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

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

Methods: Systematic review of MedLine, PsychLit and EmBase.

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

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

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

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

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

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

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

Design: Cross-sectional study.

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

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

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

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

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

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

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

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

Background: Generalized Anxiety Disorder (GAD) is one of the most prevalent anxiety disorders among the elderly. Estimates of prevalence vary from around 3% to 12%, depending on the minimum age considered and the assessment instruments. The present study tests a GAD-specific treatment recently validated among adults (Ladouceur et al., 2000) and adapted for older adults.

Method: Eight older adults (aged from 60 to 71) were included in a single-case experimental multiple-baseline design across subjects. Assessments were conducted at pre-test, post-test and at 6- and 12-months follow-ups. The treatment consisted of awareness training, worry interventions and relapse prevention. The worry interventions targeted intolerance of uncertainty, beliefs about worry, problem-solving and cognitive avoidance.

Results: According to daily self-monitoring of worry, ADIS-IV ratings and self-reported questionnaire scores, seven out of eight participants showed clinically significant improvement at post-test. These therapeutic gains were maintained at 6- and 12-month follow-ups.

Conclusions: This study shows that a cognitive-behavioral treatment that targets intolerance of uncertainty, erroneous beliefs about worry, poor problem orientation and cognitive avoidance is effective for treating GAD among elderly people.

Background: There are no existing epidemiological data on use of medications to enhance memory.

Method: A community survey was carried out in Canberra and Queanbeyan, Australia, of an electoral roll sample of 2551 adults aged 60–64 years. Data collected included self-reports of using medications to enhance memory, tests of memory and other cognitive functions, anxiety, depression, physical health and use of other medications.

Results: 2.8% of the sample reported using medications to enhance memory, the main ones being gingko biloba, vitamin E, bacopa (brahmi), and folic acid/B vitamins. Users were more likely to be female, to have subjective memory problems and to use other psychotropic medications. However, they did not differ in memory performance, anxiety, depression or physical health.

Discussion: Some older people are using complementary medications to improve their memory or prevent memory loss, despite the lack of strong evidence for their effectiveness. These people show no objective evidence of memory impairment

Storey, J. E., Rowland, J. T. J., Conforti, D. A. and Dickson, H. G. (2004) The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. International Psychogeriatrics, 16, 13–31.

Background: There is a paucity of cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD).

Method: BPSD were examined in a consecutive series of referrals to a psychogeriatric service in the United Kingdom (U.K.) and in Korea, using the BEHAVE-AD, the Cornell Scale for Depression in Dementia and the Mini-mental State Examination (MMSE). The U.K. service served a well-defined geographical catchment area with a multidisciplinary team and emphasis on home assessments. The Korean service was a nationwide service with limited community resources. The correlates of individual BPSD in each country and the differences between the two countries were examined.

Results: Koreans were younger, were more likely to be married, less likely to be single, had a greater number of people in their household and were more likely to live in their own homes than the U.K. sample. Koreans were more likely to be referred by general psychiatrists or family members, and the U.K. sample was more likely to be referred by general practitioners. Koreans were more likely to have Alzheimer's disease and the U.K. sample to have vascular dementia. The Korean sample had a lower MMSE score than the U.K. sample. In both countries, the total BEHAVE-AD score and most subscale scores were negatively correlated with the MMSE score. The total BEHAVE-AD score and all subscale scores were higher in the Korean sample than in the U.K. sample. The prevalence of all BPSD measured with the BEHAVE-AD were higher in the Korean sample (except aggressivity).

Conclusion: These differences may be explained by differing interpretation and administration of the measurement instruments, models of service delivery, availability of primary and secondary care services, health seeking behavior of patients and families, cultural influences, and knowledge, expectations and recognition of BPSD by professionals in primary and secondary care. However, despite this, there was possible evidence of genuine differences worthy of further cross-cultural population-based epidemiological study of BPSD between these two countries.