80% of people with dementia experience one or more recurrent or persistent symptoms such as hallucinations, delusions, aggression, agitation, shouting, screaming, repetitive actions, sleep disturbance or wandering behaviour during the course of their illness (Ballard et al, 1995).

These are collectively known as the behavioural and psychological symptoms of dementia.

The clinical management may include both psychosocial and pharmacological measures such as the prescription of medication, including antipsychotics.

Currently no drug is licensed for treatment of these symptoms in the UK and so clinicians need to be mindful of the fact that off label prescribing increases their professional liability in the event of an adverse event.

Studies suggest that between 54% and 88% of antipsychotic use in residential homes may be inappropriate (McGrath & Jackson, 1996).

To identify the current antipsychotics prescribing practice for behavioural and psychological symptoms in dementia and its compliance with the NICE guidelines.

A retrospective review of 50 case notes of the patients diagnosed with dementia after Nov 2006 was carried out.

Majority of the patients were male and were in the age group of 70-80 years.Alzheimer's Dementia followed by mixed dementia & vascular dementia were the main diagnosis. The main antipsychotic prescribed was Quetiapine, closely followed by Haloperidol & Promazine.The study showed that the prescription of antipsychotics was appropriate and all patients have their target symptoms recorded. However documentation of risk benefits analysis and discussion with patient and family about risk's and side effects were lacking.

To describe the relation of psychosocial factors of care (phase illness, years of care, free time, extra help and symptoms of depression) influence the care burden of dementia family caregivers. To measure the relation of the level of depressive symptoms on an intense level of burden of the dementia family caregivers.

Is selected a sample of 102 primary caregivers by criteria of inclusion to which a surveys do to those that the following information gathered: sociodemographic dates of the caregivers and of the dementia patients, care burden (Zarit Interview) and depressive symptoms (Beck Depression Inventory) of the family caregivers.

Most of the sample experiences an intense burden level (74%) opposite to a light level (26%). Psychosocial characteristics are as per statistics significant in increasing the care burden there were free time, extra help and presence of symptoms of depression. Presence of serious symptoms of depression on the intense burden level are differently front or those who had a minor burden, 22% and 5% respectively.

There are most of the daughter-father/mother and spouse-spouse caregiver couples with a high percentage of caregivers of feminine sex (as in most of the studies realized on caregiver of dependent persons at European and international level). The need for free time and psychic self-care are cost-effective strategies to prevent the depressive disorders, as well as, to improve their caregiver's work. The psychoeducation programs that have being realized at European level directed to family caregiver are necessary in our country.

The study intends to present the problems of elderly patients living in community residences, and the difficulties of staff and other residents. Solutions are also suggested.

Within the attempt of dwindling big psychiatric hospitals in Greece, and removing social and professional exclusion of patients, long-term supportive living units were established in 2001 by the General Hospital of Ioannina. Eleven patients were selected from the Psychiatric Hospital of Corfu, according to their functionality, medication compliance, and ability to take care of themselves. During the eight years of the unit's operation, four patients were forwarded in a supported flat where living is more independent. However, five psychotic patients, aged over 65, displayed new physical health problems, and deterioration of preexisting problems (epilepsy, chronic respiratory disease, kidney cancer). New disorders included hypertension, metabolic syndrome, hurt diseases, etc. The patient who suffered from respiratory disease died, an epileptic returned to the psychiatric hostel after 3 years in the protected flat, and the patient with the kidney cancer moved in a unit with more staff support.

Difficulties faced by elderly influenced hostel's operation and younger patients, and preoccupied stuff, depriving time from creative activities with patients. Furthermore, residents’ strain for physical health problems increased.

To secure regular operation of supported living units, a network of complementary units is necessary, which will forward to high supported units elderly patients who face serious health problems, or are not up to the everyday activities of the unit they live in.

Behavioral and psychological symptoms of dementia (BPSD) are common during the course of dementia and are associated with poor outcome for patients. There are some clinical data indicating that SSRI antidepressants have a positive influence on BPSD. Escitalopram has an excellent side-effect profile and might be a suitable treatment for BPSD in older demented patients.

