred to as the “paper”) (Fuh et al., 2001) has been cited widely, reflecting the importance of these clinical issues and the growing international interest in studies of BPSD.

Background: We aimed to investigate factors enabling older people with cognitive impairment to age successfully.

Methods: We used the 12-item Short Form Health Survey to measure health-related quality of life (HR-QoL) in 2,007 people aged ≥60 in the 2000 British National Psychiatric Morbidity Survey. We tested the hypothesis that affective symptoms and social support mediated the relationship between cognitive functioning and poorer HR-QoL.

Results: The mean age of the participants was 66.2 (66.0–66.4). The majority of people with suspected dementia reported high mental health-related quality of life, suggesting they may not be distressed by, or aware of, cognitive and mental impairment, and the majority are aging “successfully.” The relationship between cognitive impairment and mental HR-QoL was mediated by affective symptoms, but not by social support. After considering mediators and confounders, HR-QoL was no longer associated with cognitive impairment.

Conclusions: The lower quality of life previously reported by people with cognitive impairment is due to the greater physical and mental health problems in this population, rather than to cognitive impairment per se. Active management of mental and physical health may improve the HR-QoL of those with cognitive impairment who are not ageing successfully.

Background: A careful characterization of behavioral abnormalities in corticobasal degeneration syndrome (CBDS) and progressive supranuclear palsy (PSP) by reliable tools is still lacking. Literature data provided evidence of the usefulness of the Frontal Behavioral Inventory (FBI) to operationalize such disturbances, particularly in the frontotemporal lobar degeneration spectrum. The study aimed to evaluate the frequency and pattern of presentation of behavioral disturbances in a large sample of CBDS and PSP patients by FBI.

Methods: Sixty-eight CBDS and 57 PSP patients entered the study and underwent a standardized clinical and neuropsychological battery, and a structural brain imaging study. Behavioral disturbances were carefully analyzed by FBI.

Results: FBI scores were relatively low in both groups, being 6.7 ± 8.2 and 5.6 ± 6.1 in CBDS and PSP, respectively. Comparison of the behavioral profile between CBDS and PSP patients showed significant differences in apathy were more frequent in the latter (57.9% vs. 33.8%, P = 0.007), and the presence of alien hand/apraxia more frequent in the former group 39.7% vs. 10.5%, P = 0.001). Apathy correlated neither with age nor with motor disturbances as measured by UPDRS-III. Overall, the most frequent behavioral abnormalities present in both groups (>25%) were aspontaneity and logopenia. Aphasia (27.9%) and irritability (35.3%) were more frequent in CBDS compared to PSP, even if not statistically different.

Discussion: The present study has provided measures of behavioral disturbances in a population of PSP and CBDS patients, and further confirms the usefulness of the FBI scale.

Background: Attrition from mortality is common in longitudinal studies of the elderly. Ignoring the resulting non-response or missing data can bias study results.

Methods: 1260 elderly participants underwent biennial follow-up assessments over 10 years. Many missed one or more assessments over this period. We compared three statistical models to evaluate the impact of missing data on an analysis of depressive symptoms over time. The first analytic model (generalized mixed model) treated non-response as data missing at random. The other two models used shared parameter methods; each had different specifications for dropout but both jointly modeled both outcome and dropout through a common random effect.

Results: The presence of depressive symptoms was associated with being female, having less education, functional impairment, using more prescription drugs, and taking antidepressant drugs. In all three models, the same variables were significantly associated with depression and in the same direction. However, the strength of the associations differed widely between the generalized mixed model and the shared parameter models. Although the two shared parameter models had different assumptions about the dropout process, they yielded similar estimates for the outcome. One model fitted the data better, and the other was computationally faster.

Conclusions: Dropout does not occur randomly in longitudinal studies of the elderly. Thus, simply ignoring it can yield biased results. Shared parameter models are a powerful, flexible, and easily implemented tool for analyzing longitudinal data while minimizing bias due to nonrandom attrition.

