The International Psychogeriatric Association (IPA) was founded 25 years ago as a multidisciplinary organization with the ambitious vision of improving the mental health of the elderly around the world. For a variety of reasons, some leaders were skeptical about the value of an international organization and it was the vision and energy of Dr. Sanford Finkel, together with a relatively small group of colleagues, who brought IPA to life and nurtured it through its infancy. Dr. Finkel, known to all as Sandy, has chronicled some of the history of IPA elsewhere and I won't repeat it here other than to emphasize the profound effect that IPA's first executive director, the dedicated and beloved Fern Finkel, had on IPA until her retirement in 2006. The importance of IPA as a leading professional organization is now well established, but beyond its many achievements in molding and guiding the profession, IPA is also a professional home for our members, a place of intellectual comfort where colleagues speak a common language and share common goals. Within IPA we can relax, share universal concerns for the ambivalently viewed population of elders that the world worries about but often avoids or ignores at the same time. We can share our challenges and they are many, our hopes, our successes and our uncertainties.

Background: We reviewed studies of in-service interventions for caregivers of persons with dementia in nursing homes published between 1990 and 2004. The aim was to obtain an overview of the evaluated interventions and to characterize their methodological quality.

Methods: A thorough literature search was conducted, including searching electronic databases for selected intervention studies and previous reviews. Selected studies were summarized and compared along certain categories, and methodological quality was assessed.

Results: A total of 21 studies were identified, mostly published in the United States. Most were of poor methodological quality. Although nearly all reported positive effects, their results must be interpreted cautiously due to methodological weaknesses. Extensive interventions with ongoing support successfully demonstrated sustained implementation of new knowledge. Owing to methodological weaknesses and a lack of follow-up evaluations, little or no evidence existed for the efficacy or, particularly, the transfer of knowledge in simpler interventions when reinforcing and enabling factors were not present.

Conclusion: On an international and, particularly, on a national level a lack of evaluated in-service training programs for caregivers in homes for people with dementia is apparent. Methodological weakness is common. This study highlights the need for well-defined methodologically improved studies, providing conclusive evidence of the effects of intervention types to help improve the quality of dementia care.

Background: This paper describes an innovative education program for the management of mental health problems in long-term care (LTC) homes and the evaluation of its longer-term sustainability. Since 1998, the [ldquor]Putting the P.I.E.C.E.S. Together[rdquor] learning initiative has been providing education sessions and related learning strategies aimed at developing the knowledge and skills of health professionals who care for older persons with complex physical and mental health needs and associated behaviors, in Ontario, Canada. A major focus of this province-wide initiative was the development of in-house Psychogeriatric Resource Persons (PRPs).

Methods: Evaluation of this initiative included the completion of pre- and post-education questionnaires (over three data collection time periods) assessing learner confidence (N = 1,024 and 792, for pre- and post-education, respectively) and session evaluation questionnaires gathering feedback on the session (N = 2,029 across all sessions). A survey of LTC homes in Ontario (N = 439, 79% of the homes in the province) was conducted to assess longer-term sustainability.

Results: Ratings of the sessions indicated that they were relevant to learners' clinical practice. There were significant increases in ratings of ability to recognize and understand challenging behaviors and mental health problems, and in ability to use a variety of assessment tools. Few homes (15%) do not have a PRP; over 50% of the staff who completed the first session in 1999 continue to serve as a PRP and to apply learned skills.

Conclusions: A learning initiative with supportive and reinforcing strategies can develop in-house PRPs to enhance the care of the elderly in LTC. Incorporation of PRP functions into job descriptions and management support contributed to the success of this initiative. This study highlights the importance of work environments that support and reinforce the use of learned skills to the success of continuing education and quality improvement initiatives in LTC.

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.

Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.

Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.

Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Background: The adverse effects of behavioral and psychological symptoms of dementia (BPSD) are well described but treatment remains problematical, including overuse of psychotropic medication. This study aims to compare the outcome of two approaches to BPSD, one focusing on causality and using predominantly psychosocial interventions, the other relying predominantly on psychotropic medication.

Methods: Thirty-three residential care clients manifesting BPSD who had been referred to a community psychogeriatric service (intervention group) were assessed and treated, with the focus placed on the causes of the behavior and why it was perceived as a problem by nursing staff. Cases were managed primarily by psychosocial means with psychopharmacology as an adjunct. A control group was made up of 22 referrals to an adjacent service, which used primarily psychopharmacology with psychosocial methods as an occasional adjunct.

