This issue is the first of six which will comprise the journal's 21st volume. In my culture (and some others) it is conventional to celebrate 21st anniversaries, which for a long period were associated with the attainment of an entitlement to enjoy such privileges as the right to vote, to marry without parental consent and to enter into contracts. For International Psychogeriatrics our 21st anniversary represents something of a milestone for what began as a small association journal founded with two annual issues in 1989. To celebrate this achievement we have commissioned a number of commemorative pieces which will appear throughout 2009 and the journal has been completely redesigned in order to emulate the majority of academic journals which now appear in this larger A4 format instead of the quarto size used for our first 20 years. The cover has been changed to give us what I am told is a more attractive and contemporary look and the front of each issue will now feature one or more photographs representing aspects of the diverse discipline of psychogeriatrics. If you have an image which would enhance a future cover, please advise me by email (ipaj-ed@unimelb.edu.au) and we will try to use it.

Eleven authors, 29 patients and an open-label design would not generally be regarded as strong predictors of a publication's citation success, so this one (Grace et al., 2001) probably needs some explaining. I was advised early in my prospective publishing career always to look for “a gap in the market” and in 2001 this short paper probably filled a significant gap in clinical knowledge. It was almost a decade since the first reports had appeared about dementia with Lewy bodies (DLB) being a relatively common cause of dementia in older people, and by 2001 the first iteration of the consensus criteria for DLB diagnosis was starting to be widely used. Clinicians were therefore becoming more confident about recognizing DLB in their clinics, realized that cholinesterase inhibitors (ChEIs) were often useful in symptom control, and wanted to know more about their effects in the longer term. This short paper gave them some useful evidence to support their practice. The lead author, Janet Grace, who was working as my clinical lecturer, had for a couple of years been following up a group of DLB patients whom she had originally entered in an earlier placebo controlled study (McKeith et al., 2000) and was interested in charting their progress with the ready help of U.K. colleagues in Essex, Manchester, Southampton and Nottingham. Although the 21 patients who remained on treatment did show some evidence of disease progression after two years, neither their Mini-mental State Examination (MMSE) scores nor their Neuropsychiatric Inventory (NPI) scores were significantly worse than at baseline. And reassuringly their parkinsonism had not worsened, which was a common concern at that time.

Background: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to “undue influence” when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence.

Method: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence.

Results: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common “red flags” which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary.

Conclusion: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.

Background: It is well established that psychotherapy is effective in the treatment of depression in younger as well as in older adults. Whether these psychotherapies are equally effective in younger and older age groups has not been examined in meta-analytic research.

Methods: We conducted a systematic literature search and included 112 studies with 170 comparisons between a psychotherapy and a control group (with a total of 7,845 participants). Twenty studies with 26 comparisons were aimed at older adults.

Results: We found no indication that psychotherapies were more or less effective for older adults compared to younger adults. The effect sizes of both groups of comparisons did not differ significantly from each other (older adults: d = 0.74; 95% CI: 0.49~0.99; younger adults: d = 0.67; 95% CI: 0.58~0.76). In a multivariate meta-regression analysis, in which we controlled for major characteristics of the participants, the interventions and the study designs, no indication of a difference between psychotherapy in younger and older adults was found.

Conclusions: There appears to be no significant difference between psychotherapy in younger and older adults, although it is not clear whether this is also true for clinical samples, patients with more severe depression, and the older old.

Background: According to the cognitive reserve model, higher levels of education compensate for the neuropathology of Alzheimer's disease (AD), delaying its clinical manifestations. This model suggests that for any level of cognitive impairment, people with more education have worse neuropathology than those with less education and will therefore have shorter survival post-diagnosis. This is the first systematic review of the relationship between more education and decreased survival in people with AD.

Methods: We reviewed the literature systematically, searching electronic databases and reference lists of included studies. We used Centre for Evidence Based Medicine criteria for inclusion and rating of the validity of cohort studies that reported the relationship of education to survival in people with AD.

