Over the past twenty years, qualitative research has gained recognition as a useful approach to scientific inquiry on issues related to health and health care, including those of particular interest to psychogeriatrics. This is evidenced not only by the inclusion of health-related qualitative reports in exclusively qualitative publications but also by their acceptance in venues that have traditionally favored quantitative methods of investigation (Sandelowski, 2004). The increased number of these reports has also led in recent years to systematic reviews of qualitative studies and qualitative metasyntheses, metaethnography or meta-analyses (Nygard, 2004;Smith et al., 2005; Steeman et al., 2006).

Background: Caregiving for people with dementia has consistently been linked with psychological problems, usually in terms of caregiver burden, general psychological distress and depressive symptomatology, while morbidity due to anxiety has been relatively neglected in this group.

Methods: We conducted a systematic review of the literature, searching electronic databases, reference lists, relevant systematic reviews and contacting experts in the field. We used Centre for Evidence Based Medicine (CEBM) criteria for inclusion and rating the validity of all studies that reported (1) the prevalence, predictors and covariates of anxiety disorders or anxiety caseness, and (2) covariates and predictors of the level of anxiety symptoms.

Results: Thirty-three studies met our inclusion criteria. Clinically, significant anxiety affects about a quarter of caregivers for people with dementia and was more common than in matched controls. Such caregivers have higher anxiety levels than controls, and that confrontative and escape avoidance coping, caregiver burden and poorer caregiver physical health are factors associated with higher anxiety levels from cross-sectional studies.

Conclusions: Coping style may be more associated with anxiety than depression while other covariates (burden and poor physical health) are similar to those for caregiver depression. We found no conclusive evidence about factors associated with anxiety disorders or predicting anxiety from longitudinal studies. Neither care recipient cognition nor ADL impairment; nor caregiver age nor duration of caring are associated with caregiver anxiety levels. Good quality cohort studies are needed to determine whether these factors also predict anxiety disorders.

Background: The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery.

Methods: Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias.

Results: 26 publications reported an incidence of postoperative delirium of 4–53.3% in hip fracture samples and 3.6–28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6–28.8] vs. 12.1% [95% CI = 9.6–14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7–34.7] vs. 8.8% [95% CI = 4.1–13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%.

Conclusions: Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

Background: Evidence suggests an association between congestive heart failure (CHF) and cognitive function, particularly in heart transplant patients and patients hospitalized for CHF. We examined the association between CHF and cognitive performance in stable outpatients recruited from primary care.

Methods: This is a cross-sectional secondary data analysis of the Steel Valley Seniors Survey, an epidemiological study of elderly primary care outpatients. Participants aged ≥ 65 years were recruited in primary care clinics. The study cohort (n = 354) is a subgroup, composed of subjects with Mini-mental State Examination score < 25, and a random sample of the remaining, who underwent a baseline assessment in the home. The assessment included demographics, comorbid illnesses, depressive symptoms, functional status, a neurological examination and a neuropsychological battery. CHF is defined by self-report and/or chart review, and stable CHF as not being hospitalized in the year prior to the assessment. The associations between CHF and specific cognitive tests were examined by bivariate analysis and logistic regression, controlling for demographic variables.

Results: Subjects with CHF performed worse on tests of visual memory [10.1 (S.D. 5.4) vs. 12.7 (S.D. 5.2), p = 0.007], Trailmaking B [0.1 (0.1) vs. 0.2 (0.1), p = 0.002], category fluency [11.1 (4.4) vs. 13.4 (4.5), p = 0.008], and clock drawing [5.6 (1.9) vs. 6.7 (1.4), p < 0.001] compared to subjects without CHF, after adjustment for relevant demographic variables.

Conclusion: CHF is associated with lower cognitive functioning in a population of patients with stable heart failure in primary care settings.

Objectives: To examine the effect of risperidone on specific behavioral and psychological symptoms of dementia (BPSD) among patients with psychosis of Alzheimer's disease (AD).

Methods: Post hoc exploratory analysis of data on 479 nursing-home patients with psychosis of AD from three 12-week, double-blind, placebo-controlled clinical trials. Criteria for psychosis of AD were a diagnosis of AD or mixed dementia and a rating of ≥ 2 on any delusion or hallucination item of the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale when entering the trial. Mean changes from baseline to endpoint were examined for items on the Cohen-Mansfield Agitation Inventory (CMAI) and BEHAVE- AD.

Results: On the CMAI, risperidone was significantly more effective than placebo in treating cursing or verbal aggression (p = 0.004), hitting (p < 0.001), performing repetitious mannerisms (p < 0.001), pacing, aimless wandering (p = 0.017), hoarding things (p = 0.02), hiding things (p = 0.02) and repetitive sentences or questions (p = 0.025). On the BEHAVE-AD, risperidone was significantly more effective than placebo in treating physical threats and/or violence (p = 0.001), agitation (other) (p = 0.001) and verbal outbursts (p = 0.026). Although analysis on individual hallucination and delusional items did not demonstrate specific responses, analyses of a composite of delusional items revealed significant drug-placebo differences.