Results: Measures of behavior and staff response showed significant improvement in both groups at two- and five-months' follow-up. Antipsychotic use in the intervention group decreased over time while in the control group it increased. Service measures showed both groups required approximately the same number of clinical visits but the intervention group experienced fewer medication changes, fewer drug side effects, and all but one case could be treated in situ. Five control group participants spent extended periods as inpatients in a psychogeriatric unit. Minor sampling differences did not affect the results, and neither they nor the nature of the behavior explained the difference in clinical approach.

Conclusion: The causality-focused approach appears to be as effective as the more common predominantly pharmacological approach, and appears to involve lower human and financial costs.

Background: Dementia in the elderly is associated with a greater risk of being subjected to abuse. More than half of those in Japan who abuse elderly relatives with dementia do not realize that their behavior corresponds to abuse.

Objective: This study sought to examine the effect of the presence of dementia in the elderly on attitudes toward abuse.

Methods: The subjects of this study were 135 people aged between 18 and 86 who were not taking care of elderly relatives at the time of the survey. The subjects were asked to rate how abusive they thought each of 12 behaviors listed in a questionnaire was in regard to three categories of elderly: (1) elderly with dementia who require care (DC); (2) elderly without dementia who require care (NC); and (3) elderly without dementia who do not require care (NN).

Results: The results of ANOVAs showed that the attitude of the subjects was associated with experience of caregiving, category of elderly, and type of abuse. The results of Bonferroni's tests indicated that the behaviors, especially those behaviors that included physical, psychological, and economic abuse, toward the DC category were not considered to be as abusive as those toward either the NC category or NN category.

Conclusions: This study suggests that people might rate abusive behavior as being less abusive when the person being cared for has dementia.

Background: Depression and anxiety is prevalent among patients with dementia but the extent to which these conditions are treated with antidepressants has not previously been investigated.

Methods: Nationwide register-based data in Denmark were used to identify all patients diagnosed with dementia or osteoarthritis at hospital admission or at first outpatient contact during the period 1995–2000. Rates of subsequent purchase of antidepressants from pharmacies were then calculated. Further, the rate of antidepressant use for patients with dementia was compared with the rate in a gender-, age-, and calendar-matched sample of the general population.

Results: In total, 24,137 patients with a main diagnosis of dementia and 100,378 patients with a main first diagnosis of osteoarthritis were incorporated in the study. A total of 43.2% of patients with dementia received antidepressants during follow-up compared to 16.0% of patients with osteoarthritis. Among patients with a diagnosis of dementia, the rate of subsequently purchasing antidepressants was 4.17 times higher (95% CI = 4.05–4.29) than that of patients with a first diagnosis of osteoarthritis, and 8.85 times higher (95% CI = 8.68–9.03) than that of a gender-, age- and calendar-matched sample of the general population. The rate was increased in all subgroups of patients regardless of gender, age, socio-economic group and time since diagnosis.

Conclusions: The findings challenge the widely held contention that depression and anxiety in patients with dementia is underdiagnosed and undertreated in clinical practice.

Background: Late-life depression has been associated with vascular diseases and with increases in circulating cytokines and cell adhesion molecules in the prefrontal cortex. We hypothesized that soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) would be increased in late-life major depression.

Methods: Serum levels of sICAM-1 and sVCAM-1 were measured in subjects over 60 with major depression (N = 23), subsyndromal depression (N = 20) and controls (N = 25). Depression severity was assessed using the Montgomery-Åsberg (MDRS) and Geriatric Depression (GDS) rating scales.

Results: There was no significant increase in sICAM-1 (p = 0.240) or sVCAM-1 (p = 0.600) in depression nor was there any correlation of either molecule with depression severity. Adjusting for differences in cognitive impairment did not alter these findings. There was also no difference between subjects with an early onset of depression (before 60) and those with late-onset depression.

Conclusions: These findings do not provide evidence that previously reported increases in serum cytokines in depression are due to peripheral vascular disease. Although we assessed subjects for vascular diseases it is possible that subtle but important differences between groups may still have been present and may have contributed to our negative findings.

Our results suggest central nervous system mechanisms, such as related to HPA axis activation, may be responsible for the enhanced inflammatory response in depression.

Background: The impact of spousal bereavement on mental health varies among the widowed. More information is needed on factors influencing bereavement outcome.