Results: 22 studies met inclusion criteria. We found Grade A evidence (highest evidence level) that more education was not associated with decreased survival post-diagnosis in AD. Only one of 11 studies rated 1b (highest level of quality) supported our hypothesis that more education predicted reduced survival after adjusting for age, gender and dementia severity; it comprised African-Caribbean participants, who had on average more severe cognitive impairment than other studies' participants.

Conclusions: Education delays the onset of the dementia syndrome in AD, but does not lead to earlier death after diagnosis.

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.

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.

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: Despite the high prevalence and morbidity of minor and subsyndromal depression in primary care elderly people, there are few data to identify those at highest risk of poor outcomes. The goal of this observational cohort study was to characterize the one-year outcomes of minor and subsyndromal depression, examining the predictive strength of a range of putative risks including clinical, functional and psychosocial variables.

Methods: Patients aged ≥ 65 years were recruited from primary care medicine and family medicine practices. Of 750 enrollees, 484 (64.5%) completed baseline and one-year follow-up assessments of depression diagnosis (major depression vs. minor and subsyndromal depression vs. non-depressed) by the Structured Clinical Interview for DSM-IV, depressive symptom severity (Hamilton Rating Scale for Depression), and validated measures of other predictors.

Results: Patients with baseline minor and subsyndromal depression were more depressed than the non-depressed group at follow-up: They had a 7.0-fold (95% CI 4.5–10.8) risk of developing major depression, and a one-year adjusted Hamilton Depression Score of 11.0 (95% CI 10.2–11.8) compared with 7.8 (95% CI 7.1–8.5) for the non-depressed group; these outcomes were less severe than those of the major depression group. Independent predictors of depression outcomes included race, psychiatric and physical functioning, and social support.

Conclusions: Minor and subsyndromal depression are likely to persist, and pose an elevated risk of worsening over one year. Clinicians and preventive interventions researchers should focus on modifiable risks, such as psychiatric functioning or social support, in elders suffering clinically significant depressive symptoms.

Background: Elderly suicides rates are associated with socio-economic status and life expectancy. Although suicide rates in younger people are associated with both higher and lower levels of educational attainment, little is known about this association in the elderly.

Method: The relationship between Human Development Index (HDI) – a composite index measuring average achievements on three basic dimensions of human development (life expectancy, educational attainment and socio-economic status) – and elderly suicide rates was examined in a cross-national study utilizing secondary data from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (inverted U-shaped curve) relationship between elderly suicide rates in males and the HDI, fitting the quadratic equation y = a + bx − cx2. A similar curvilinear relationship was observed in females, but the significance level only approached 0.05.

Conclusions: A model with four sequential stages was proposed to explain the findings: (i) low elderly suicide rate – low human development society; (ii) high elderly suicide rate – low human development society; (iii) high elderly suicide rate – high human development society; and (iv) low elderly suicide rate – high human development society.

Background: Psychotic symptoms in Alzheimer disease (AD + P) identify a heritable phenotype associated with greater cognitive impairment. Knowing when the cognitive course of AD + P subjects diverges from that of subjects without psychosis would enhance understanding of how genetic variation results in AD + P and its associated cognitive burden. This study seeks to determine whether the degree of cognitive impairment and cognitive decline in early AD predicts subsequent AD + P onset.

Methods: 361 subjects with possible or probable AD or mild cognitive impairment (MCI) without psychosis were evaluated every 6 months until psychosis onset.

Results: Severity of cognitive dysfunction was a strong predictor of AD + P up to two years prior to psychosis onset. Cognition did not decline more rapidly prior to onset of AD + P.

Conclusions: Individuals who will develop AD + P already demonstrate excess cognitive impairment during the mild stages of disease. Genetic variation and brain pathophysiology may lead to a cognitive risk phenotype which is present prior to dementia onset.

