The need to train more health workers, and particularly mental health workers, in the care of older adults, has been highlighted by a variety of disciplines including psychiatry (Jeste et al., 1999), psychology (Knight et al., 1995), social work (Rosen et al., 2002) and nursing (Hirst et al., 1996). This rise in attention paid to geriatric health care is partly driven by demographics. Over the next 50 years, the global population of people aged 60 years and over is expected to triple to 2 billion by 2050 (U.N. Department of Economic and Social Affairs, Population Division, 2007). This same UN report states that the expected number of centenarians is set to increase globally by a factor of 20. Worldwide, the demographic trends in aging suggest that the number of people in the world aged 65 years and over will surpass the number aged 5 years or less in approximately 2017 (UN Department of Economic and Social Affairs, Population Division, 2005). The issues concerning who will care for older adults are faced by a growing number of nations throughout the world.

Background: In response to the global challenges of population aging in Portugal, it is crucial to improve research, education and clinical training in old age in order to meet the growing demands placed on psychogeriatric care services.

Methods: An overview is provided on the status of old age psychology and psychiatry as part of the multidisciplinary care delivery system for the elderly in Portugal. Available educational offerings and clinical training in geriatric mental health at both undergraduate and postgraduate level are described, as well as primary research associations and initiatives within Portugal.

Results: Important issues raised include the need for more educational and clinical training programs for specialists, a broader commitment to aging research and the need to increase interest in working with older adults among students across disciplines. The recent movement towards multidisciplinary work conducted by researchers, psychiatrists, psychologist and other health professionals in Portugal points to the urgent need for specialist education for all health professionals working in geriatrics. This educational initiative must focus not only on the transmission of knowledge on aging-related topics, but also on the training of specific skills and competencies. Improving geriatric mental health service delivery and connecting research with clinical practice constitute other significant steps forward.

Conclusions: An effective intervention in psychogeriatrics should involve a strategy with the participation of a multidimensional network that includes the commitment of researchers, educators, clinicians, health policy-makers and older adults. Several recommendations to improve late life mental health care are presented.

Background: Florida is a leader in requiring that all direct care staff employed in assisted living, nursing homes, hospice, adult day care and home health undergo Alzheimer's disease (AD) training. Legislative requirements prescribe the curricula components and require a review of curricular content and minimum standards for the training providers.

Methods: We describe Florida's AD training program review process, and report the results of our review of 445 curricula received over four and a half years.

Results: On initial submission, over 90% of curricula submitted did not include learning objectives, time formats or didactic approach. During a review of content we often found inaccurate information, language that was not person-centered, and missing required training components.

Conclusion: Form and content problems were prevalent across all curricular types. We propose the Florida credentialing program as a model to ensure that accurate and educationally sound curricula are used to train direct care workers.

Background: Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams.

Methods: A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes.

Results: 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories.

Conclusions: The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Background: Workforce shortages to meet the mental health needs of the world's aging population are well documented. Within the field of professional geropsychology in the U.S.A., a national conference was convened in 2006 to delineate competencies for psychological practice with older adults and a training model for the field. The conference produced the Pikes Peak Model of Geropsychology Training. The Council of Professional Geropsychology Training Programs (CoPGTP) aimed to produce a competency evaluation tool to help individuals define training needs for and evaluate progress in development of the Pikes Peak professional geropsychology competencies.

Methods: A CoPGTP task force worked for one year to adapt the Pikes Peak Model geropsychology attitude, knowledge, and skill competencies into an evaluation tool for use by supervisors, students and professional psychologists at all levels of geropsychology training. The task force developed a competency rating tool, which included delineation of behavioral anchors for each of the Pikes Peak geropsychology knowledge and skill competencies and use of a developmental rating scale. Pilot testing was conducted, with 13 individuals providing feedback on the clarity and feasibility of the tool for evaluation of oneself or students.

Results: The Geropsychology Knowledge and Skills Assessment Tool, Version 1.1, is now posted on the CoPGTP website and is being used by geropsychology training programs in the U.S.A.

Conclusions: The evaluation tool has both strengths and limitations. We discuss future directions for its ongoing validation and professional use.

Background: There has been limited focus on evaluation of continuing education (CEU) and continuing medical education (CME) in the fields of gerontology and geriatrics. The increasing elderly population combined with the limited clinical workforce highlights the need for more effective methods of continuing education. Traditionally, outcomes of CEU and CME programs relied on self-report measures of satisfaction with the scope and quality of the training, but more recent efforts in this area have focused on outcomes indicating level of improved skills and attitudinal changes of medical and allied health professionals towards working with elderly patients in need of assistance.

Methods: This study focused on the use of “Action Plans” as a tool to stimulate changes in clinical programs following training, along with attempting to determine typical barriers to change and how to deal with them. More than 600 action plans were obtained from participants attending various continuing education classes providing training on care of patients with dementia (PWD) and their families. Both qualitative and quantitative methods, including logistic regression models were used to analyze the data.