Conclusions: These data indicate that risperidone is effective in treating a variety of symptoms associated with psychosis of AD.

Background: There is general consensus regarding the benefit of acetylcholinesterase inhibitors (e.g. donepezil) in Alzheimer's disease (AD). However, the combined effect of acetylcholinesterase and cognitive stimulation therapy (CST) is still controversial.

Objective: This study examines their combined effect on the progression of cognitive decline in AD by comparing the cognitive performance of 17 AD patients treated with CST and donepezil (combined treatment group) and 13 AD patients treated with donepezil alone (control group).

Methods: Patients in the combined treatment group received 5 mg of donepezil per day and about 20 one-hour CST sessions for one year, whereas the control group received only 5 mg of donepezil per day. The first eight sessions were carried out once a week, and subsequent sessions were generally once every two weeks. The patients were evaluated for changes in cognitive ability by administering the Mini-mental State Examination (MMSE) before the start of CST (baseline) and about one year later (follow-up).

Results: A repeated-measure analysis of variance revealed a significant group × time interaction. The MMSE score decreased significantly in the control group, but did not change significantly in the combined treatment group. Three patients in the control group declined by four points on the MMSE, compared to none in the combined treatment group. Effect size (ES) in the control group was relatively large and negative, while the ES in the combined treatment group was close to zero.

Conclusions: The results suggest the possibility that donepezil plus CST slowed the rate of cognitive decline more than the administration of donepezil alone.

Background: The rapid increase in the elderly population in Japan has triggered a debate on whether or not patients with dementia should be informed of their diagnosis. The purpose of the present study was to investigate the attitudes of people in a large city in Japan toward the disclosure of a diagnosis of dementia.

Methods: In Study 1, 2000 residents aged 40–64 and 5000 residents aged 65 and over were sampled randomly, and a structured questionnaire was sent to them by mail. In Study 2, we administered a structured interview-based questionnaire to 3949 randomly enrolled residents of Nagoya City aged 45 and over whose family member had been certified as needing long-term care.

Results: In Study 1, 79.8% of the younger respondents (n = 710) stated that they would prefer the disclosure of a hypothetical diagnosis of dementia, as did 75.5% of the older respondents (n = 2162). Furthermore, 85.1% (n = 749) of the younger respondents and 82.5% (n = 2181) of the older respondents stated that they would prefer that the patient be told his or her hypothetical diagnosis of dementia. In Study 2, in the case of care recipients without dementia, 68.3% (n = 650) of their family members preferred disclosure of a hypothetical diagnosis of dementia. Among the families of care recipients who had dementia, 58.4% (n = 301) of family members preferred disclosure.

Conclusions: The present survey of caregivers and non-caregivers in an urban city of Japan demonstrated that the desire for disclosure of a diagnosis of dementia is relatively high.

Background: The development of effective medication for the treatment of Alzheimer's disease led to an expansion in the use of memory clinics ther clinic-based services for the delivery and monitoring of the drugs. In contrast, there is an increased emphasis on providing home and community based service delivery for a range of illnesses including dementia.

Methods: This paper reports the findings of an evaluation study comparing a clinic-based and a community service. A convenience sample of 10 service users and carer dyads took part in in-depth qualitative interviews. Service users were diagnosed with mild to moderate dementia of Alzheimer's type. Interviews were recorded, transcribed and subsequently analyzed using template analysis.

Results: Service users and carers were satisfied with both services, with determinants of satisfaction differing between the two services. Issues relating to the location and spatial design of services, comfort, familiarity, communication with staff, and ease of use are highlighted as important determinants of satisfaction amongst service users and their carers.

Conclusion: This study has implications for person-centred care practices in service delivery and for the future design of mental health services for people with dementia.

Background: This study examines predictors of loneliness among low-income older adults through a framework named MODEL (Model of Depression and Loneliness), which we developed to address the need for a comprehensive and intervention-oriented theory of loneliness in old age. The framework is rooted in a cognitive-behavioral theory that conceptualizes behaviors as resulting from an interaction of cognitive processes and environmental events.

Methods: 161 residents of five independent-living buildings for low-income older adults in Maryland were interviewed individually. The assessments were based on the theoretical framework, MODEL, which describes the influences that environmental resources, health, and psychological factors have on loneliness and depression.

Results: MODEL explained a large percentage of the variance of both loneliness and depressed affect. Of all the barriers examined in the present study, our findings suggest that psychosocial factors/barriers have the strongest influence in the etiology of loneliness.