Background: The study aims to provide insight into the type of music being offered in Dutch nursing homes to patients with both dementia and verbal and vocal agitation. It also investigates the degree to which the music offered corresponds to the musical preferences of the nursing home residents.

Method: Using random sampling, 20 nursing homes were selected to participate in this study. Within these homes, semi-structured interviews were conducted with nursing home physicians (n = 17) and other nursing home care providers (n = 20). Each interview focused on up to three psychogeriatric residents with verbal and vocal agitation. In total, 51 residents were discussed in the interviews.

Results: For each resident, the frequency of music, the type of music being offered, and the degree of correspondence between the music being offered and the resident's preferences varied. In almost all cases, music was being offered in the communal living room during the mid-morning coffee and the afternoon tea, while music was only infrequently offered to residents during meals. However, this music was not tailored to the preferences of the residents. During patient-centered care activities in the early morning and before sleep, when offered, the music was generally tailored to the preferences of the resident(s).

Conclusion: Music is frequently played in nursing homes to patients with dementia who have verbal and vocal agitation. When offered to a group of residents, the music tends not to be tailored to the preferences of the residents. However, when offered individually, musical preferences are generally taken into account.

Background: The Camberwell Assessment of Need for the Elderly (CANE) is widely used for multidimensional evaluation of older people with mental health problems. The aim of this study was to evaluate reliability and validity of a Portuguese version of CANE.

Method: A cross-sectional multicenter study was designed using a convenience sample of elderly mental health services' users. CANE was compared with EASYCare, GHQ12, MMSE, Barthel Index and GDS15 to assess criterion and construct validity. Inter-rater and test-retest reliability were also assessed.

Results: 79 patients (76% female), with mean age of 74 (± 6.6) years were included. Most patients lived at home with a family caregiver, generally female. Only 32% had no carer. Dementia was the commonest psychiatric diagnosis (61%) and somatic comorbidity was very prevalent (85%). Kappa values (κ) for inter-rater item reliability ranged from 0.72 to 1.00 (mean values: 0.96 patient, 0.93 carer, 0.90 staff). The intraclass correlation coefficient (ICC) for total scores ranged from 0.95 to 0.98.

For test-retest item reliability, the mean κ value was: 0.80 patient, 0.77 carer, 0.81 staff. ICC for total scores ranged from 0.82 to 0.92. Given the absence of a gold standard, criterion validity was assessed by comparing CANE with EASYCare (rs0.460; p ≤ 0.01), GDS (rs0.615; p ≤ 0.01), GHQ (rs0.581; p ≤ 0.01) and Barthel Index (rs-0.435; p ≤ 0.01). Overall, inter-item and item-total correlations for CANE and item comparison with other measures indicated reasonable construct validity.

Conclusion: The psychometric proprieties of CANE seem to be consistently good, in accordance with other studies. Robust results on ecological, face, content, criterion and construct validity, as well as good reliability, were achieved. This version is a promising tool for research and practical use in Portuguese old age settings.

Background: In the absence of an easily applicable performance test for making valid measurements of fundamental activities of daily living (ADL) in dementia patients, this study reports the development of an ADL performance test which constitutes both a reliable and a valid measurement of the relevant autonomous areas of everyday activities for dementia patients.

Methods: The Erlangen Test of Activities of Daily Living (E-ADL-Test) consists of five items: pouring a drink, cutting a piece of bread, opening a small cupboard, washing hands and tying a bow. Each test item underwent standardized evaluation on a scale of 0 to 6. To determine retest reliability each assessment was repeated at two-weekly intervals. The Global Deterioration Scale, Mini-mental State Examination (MMSE) and Nurses' Observations Scale for Geriatric Patients (NOSGER) were used to assess construct validity. Spearman's rank correlation coefficient was applied. Forty-six patients (42 women and 4 men) with clinically diagnosed dementia, who were resident in nursing homes, took part in the validation study. Their average age was 86.