Results: Three months following training 366 participants reported whether they were successful in implementing their action plans and identified factors that either facilitated or hindered their goal to make changes outlined in their action plans. Despite the low response rate of program participants, the “action plan” (with follow up to determine degree of completion) appeared to stimulate effective behavioral changes in clinicians working with dementia patients and their family members. Seventy three percent of the respondents reported at least some level of success in implementing specific changes. Specific details about barriers to change and how to overcome them are discussed.

Conclusions: Our results support that developing and writing action plans can be a useful tool to self- monitor behavioral change among trainees over time.

Background: There is a worldwide shortage of mental health professionals trained in the provision of mental health services to older adults. This shortage in many countries is most acutely felt in the discipline of psychology. Examining training programs in clinical psychology with respect to training content may shed light on ways to increase interest among students and improve practical experiences in working with older adults.

Methods: A large multinational survey of geropsychology content in university-based clinical and counselling psychology training programs was conducted in 2007 in the U.S.A., Australia, and Canada. Both clinical/counseling programs and internship/practicum placements were surveyed as to staffing, didactic content and training opportunities with respect to geropsychology.

Results: Survey response rates varied from 15% in the U.S.A. (n = 46), 70% in Australia (n = 25) to 91.5% in Canada (n = 22). The U.S.A. and Australia reported specialist concentrations in geropsychology within graduate clinical psychology training programs. More assessment and psychopathology courses in the three countries were cited as having ageing content than psychotherapy courses. Many non-specialist programs in all three countries offered course work in geropsychology, and many had staff who specialized in working clinically with an older population. Interest in expanding aging courses and placements was cited by several training sites. Recruiting staff and finding appropriate placement opportunities with older adult populations were cited as barriers to expanding geropsychology offerings.

Conclusions: In light of our results, we conclude with a discussion of innovative means of engaging students with ageing content/populations, and suggestions for overcoming staffing and placement shortcomings.

Background: This paper outlines the evolution of the training of Canadian physicians and other professionals in the mental health care needs of older adults over the past 2 decades, which has culminated in long-awaited subspecialty recognition by the Royal College of Physicians and Surgeons of Canada (RCPSC). Despite the fact that Canada has more than 4000 psychiatrists officially recognized by RCPSC, and a national body of more than 200 members who practice primarily in geriatric psychiatry, the status of geriatric psychiatry as a subspecialty of psychiatry in Canada remained “unofficial” until 2009.

Methods: Early along the pathway toward subspecialization, Canadian educational efforts focused on enhancing the capacity of primary care physicians and other mental health professionals to meet the mental health needs of older adults. Over the past decade, and with the encouragement of RCPSC, Canadian psychiatric educators have carefully and collaboratively defined the competencies necessary for general psychiatrists to practice across the life span, thereby influencing the psychiatry training programs to include dedicated time in geriatric psychiatry, and a more consistently defined training experience.

Results: With these two important building blocks in place, Canadian psychiatry was truly ready to move ahead with subspecialization. Three new psychiatric subspecialties – geriatric, child and adolescent, and forensic – were approved at the RCPSC in September 2009.

Conclusions: The developments of the past 20 years have paved the way for a subspecialty geriatric psychiatry curriculum that will be well-aligned with a new general psychiatry curriculum, and ready to complement the existing mental health work force with subspecialized skills aimed at caring for the most complex elderly patients.

Background: The prevalence of depression among older people receiving care is high, yet the rate of treatment of this disorder is low. One way to improve the pathway to care is to train care staff to recognize the symptoms of depression and raise their confidence in responding to them. In this study we evaluated the efficacy of the beyondblue Depression Training Program to achieve this aim.

Methods: Staff (N = 148) from low level care facilities and community care facilities in metropolitan Melbourne completed the beyondblue Depression Training Program, while staff in other facilities (N = 96) acted as controls. Pre-program, post-program and follow-up questionnaire data were collected and referrals for depression by staff were recorded.

Results: Training improved carers’ knowledge about depression, their self-efficacy in responding to signs of depression and their attitudes towards working with depressed aged care recipients. In addition, training increased the number of referrals for depression made by carers.

Conclusion: Training aged care staff in depression can improve the pathways to care for depressed care recipients, and has the potential to improve the quality of life of older people.

Background: There is uncertainty regarding the optimal use of pharmacological strategies in delirium particularly regarding preferred agents, duration of treatment and effectiveness in different populations.

Methods: Attitudes towards delirium pharmacotherapy were investigated before and after an educational workshop using the format of a televison game show.

Results: Most respondents (65/66) reported psychotropic use with variable frequency (median 60%). Antipsychotic use was inversely related to perception of supporting evidence (p = 0.02). Respondents rated sedative (38%) and antipsychotic (33%) effects as the principal mechanism of action rather than a specific neurochemical anti-delirium effect (21%). Haloperidol was the preferred first-line agent (65%). Suggested continuation treatment after symptom resolution was three days. Eleven respondents had used psychotropics prophylactically. Antipsychotic use was influenced by concerns regarding potential for extrapyramidal (52%), sedative (32%), cerebrovascular (30%) and metabolic (8%) effects. Post-workshop concerns regarding extrapyramidal effects were reduced with a more positive general attitude towards pharmacological interventions, especially in hypoactive presentations (61%) and prophylactically in high-risk patients (56%).