Background: This exploratory study examines factors associated with isolation from informal social ties among geriatric psychiatry inpatients. Specifically, it examines the associations of diagnoses, psychiatric history, and measures of current functioning with social isolation.

Methods: Analyses rely upon data derived from the Resident Assessment Instrument – Mental Health (RAI-MH), which is a patient focused, multidimensional, comprehensive assessment instrument designed to be a component of a larger, integrated health information system linking mental health with home care, long-term care, acute care, rehabilitation, and palliative care.

Results: Controlling for age, multivariate results show that being married or widowed was associated with a lower odds of being isolated. Mood disorders were also associated with a lower odds of isolation, while a history of a personality disorder and a personal biography of institutionalization were both clearly associated with an increased odds for isolation. Although significant bivariate predictors in the multivariate model, both schizophrenic and organic diagnoses failed to reach statistical significance. In addition, patients hospitalized at an earlier age and/or predicted to have a longer stay on the current admission were much less likely to have contact with informal supports. Of the study variables indexing functional status, only activities of daily living (ADLs) remained a significant predictor for isolation in the final multivariate model.

Conclusions: The analyses demonstrate the detrimental effects of an earlier life experience with mental illness. Having an earlier age of illness onset may lead to a potentially greater impairment in establishing and maintaining informal social ties throughout the life course into older age. These analyses reinforce the need for comprehensive assessment of patients on admission and over time.

Background: When a person has dementia, non-cognitive behaviors and symptoms might constitute a greater problem than the cognitive decline itself. Male or female sex might be a predisposing factor for certain types of behavior disturbances and symptoms. The aim of the present analysis was to explore the correlation between sex and the prevalence of behavioral and psychological symptoms of dementia.

Method: A total of 3395 people with cognitive impairment (1056 men and 2339 women) were selected from two large cross-sectional surveys of those in geriatric care settings, conducted in 1982 and 2000 in the county of Västerbotten, Sweden. Symptoms were assessed using the Multi-Dimensional Dementia Assessment Scale (MDDAS), and prevalence was compared using multivariate logistic regression. Drug data were obtained from prescription records.

Results: For 17 out of 39 behaviors and symptoms, the prevalence differed significantly between men and women. Men more often exhibited aggressive behavior and regressive behaviors, and women more often exhibited depressive symptoms. There were no sex differences for passiveness and hallucinations. The prevalence of antipsychotic drug use was higher among men (35.5% compared to 28.9%, p < 0.001) and antidepressant drug use higher among women (30.1% compared to 25.6%, p = 0.006). The prevalence of use of anxiolytics, hypnotics and sedatives did not differ.

Conclusion: There are some differences in the prevalence of behavioral and psychological symptoms of dementia between men and women. These different symptom profiles might possibly explain some of the differences found in the pharmacological treatment of men and women with a dementia disorder.

Background: There is large cross-national variation in the characteristics of small, domestic-style care settings which emphasize normalized living. However, a systematic overview of existing types is lacking. This study provides an international comparison of the care concepts which have adopted a homelike philosophy in a small-scale context. Insight into their characteristics is vital for theory, planning and implementation of such dementia care settings.

Method: A literature search was performed using various electronic databases, including PubMed, Medline, CINAHL and PsycINFO. In addition, “gray” literature was identified on the internet. Concepts were analyzed according to five main characteristics: physical setting, number of residents, residents' characteristics, domestic characteristics and care concept.

Results: 75 papers were included covering 11 different concept types in various countries. Similarities among concepts reflected a focus on meaningful activities centered around the daily household. Staff have integrated tasks and are part of the household, and archetypical home-style features, such as kitchens, are incorporated in the buildings. Differences among concepts were found mainly in the physical settings, numbers of residents and residents' characteristics. Some concepts have become regular dementia care settings, while others are smaller initiatives.

Conclusion: The care concepts are implemented in various ways with a changing staff role. However, many aspects of these small, homelike facilities remain unclear. Future research is needed, focusing on residents' characteristics, family, staff and costs.