Conclusion: In this population of low-income older persons, the importance of new contacts, mobility, and financial resources in predicting loneliness suggests that preventive social services should target these factors in developing opportunities for socialization.

Background: Studies indicate that diet may be related to the occurrence of brain lesions. The cross-sectional association between food intake and brain lesion volumes in late-life depression was examined in a cohort of elderly individuals with current or prior depression.

Methods: Food intake was assessed in 54 elderly vascular depression subjects (vascular depression defined by presence of hyperintensities on brain MRI) using a Block 1998 food frequency questionnaire. Food and kilocalorie intake were determined. Brain lesion volumes were calculated from MRI. Subjects were aged 60 or over and were participants in a longitudinal study of major depression. All subjects received psychiatric assessment and treatment, and medical comorbidity assessments.

Results: High-fat dairy and whole grains were significantly positively correlated with brain lesion volume, while other food groups were not significantly associated with lesion volume. In multivariable analyses, controlling for age, sex, hypertension, diabetes and total kilocalories, the positive association with lesion volume remained significant for both high-fat dairy and whole grains.

Conclusions: High fat dairy and whole grain consumption may be associated with brain lesions in elderly subjects with depression.

Background: The 12-item Clock Reading Test (CRT) allows a fine-graded assessment of clock-reading ability. It has a strong focus on visuo-spatial processing and requires no executive processing. This study evaluated the reliability, validity, sensitivity and specificity of the CRT for the diagnosis of dementia and visuo-spatial dysfunction.

Methods: The CRT, the Clock Drawing Test (CDT) and other tests were applied to groups of 200 subjects with dementia, 105 subjects with mild cognitive impairment (MCI), 20 subjects with focal parietal lesions and 64 elderly control subjects.

Results: The CRT was found to be reliable and sensitive for the detection of cognitive impairment in parietal lesions, Alzheimer-, mixed- and Lewy Body dementia. Normal subjects and patients with MCI, frontotemporal dementia or cerebral small vessel disease showed little or no impairment.

Conclusion: CRT and CDT are clock-processing tests with different demand profiles. They can supplement each other in the neuropsychological diagnosis of dementia and visuo-spatial dysfunction.

Background: Spanish-language screening tests that are sensitive to the early cognitive changes of Alzheimer's disease (AD) are needed. Persons known to be at 50% risk for young-onset AD due to presenilin-1 (PSEN1) mutations provide the opportunity to assess which measures on the Mini-mental State Examination (MMSE) are most sensitive to these early changes.

Methods: We performed genetic and Spanish-language cognitive testing on 50 Mexican persons without dementia at risk for inheriting PSEN1 mutations. We then compared the performance on sub-items of the MMSE between PSEN1 mutation carriers (MCs) and non-carriers (NCs) using t-tests and Fisher's exact tests. Exploratory multiple logistic regression analyses were also performed.

Results: Twenty-nine persons were MCs and 21 NCs. NCs tended to achieve higher levels of education (p = 0.039) than did MCs. MCs tended to perform more poorly when spelling “MUNDO” backwards and on Orientation, particularly regarding the date. In multiple regression analyses the ability of backwards spelling to predict PSEN1 mutation status was reduced when education was included as an independent variable.

Conclusion: Subjects in the earliest stage of PSEN1-related AD showed deficits on orientation to date and in divided attention when spelling backwards. It is unclear if educational level should be considered an associated feature or a con-founding variable in this population although it should be taken into account when considering performance on the MMSE task of divided attention. The relative lack of deficits on delayed recall of three words probably represents the insensitivity of this measure in early AD. This study supports the utility of autosomal dominant AD as a model of the more common sporadic form of the disorder.

The Geriatric Anxiety Inventory (GAI) is a newly developed instrument specifically designed to measure common symptoms of anxiety in older adults Pachana et al., 2006). It contains 20 items with a dichotomous response format “agree/disagree”. The GAI can be self-rating or administered by a trained health professional. Pachana et al. reported the GAI to have sound psychometric properties in both normal older people and in a sample of geriatric psychiatry patients. The geriatric psychiatry patients consisted of 46 older people attending a community geriatric psychiatric service and were free of clinically significant cognitive impairment. In this sample, a cut-off point of 8/9 (out of 20) has a sensitivity of 73% and a specificity of 80% in identifying patients with an anxiety disorder. The GAI, however, was not designed to diagnose specific anxiety disorders but to assess the severity of anxiety symptoms across a range of presentations in older adults.

Papers submitted to International Psychogeriatrics undergo peer review, with each manuscript read by two or more reviewers possessing expertise relevant to the paper's topic. The advice of reviewers is often highly valuable to authors working to strengthen papers through revision, and their recommendations are central to the process of determining what is published in International Psychogeriatrics.