Results: The E-ADL-Test revealed good inter-individual differentiation ability, particularly in cases of moderate to severe dementia. Cronbach's α was 0.77, retest reliability 0.73. The correlation coefficients were −0.47 with GDS, 0.60 with NOSGER and 0.72 with MMSE.

Conclusions: The E-ADL-Test is a suitable performance test for measuring activities of daily living as it is easy to use, reliable, valid and well accepted.

Background: The Mini-mental State Examination (MMSE) is widely used in Japan and the U.S.A. for cognitive screening in the clinical setting and in epidemiological studies. A previous Japanese community study reported distributions of the MMSE total score very similar to that of the U.S.A.

Methods: Data were obtained from the Monongahela Valley Independent Elder's Study (MoVIES), a representative sample of community-dwelling elderly people aged 65 and older living near Pittsburgh, U.S.A., and from the Tajiri Project, with similar aims in Tajiri, Japan. We examined item-by-item distributions of the MMSE between two cohorts, comparing (1) percentage of correct answers for each item within each cohort, and (2) relative difficulty of each item measured by Item Characteristic Curve analysis (ICC), which estimates log odds of obtaining a correct answer adjusted for the remaining MMSE items, demographic variables (age, gender, education) and interactions of demographic variables and cohort.

Results: Median MMSE scores were very similar between the two samples within the same education groups. However, the relative difficulty of each item differed substantially between the two cohorts. Specifically, recall and auditory comprehension were easier for the Tajiri group, but reading comprehension and sentence construction were easier for the MoVIES group.

Conclusions: Our results reaffirm the importance of validation and examination of thresholds in each cohort to be studied when a common instrument is used as a dementia screening tool or for defining cognitive impairment.

Background: The Mini-mental State Examination (MMSE) is a globally used instrument for cognitive screening, which nevertheless has a bias with respect to education and language. The Indo-U.S. Cross National Epidemiology Study developed a modified version of MMSE, the Hindi Mental State Examination (HMSE), to counter this bias in India among rural and illiterate elderly. Thus, two parallel tests are available for screening the population. This study was conducted to explore and compare the applicability of MMSE and HMSE when scanning for cognitive impairment among urban elderly people.

Methods: The sample consisted of 40 subjects (20 illiterate and 20 literate) aged 60 years and above drawn from the urban community who met the inclusion criteria. A systematically translated Hindi version of MMSE (HVMMSE) was administered to both groups. After one month, HMSE was administered to the same groups. χ2 with Yate's correction, percentage, rank order correlation and qualitative analysis were used to analyze data.

Results: All illiterate subjects scored below the cut-off on translated HVMMSE while only four of them scored below the cut-off on HMSE. Among literate subjects, the translated HVMMSE and HMSE classified three subjects and one subject respectively as having possible cognitive impairment among urban elderlies.

Conclusion: The two instruments are not in agreement with regard to classifying elderly people as having possible cognitive impairment or not. This disagreement is more pronounced in the case of illiterate subjects. The study emphasizes the need to develop a fair cognitive screening instrument for elderly people in India.

Background: The Cognitive Abilities Screening Instrument (CASI) was designed for use in cross-cultural studies of Japanese and Japanese-American elderly in Japan and the U.S.A. The measurement equivalence in Japanese and English had not been confirmed in prior studies.

Methods: We analyzed the 40 CASI items for differential item functioning (DIF) related to test language, as well as self-reported proficiency with written Japanese, age, and educational attainment in two large epidemiologic studies of Japanese-American elderly: the Kame Project (n=1708) and the Honolulu-Asia Aging Study (HAAS; n = 3148). DIF was present if the demographic groups differed in the probability of success on an item, after controlling for their underlying cognitive functioning ability.