An open-label observation of inpatients aged 65 to 90 years with a clinical diagnosis of probable AD and an MMSE score of 6 to 20 points and NPI total score ≥20 points treated with escitalopram for 8 weeks. The evaluation of improvement/worsening counted as ±10% change from baseline score in NPI and CMAI short. The results expressed in numbers of improved, unchanged and worsened patients.

13 patients, 12 women and 2 men. The average age was 79.3 years, the average MMSE was 12.8 points. Three patients discontinued due to AEs (bronchopneumonia, progressive worsening of dementia, transfer to another institution). The other AEs were mild and not related to study medication.

Most patients exhibited a reduction of BPSD, half of them with a very substantial reduction. Patients exhibited very good tolerance of the medication.

There is a growing appreciation that depression may be a presenting syndrome of dementia.

This study intends to show that the presence of cognitive impairment in a depressive episode in older people may have important prognostic implications in developing dementia.

In this study a first group of 17 depressed patients with mild cognitive impairment (MMSE over 26) was compared with a second group of 18 depressed patients with mild to moderate cognitive impairment (MMSE bellow 26). The mean age for both groups was 68. The depression was measured using the MADRS scale. All the patients included were severely depressed at the inclusion. Both groups showed important improvement of the depressive episode, following the treatment with antidepressants (escitalopramum, sertralinum, venlafaxinum).

Both groups were followed for 2 years after the depression resolution.

In the first group of patients the MMSE was 26 at baseline and 26 or over at discharge.

In the second group of patients the score of MMSE had a value of minimum 17 at baseline and a maximum of 26 at discharge.

Five patients (three in the first group and two into second group) did not complete the 2 years follow up period.

Over the period of 2 years, 37% of patients from the second group developed a dementia, comparing with only 14% of the patients from the first group.

After 2 years, the patients with depression and significant cognitive impairment had twice the risk of developing dementia as those who had only depression.

To explore autobiographical life review therapy as a therapeutic intervention in enhancing the stroke patients’ and caregivers’ state hope, life satisfaction, life mastery level as well as in reducing their loneliness.

20 Korean-American aged stroke patients (mean age=73.6) and 20 female Korean-American caregivers (wives) (mean age=67.5) were selected for autobiographical life review therapy. 20 male stroke patients out of 46 stroke patients were screened, by using the Hastean-Reitan Neuropsychological Test battery. During pretreatment testing sessions, the subjects completed state hope scale, life satisfaction scale, life mastery scale, and loneliness scale. At the end of total 10 sessions of autobiographical life review therapy interventions, the subjects completed these scales again. Pretreatment and posttreatment assessments of the selected scales were administered for both the stroke patients and their caregivers.

Between pretreatment and posttreatment, there were significant increases in the subjects’ assessments of state hope (male: p< .01 and female: p< .001), life satisfaction (male: p< .01 and female: p< .01) and of life mastery (male: p< .05 and female: p< .01) as well as significant reduction of their loneliness scale (male: p< .001 and female: p< .01).

The research results demonstrated the effectiveness of autobiographical life therapy interventions as an aid in improving the stroke patients’ and caregivers’ quality of life.

Doing there is no consensus for a multidimensional definition of Quality of Life (QoL) in dementia, and that informant- and self-perceptions of QoL differed substantially, lately it has been proposed to analyze Overall QoL using a simple item. Our objective was to investigate Overall QoL and how this perception among people with Cognitive Impairment and Dementia is associated with other variables. Thus, obtained predictor variables of QoL will act as confirmatory indexes to corroborate the self-reported QoL in clinical setting.

We conducted a cross-sectional survey where 106 participants with Cognitive Impairment (CI) and Dementia completed a face to face interview including diagnosis of dementia (DSM-III-R / DSM-IV), sociodemographic information, health perception and a list of chronic medical conditions, depressive symptoms (GDS-15) and functional ability (Barthel Index). Quality of life was measured with the self-assessment of overall QoL item from WHOQOL-BREF.