Method: We conducted a cross-sectional study on a sample of 216 widowed individuals. Initial non-response was high, with only 8% of all approached persons participating in the study. The influence of demographic and psychosocial predictors on four general outcome measures (depression, anxiety, somatization, and quality of life) and one loss-related outcome (complicated grief) was studied by means of backward linear regression analysis. Further analyses were performed to explore the possibility of a buffer effect.

Results: Depressive symptomatology was best predicted by: age, duration of widowhood, perceived non-supportiveness, physical disorders, and mastery. The other outcome measures were predicted by the same predictors supplemented by gender and education. Mastery interacted with the number of physical disorders while perceived social support interacted with duration of widowhood and age.

Conclusions: Enhancement of mastery should probably be one of the components of effective support for widowed individuals most vulnerable to psychiatric complications. The widowed could furthermore benefit from social support. Obviously, these suggestions need to be further examined in longitudinal research with more representative samples.

Background: A growing body of literature suggests that caregiving burden is associated with impaired immune system functioning, which may contribute to elevated morbidity and mortality risk among dementia caregivers. However, potential mechanisms linking these relationships are not well understood. The purpose of this study was to investigate whether stress-related experience of depressive symptoms and reductions in personal mastery were related to alterations in ß2-adrenergic receptor sensitivity.

Methods: Spousal Alzheimer's caregivers (N = 106) completed measures assessing the extent to which they felt overloaded by their caregiving responsibilities, experienced depressive symptoms, and believed their life circumstances were under their control. We hypothesized that caregivers reporting elevated stress would report increased depressive symptoms and reduced mastery, which in turn would be associated with reduced ß2- adrenergic receptor sensitivity on peripheral blood mononuclear cells (PBMC), as assessed by in vitro isoproterenol stimulation.

Results: Regression analyses indicated that overload was negatively associated with mastery (β = −0.36, p = 0.001) and receptor sensitivity (β = −0.24, p = 0.030), whereas mastery was positively associated with receptor sensitivity (β = 0.29, p = 0.005). Finally, the relationship between overload and receptor sensitivity diminshed upon simultaneous entry of mastery. Sobel's test confirmed that mastery significantly mediated some of the relationship between overload and receptor sensitivity (z = −2.02, p = 0.044).

Conclusions: These results suggest that a reduced sense of mastery may help explain the association between caregiving burden and reduced immune cell ß2-receptor sensitivity.

Background and objectives: Endothelial function plays a key role in determining the clinical manifestations of atherosclerosis. Recent reports have shown that healthy elderly subjects with higher trait anxiety tend to have heightened risks of atherosclerotic lesions and cardiovascular disease. The present study was intended to examine whether an association exists between trait anxiety and endothelial function in healthy young and elderly subjects.

Methods: This study examined 26 young male and 30 elderly male subjects using brachial artery flow-mediated dilation (FMD) – a non-invasive ultrasound method – to evaluate endothelial function by measuring the dilation responses of vascular smooth muscle to the nitric oxide produced by endothelial cells following hyperemia.

Results: A significant negative correlation was observed between the State and Trait Anxiety Inventory (STAI)-trait score as a parameter of anxiety and the percentage change of FMD (%FMD) in the elderly subjects, but not in the young subjects. The elderly subjects showed significantly lower %FMD than the young subjects.

Conclusion: These results suggest the possibility that trait anxiety is a predisposing risk factor for cardiovascular damage that might, over a long period, induce atherosclerotic lesions.

Background: The aim of the study was to determine the amount of trauma impact, post-traumatic stress symptoms and current psychopathological distress in a sample of former German children of World War II.

Methods: 93 participants were recruited through the local press, and assessed using the modified Post-traumatic Diagnostic Scale (PDS) and the Symptom Checklist (SCL-90-R).

Results: Subjects reported a high qualitative and quantitative degree of trauma exposure. 13.8% reported PTSD-related symptoms after the war, and 10.8% reported current symptoms. PTSD symptoms after World War II were significantly correlated with current psychopathological distress.

Conclusions: In line with other studies, our data document a high degree of trauma exposure during warchildhood. In comparison with other studies on PTSD in warchildren, there is a persisting high prevalence of war-associated PTSD symptoms in this sample. Despite some methodological limitations, our data underline the urgent need for further studies on the ageing group of former children of World War II.

Background: The aim of this survey is to investigate professional attitudes to the presence and value of spiritual care from Old Age Psychiatrists.

Method: All registered members of the Faculty of the Psychiatry of Old Age in the United Kingdom were asked to complete a 21-question semi-structured questionnaire. The first mail shot took place in 2002 and the second mail shot to non-respondents in 2003. Quantitative and qualitative analyses were carried out on the answers received.