Results: While seven CASI items had DIF related to language of testing in Kame (registration of one item; recall of one item; similes; judgment; repeating a phrase; reading and performing a command; and following a three-step instruction), the impact of DIF on participants' scores was minimal. Mean scores for Japanese and English speakers in Kame changed by <0.1 SD after accounting for DIF related to test language. In HAAS, insufficient numbers of participants were tested in Japanese to assess DIF related to test language. In both studies, DIF related to written Japanese proficiency, age, and educational attainment had minimal impact.

Conclusions: To the extent that DIF could be assessed, the CASI appeared to meet the goal of measuring cognitive function equivalently in Japanese and English. Stratified data collection would be needed to confirm this conclusion. DIF assessment should be used in other studies with multiple language groups to confirm that measures function equivalently or, if not, form scores that account for DIF.

Background: The aim of this study is to determine whether B12 replacement would ameliorate cognitive and psychiatric symptoms in elderly subjects with dementia and low serum B12 levels.

Methods: A test group (n = 28) of nursing home residents with low serum B12 levels (<250 pg/mL) and a matched comparison group (n = 28) with normal serum B12 levels (>300 pg/mL) were evaluated by blinded raters while the test group received intramuscular (IM) B12 replacement therapy. All subjects were assessed at baseline, 8 weeks, and 16 weeks with the Dementia Rating Scale, Brief Psychiatric Rating Scale, and Geriatric Depression Scale.

Results: Although B12 replacement produced significant improvement in hematologic and metabolic parameters, it yielded no significant effect on cognitive or psychiatric variables. A few subjects evidenced notable individual treatment responses; however, these were not statistically more frequent than in the normal B12 group.

Conclusions: These results suggest that B12 replacement is unlikely to benefit cognitive or psychiatric symptoms in the vast majority of elderly dementia patients with low serum B12 levels.

Background: Several follow-up [18F]fluorodeoxy glucose (FDG)-positron emission tomography (PET) studies have been performed in patients with mild cognitive impairment, but none have examined subjects with a Clinical Dementia Rating (CDR) of 0.5. Therefore, we used FDG-PET to investigate whether baseline glucose metabolism (CMRglc) in CDR 0.5 converters to dementia showed changes consistent with early Alzheimer's disease (AD).

Methods: Based on our earlier study, which we refer to as Prevalence Study 1998, we were able to examine 14 CDR 0, 42 CDR 0.5, and 12 AD subjects with PET and follow these subjects for five years. Baseline neuropsychological and CMRglc values were compared among groups of CDR 0, CDR 0.5/converters, CDR 0.5/non-converters, and AD subjects.

Results: All CDR 0 subjects were reassessed as CDR 0 after the five-year period. For CDR 0.5 subjects, 20 had converted to AD and 22 remained as CDR 0.5. In cognitive tests, CDR 0.5/converters showed significantly deteriorated recent memory function compared with CDR 0.5/non-converters at the baseline evaluation. Most brain areas showed decreased CMRglc in AD patients. CDR 0.5/converters had a significantly lower baseline CMRglc in the right cingulate, left inferior parietal and left temporal gyrus compared with CDR 0.5/non-converters.

Conclusions: Our findings suggest that CDR 0.5/converters have a baseline metabolic decline in areas that might be specific to AD.

Background: Pain poses a major problem in older adults, specifically for those living in homes for the elderly. Previous research indicates that the presence of pain may be associated with changes in cognitive functions. It is unclear, however, how the reported experience of pain relates to cognitive functioning in elderly people with chronic pain. The present study was intended to examine the relationship between clinical pain experience and neuropsychological status in residents of homes for the elderly.

Methods: Forty-one residents suffering from arthritis or arthrosis completed tests measuring memory, processing speed, and executive function. The sensory-discriminative and the affective-motivational aspects of clinical pain were measured.

Results: Performance on executive function tests was positively related to self-reported pain experience. No relationship was observed between pain and memory or processing speed performance.

Conclusion: The present study shows that executive functioning is related to the severity of subjectively reported pain. Possible explanations for this association are discussed.