Mean age was 78.7 y.o. (SD: 7.1, range 55-91); 64.8% were female and 50% had primary school or more. Ordinal Logistic Regression analysis showed four factors correlated with a better QoL: (1) patients rating their health as good or more than good, (2) patients considering themselves healthy, (3) patients reporting not having depression, and (4) patients having less depressive symptoms (lower GDS scores).

A single-item global rating of patient QoL could prove useful in assessing QoL of most mild-to-moderate-stage CI and dementia patients. Affective states should be considered when assessing QoL in patients with CI and dementia; consistently, negative mood have a detrimental impact on QoL.

Increasing evidence suggests that training in complex reasoning skills may delay the onset of cognitive impairment. A key challenge is to develop cost effective brief interventions which lead to optimal performance.

Hence the major aims of this research were to examine the benefits of a brief intervention for elders, and to compare any improvements with those achieved after more training is provided.

A fully randomised controlled trial was conducted with 30 healthy older adults (M = 64 years) Participants completed measures of the WASI Matrix Reasoning subtest before and after the brief intervention, and again after the extended intervention. Those allocated to training were asked to complete a two week program of sudoku problems of increasing difficulty using tactics demonstrated in guidelines provided. This was followed by an advanced suduko program with harder problems and more sophisticated tactics.

A 2 × 3 (Training × Time) mixed ANOVA on WASI scores was conducted. This showed a significant interaction between Training and Time (F(2,56) = 4.18, p< .05, partial eta squared = .13). Further ANOVAs were conducted to examine this interaction. These showed that the training group improved over time but that the control group did not. Furthermore the training group improved significantly after the brief intervention, and improved more after the extended intervention.

A brief two week training program in suduko enhanced cognitive reasoning in older adults as assessed by the WASI reasoning subtest. A further two week advanced program in suduko further improved cognitive reasoning.

Mitochodrial Encephalopathy, Lactic Acidosis and Stroke like episodes, better known as MELAS continues to be rare and psychiatric literature on this disorder remains sparse. This maternally transmitted genetic disorder is progressive and fatal.

The neurological and neurophysiological symptoms of the disorder can be made out from the name MELAS which does not convey the plethora of psychiatric manifestations it can have. The psychiatric presentations can range from anxiety disorders, attention deficit, eating disorders, personality disorders and psychoses of the paranoid or affective types. Psychopathology can precede or appear during the course of neurological symptomatology leading to dementia. More knowledge about the possible psychiatric presentations is required to help detection and develop management guidelines.

Awareness of MELAS can result only from cohort studies. In the background of nearly fifteen years' follow up of a cohort with heavy genetic loading, the role of psychiatry in managing ongoing symptomatology with scope for futuristic interventions is discussed.

The fatality or the rarity of the disorder should not be a deterrant in charting out treatment guidelines for MELAS. Psychotropics, multidisciplinary care package and primary support net work maintain quality of life against progress of the disorder.

Understanding MELAS would help in maintaining and improving the quality of life of this patient group. MELAS requires further, in depth multidisciplinary studies. Comprehensive neuro-psychiatric, psychosocial and palliative models of management protocols need to be developed.

In the eldery population anti-epileptic drugs (AED) are used in epilepsy, neuralgiform pain, psychiatric disorders and behavioral problems in dementia. The prevalence of AED- treatment in the community is 1%; among nursing home residents 10%. A complex of adverse effects, known as Drug Reaction Eosinophilia and Systemic Symptoms (DRESS), is associated with several drugs, in particular AED. The incidence of DRESS syndrome is estimated between 1 in 1000 and 1 in 10000. DRESS syndrome has a high mortality rate (around 10%), primarily due to doctor's delay in recognition.

As AED-induced DRESS syndrome is rarely described in elderly patients, we describe two with dementia-related behavioural problems, treated with carbamazepine. Both patients developed severe rash, eosinophilia and fever after three weeks of administration. Patient 1 also developed anemia, diarrhoea and delirium; Patient 2 suffered from a severe edema of arms and face. Initially the clinical presentation of inflammatory and hypersensitivity symptoms was attributed to several diseases and/or medication other than carbamazepine. After recognition of DRESS by carbamazepine and stopping this drug, both patients fully recovered.