Results: The response rate was 46%. The majority of respondents (92%) recognize the importance of spiritual dimensions of care for older people with mental health needs and about a quarter of respondents appear to consider referring patients to the chaplaincy service. In contrast, integration of spiritual advisors within the assessment and management of individual cases is rare.

Conclusions: Opinions vary as to whether provision of spiritual care should become widely available to older people with mental health needs who are admitted to hospital. Old age psychiatrists recognize that awareness of spiritual dimensions may be important for their patients. They seem less clear about the role of spiritual advisors and how NHS multidisciplinary clinical teams and spiritual and pastoral care services can be best integrated. Much work needs to be done on developing effective training and operational policies in this area.

Background: The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce.

Objectives: To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies.

Method:Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded.

Results: Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns – the “workhorse” and the “dabbler” – were observed, as was a culture of postponed retirement due to a sense of obligation and working “until you drop.” Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.

Conclusion: To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer “the four Ds”: dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

Dr. Lim's practice audit of maintenance electroconvulsive therapy (M-ECT) in the elderly (Lim, 2006) describes a group of older people treated with M-ECT in Australia but does not describe the views of Australian psychiatrists regarding the use of this form of treatment. We explored the views of psychiatrists in northwest England regarding the use of M-ECT in the 1990s: our study group was a subset of the cohort reported in Benbow et al. (1998), namely those respondents to a first-stage questionnaire who stated that they had used M-ECT (25%) or were prepared to consider its use (67%). A second-stage questionnaire inquired specifically about practice in relation to M-ECT, defined as the regular administration of ECT in order to minimize the likelihood of further episodes of illness, and was sent to 85 individuals of whom 77 responded, giving a response rate of 87.5%. Of these respondents, 49% stated that they had not prescribed maintenance treatment within the past 10 years; 42% estimated that they had prescribed one or two courses; 8% three to four courses and 1% five to six courses. None had prescribed more than six courses, so the experience of any one individual was relatively limited.

We report the case of an Italian family in which three sisters experienced transient global amnesia (TGA). Since its early description, this transitory pure memory deficit has attracted increasing interest, especially within the neurological community. In 1964 the term “TGA” was coined to identify the abrupt onset of anterograde amnesia, accompanied by repetitive queries lasting for hours and then gradually recovering, leaving an amnesic gap for the duration of the attack. Afterwards, many studies focused on TGA, and in 1990 clinical criteria were defined by Hodges and Warlow (1990). Further studies showed that meeting diagnostic criteria was a significant predictor for a better outcome than in other forms of transient amnesia, while amnesic patients who did not fulfil the TGA criteria had different outcomes. Precipitating and trigger events for TGA were identified and divided into physical and psychological factors (Inzitari et al., 1997; Quinette et al., 2006). Physical precipitants were found to be gardening, housework and sawing wood, contact with water and changes in body temperature occurring during hot baths or showers, or a cold swim at the swimming pool. Emotional trigger events included a major life or death event, emotional stress triggered by a gastric endoscopy, an exhausting work session, and anxiety resulting from conflicts at home or at work, health problems and money worries. Several hypotheses have been proposed for its pathogenesis such as psychogenic, venous dysfunction due to jugular venous valve incompetence, or ischemic aetiology, but the enigma of TGA still needs to be unravelled (Lewis, 1998; Akkawi et al., 2001).

Traditionally, suicide rates increase with aging in many countries (Shah and De, 1998). However, exceptions to this observation are emerging. Data from the World Health Organization (WHO) in 1995 revealed that female suicide rates did not increase with age in Mauritius, Colombia, Albania and Finland (Shah and De, 1998). Suicide rates increased with age in Switzerland (Ajdacic-Gross et al., 2006), Brazil (Mello-Santos et al., 2005) and China (Yip et al., 2000), but there were smaller peaks in the younger age-bands. Suicide rates among Australian, New Zealand and white American males increased with age, but suicide rates for females initially increased with age, peaking at menopause, and declining thereafter (Skegg and Cox, 1991; Woodbury et al., 1988; Snowdon and Snowdon, 1995). Suicide rates among non-white Americans (Seiden, 1981; Woodbury et al., 1988), Indians (Adityanjee, 1986; Bhatia et al., 1987), Jordanians (Daradekh, 1989), Indian immigrants to the U.K. (Raleigh et al., 1990; Needleman et al., 1997) and some east European countries (Sartorius, 1995) declined with increasing age.