Recognition of DRESS syndrome induced by AED is difficult as the condition is rare, symptoms occur 1 to 8 weeks after start of treatment; there may be slow progression and similarity with infections and neoplastic disorders exists. Withdrawal of the offending drug is the primary treatment of the DRESS syndrome and patients relatives must be informed since the incidence of the DRESS syndrome is higher amongst first- degree relatives.

Dementia is an acquired syndrome of organic nature, characterized by permanent impairment of memory and other intellectual functions, often associated with psychological and behavioral symptoms without impairment of consciousness. There are psychopathological manifestations.There are different subtypes of dementia. To determine a mild cognitive impairment, the average score of Minimental scale test must be between 21 and 26.

It has been shown that patients with cognitive impairment have a decreased activity of acetylcholine and increased activity of glutamate. Therefore there is a decline in cognitive ability with significant memory impairment and increased aurousal. There is an impairment of cognitive function to perceive, process and use information, which contributes, along with the intelligence, plan and solve problems, learn from the experience, plan tasks and predict results.

For this postulate two fundamental ways in the treatment by use of cholinesterase inhibitors using memantine that blocks NMDA receptors.

However in mild cognitive impairment there is no evidence that these treatments improve patient outcome. Therefore we start treatment with cholinesterase inhibitors when Minimental score between 14 and 24. We'll use cholinesterase inhibitors in combination with memantine when the Minimental score between 10 and 14. We will use only memantine when the score between 3-14. It has been shown that only 30% of mild cognitive impairment progress to dementia. It is important to consider the use of these treatments because it is'nt shown a clear benefit in mild cognitive impairment and have side effects.

The aim of the present study is to evaluate the effects of Pet Therapy intervention on cognitive function, mood and perceived quality of life on elderly subjects (mean age 84.7 years; 95.2% women) living in a nursing home.

Participants were 21 subjects affected by mental illness including dementia, depression and psychosis (diagnosis based on the International Statistical Classification of Disease - ICD-10). The Mini-Mental State Examination (MMSE) and the 15-items Geriatric Depression Scale (GDS) were administered to ten persons (pet-group) and eleven subjects (control-group) together with a self-perceived quality of life questionnaire. The pet-group underwent a dog-assisted educational intervention lasting 90 minutes, once a week for six weeks. MMSE and GDS mean scores were compared between and within groups by Student's t-test.

The mean age ± standard deviation of the overall sample was 84.7±9.9 years. Mean schooling level was 4.0±3.4 years. Dementia was the most frequent diagnosis (47.6%), followed by psychosis (33.3%) and depression (19.0%). Both pet-group and control-group improved on GDS and MMSE. Within the pet-group, GDS symptoms decreased by 50% (from 5.9 to 2.7, p=0.013), whereas mean MMSE score increased by 4.5 (p=0.060). The between group comparison showed positive effect of Pet intervention on GDS (p=0.070). Furthermore, most of the participants reported an improvement of their perceived quality of life.

According to the most recent literature, our findings suggest that Pet Therapy program can be efficient in improving depressive symptoms and cognitive function in residents of long-term care facilities with mental illness.

To report a clinical case on neurosyphilis.

Clinical history, neuroimaging and lab investigations, and neuropsychological assessments.

A 66-year-old married man was admitted to an Old Age psychiatric ward presenting with a two-year history of desinhibited behaviour, hetero-aggression and a gradual loss of his ability cope with activities of daily living. His Mini Mental State Examination (MMSE) score was 20/30 on admission. The symptoms described above raised the working diagnosis of a frontotemporal dementia. Computerized axial tomography was normal. Laboratory and additional examinations were performed. Serological tests for syphilis were positive for both the Venereal Disease Research Laboratory test (VDRL) and Treponema pallidum hemaglutination test (TPHA). Cerebrospinal fluid (CSF) revealed a positive VDRL (cytology: 2 erythrocytes/μl, 30 leucocytes/μl with 24 mononuclear cells/ μl). Additional tests including human immunodeficiency virus (HIV) test were negative. Based on these findings the patient was treated for neurosyphilis according to the IUSTI 2008 European Guidelines on the management of Syphilis: Benzyl penicillin 18 million units i.v. daily, as 3 million units every four hours during 21 days. Two months later, he scored 28/30 at the MMSE but showing only slight improvement at the executive function battery.

Neurosyphilis remains a differential diagnosis for a wide variety of psychiatric syndromes, including dementia. However, the incidence of neurosyphilis presenting initially with frontotemporal impairment is unclear. High-risk groups such as patients with neuropsychiatric diseases should be routinely screened with serological tests in order to prevent morbidity and help to eliminate syphilis.

Elderly people are likely to have inadequate storage of vitamin D. Physical consequences may include pain, loss of bone tissue, decrease of muscle power, increase of fall risk and fractures. Also, among women an association of low vitamin D levels and a higher incidence of mood disorders has been reported.Prevalence of vitamin D deficiency is highest among institutionalized elderly. Elderly psychiatric patients could be at increased risk because of inadequate diet, polypharmacy, diseases that interfere with vitamin D metabolism and less exposure to sunlight due to homeboundness.In July 2008 we started a study on a clinical department of geriatricpsychiatry ward with the aim to establish the nutritional and vitamin status (including vitamin D) at and during admission.

All patients admitted to the clinical department of geriatric psychiatry of De Gelderse Roos Mental Health Care Institute (Arnhem, The Netherlands) were included.

During six months (July 2008-January 2009) the vitamin D level was established in 50 patients. At admission a vitamin D deficiency was found in 40 patients (80%).

Because vitamin D deficiency could have serious implications, both physical and psychiatric, we recommend routine assessment of vitamin D levels at psychiatric admission. If found too low, supplementation needs to be considered. In further research we will establish whether there is an association between vitamin D deficiency and the occurrence of psychiatric disorders. Also we will investigate if non-deficient patients at admission develop deficiency during admission.

Even Emil Kraepelin's description of dementia praecox emphasized the change in cognition and the long-term deteriorating course of schizophrenic patients, opposed to the ones having manic-depressive psychosis or paranoia.

Currently, neurocognitive impairment is considered a core component of schizophrenia, particularly affecting the domains of attention, executive-frontal lobe function, working memory, and episodic memory. The dorsolateral prefrontal cortex has been implicated in cognitive disorganization and current therapeutic options have only a modest effect on this chronic disability. Although these impairments cannot function as diagnostic tools, they are strongly related to the functional outcome of the illness, and have significant prognostic value.

Negative symptoms, such as poverty of speech or blunted affect, are among the most chronic symptoms of schizophrenia. They respond poorly to antipsychotics, and are widely suspected to reflect a dorsolateral frontal lobe dysfunction, as well. This negative dimension is associated with a poor long-term cognitive outcome and may be closely related to the primary cognitive deficit in schizophrenia.

Objectives and methods: The authors aim to provide an overview of the existing literature regarding these dimensions of schizophrenia, and the hypotheses of a possible association between schizophrenia and dementia.

Given the prognostic value of mild cognitive impairment, and regardless of the evidence of frontal lobe dysfunction in schizophrenia, few studies have examined the longitudinal relationship between psychosis and the development of (frontotemporal) dementia. This theoretical association raises the possibility that these distinct entities could result from a common neurodegenerative pathway.

To estimate the prevalence and severity of neuropsychiatric symptoms in patients with dementia in nursing homes, assessing their association with certain factors that may promote or prevent its occurrence.

A cross-sectional study was carried out. We included all elderly diagnosed with degenerative, vascular, or mixed dementia, stage 4 to 7 of the GDS, and residents in 6 nursing homes in the province of Ourense (Spain). The assessment of symptoms was performed using the Neuropsychiatric Inventory - Nursing Home (NPI-NH) test. A sample size of 120 individuals was determined to be necessary.

We included 212 cases, with an average age of 85.7 (SD = 6.7) years. The prevalence of neuropsychiatric symptoms was 84.4%. The most common symptom was apathy, followed by agitation and delirium, the least frequent were euphoria and hallucinations. The symptom that produced most occupational disruption was agitation. Multivariate analysis showed that a higher score on the NPI-NH was associated with the use of neuroleptics, both typical and atypical, and with a higher score on the Reisberg Scale. Negative association was demonstrated with the number of days of institutionalization and the diagnosis of vascular dementia.

Patients with dementia in nursing homes in our area have a high frequency of neuropsychiatric symptoms that are associated with neuroleptic use and decreases as the patient remains institutionalized for longer. Patients diagnosed with vascular dementia have lower scores on the NPI-NH test.

Behavioral and psychological symptoms in dementia are known to increase caregiver stress and proceed admission to a nursing home. We studied caregiver stress due to the impact of sleep disturbances in different types of mild dementia.

A sample of 151 persons with mild dementia from the Norwegian DEMWEST- cohort and their caregivers. Sleep problems in dementia were studied with the Mayo Sleep Questionnaire and the Neuropsychiatric Inventory. Caregiver stress was studied with the Relative's Stress Scale.

Caring for a person with mild dementia with any sleep disturbance significantly increased caregiver stress as compared to caring for a person with mild dementia without any sleep disturbances. (18.2 vs. 13.0, p=0.017) Caregivers to patients diagnosed as having mild Dementia with Lewybodies with any sleep disturbance reported significantly more stress as compared to caregivers to person with mild Alzheimer's Disease with any sleep disturbance. (14.7 vs. 21.7 p=0.010).

Sleep disturbances in mild dementia significantly impact on caregiver stress, more so in DLB as compared to AD.

Time until nursing home admission (NHA) in different types of dementia is not known. Few studies in Alzheimer's disease (AD) have been reported previously and focused on demographic, socioeconomic, behavioral and psychiatric symptoms as predictors for NHA.

We use data from the Norwegian DEMVEST-cohort to calculate time until NHA applying Kaplan-Meier survival analysis comparing the Lewy body dementias (LBD) (Dementia with Lewy Bodies (DLB) and Parkinson's Disease Dementia (PDD)) to non-LBD patients. Associated factors were studied with a Cox proportional hazard model.

190 cases with the same degree of mild dementia at baseline were followed for on average 880 ± 397 days 95% CI (823, 937), 56 (29.5%) individuals were placed in a nursing home during follow up and mean time until institutionalization was 1204 days 95% CI(1130, 1279) for all included, 987 days 95% CI (823, 1151) for LBD patients and 1263 days 95% CI (1184, 1342) for non-LBD patients. p=0.007 (Log-Rank test) Chi-square= 7.330 df=1. Mean time until NHA for DLB patients is 985days 95%CI (801, 1169) and for AD patients 1264days 95% CI (1180, 1347) p=0.013 (Log-Rank test) Chi square=6.194 df=1

After controlling for age and duration at baseline we find that having a LBD diagnosis (DLB or PDD) increases the risk for nursing home placement during follow-up, hazard ratio =1.9 95%CI (1.1, 3.4) p= 0.030.

We find that a LBD diagnosis significantly shortens time until NHP controlling for age and duration at baseline compared to non-LBD patients.

To report a case of diagnosis and progression of Semantic Dementia.

Case report data were obtained through three years’ follow-up, review of records, neuropsychological and imagiological studies.

The 66 year old female patient presented with depressive complaints after the loss of her partner. With the remission of the depressive symptoms, the patient kept complaining of “forgetting words”. Her progressive verbal semantic memory impairment through the years and detailed examinations have revealed a naming and comprehension deficit. Scan pattern has shown progression of the left temporal-lobe variant of frontotemporal dementia.

The meagre psychopharmachological approach (SSRI) colud ot avoid the major disturbances in the patient's quality of life. Directive community and social support may be seen as the most powerfull tool available.