Conclusions: Attitudes towards key aspects of delirium pharmacotherapy vary considerably and relate to concerns regarding side effect potential more than perceived mechanism of action. Educational interventions can impact positively upon attitudes.

In 2011, the baby boomer generation officially commences its residency in the 65 years and over age group (U.S. Census Bureau, 2006). The much anticipated rapid growth in the population aged 65 years and over between 2011 and 2030 will challenge health care systems worldwide. Mental health services for older people will need to prepare for a near doubling of possible demand based upon estimates of the increase in prevalence of mental disorders in late life in this period in the developed world, with the increase likely to be greater in low and middle income countries (Bartels, 2003; Alzheimer's Disease International, 2009). The pressures that this will place upon the old age psychiatry workforce has contributed to the impetus for the Faculties of Psychiatry of Old Age of the Royal College of Psychiatrists and the Royal Australian and New Zealand College of Psychiatrists to prepare a ‘Joint Statement on Specialist Old Age Psychiatry Workforce and Training’ (see Appendix).

Background: With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature.

Methods: A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium.

Results: The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a “lucid interval” when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion?

Conclusions: This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

Background: Over the years, a number of non-medical and psychosocial explanations and models of dementia have been proposed, due to the complex nature of the illness. However, there is a need for a more pragmatic, user-friendly model which takes into account the biological, psychological and social processes.

Methods: Existing models of dementia were amalgamated into a revised, pragmatic model which aims to increase our understanding of the factors that may lead to improvement or deterioration in dementia and to illustrate the role of psychosocial factors in the context of biological processes. The model suggests that in both psychosocial and biological domains there are fixed factors (aspects which relate to history or risk factors and therefore not amenable to change), tractable factors (aspects which may be amenable to change), and interventions with potential benefit.

Results: The trajectory of dementia is presented as a process, beginning with aging and ending in death. Both the fixed and the tractable factors may influence the severity of dementia, affecting function, the speed and nature of the deterioration, and the appropriateness and effectiveness of interventions. A working case example is provided, demonstrating how the model may be used by clinicians when assessing the difficulties of an individual with dementia and identifying ways to improve the quality of life and reduce excess disability for that person.

Conclusions: This model provides a theoretical framework and an ambitious approach to care in dementia which takes into account positive as well as negative factors. We hope it may become a useful tool for researchers and clinicians to help understand what impacts on individuals with dementia and the most appropriate ways to intervene.

Background: Deposition of amyloid β in senile plaques and in cerebral blood vessels is one hallmark of the pathogenesis of Alzheimer's disease (AD). The ability of several matrix metalloproteinases (MMPs) to degrade amyloid precursor protein leading to aggregation of amyloid β, as well as the increased expression of MMPs in post mortem brain tissue of Alzheimer's patients, indicate that MMPs play an important role in the pathogenesis of AD.

Methods: We investigated levels of MMP-2,-3,-9 and -10 in plasma and cerebrospinal fluid (CSF) of AD patients (n = 14) by gelatin and casein zymography. Comparisons between AD patients and controls relative to levels of MMP-2, MMP-3, MMP-9, and MMP-10 were made with Wilcoxon rank statistics. Pearson correlations were computed as measures of association.

Results: MMP-3 in AD was significantly elevated in plasma (p = 0.006) and there was a trend towards increase in CSF (p = 0.05). MMP-2 in CSF of AD patients was significantly decreased (p = 0.02) while levels in plasma remained unchanged. MMP-9 and MMP-10 could not be detected in CSF; MMP-10 was unchanged in plasma, but MMP-9 was significantly decreased (p = 0.02).

Conclusions: These findings constitute further evidence for the important role of MMPs in the pathogenesis of AD.

Background: We aimed to develop a standardization method to pool data recorded on different activities of daily living (ADL) scales in order to reduce variability of functional outcome data from Alzheimer's disease (AD) clinical trials and to better evaluate the effect of donepezil treatment on function in patients with AD.

Methods: Based on pre-specified criteria, six studies were selected from among all donepezil clinical trials in AD. Individual items from nine ADL scales used in these trials were mapped to a standardized functional scale comprising 12 domains (six basic, six instrumental); scores were transformed to a 0–100 scale. External validation of this scale yielded a concordance rate of 90.8%. For each domain, mean change from baseline to 24 weeks in the placebo and donepezil groups was compared for the total population and for subgroups stratified by baseline disease severity. Study settings included outpatient, assisted living, and skilled nursing facilities. Participants comprised 2183 patients (donepezil, 1261; placebo; 922) with baseline Mini-mental State Examination (MMSE) scores 5–26.

Results: Significant treatment differences favoring donepezil were observed for five items (two instrumental and three basic). Patients with moderate AD at baseline (MMSE 10–17) demonstrated the greatest treatment effect.

Conclusion: Functional data were successfully pooled using standardizing methodology. A beneficial effect of donepezil treatment on function was demonstrated using this standardized functional scale. Similar analyses from studies with other anti-dementia drugs may help to determine the generalizability of these findings and potentially encourage use of functional assessment as a clinical tool.

Background: Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages).

Methods: Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity.

Results: Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains.

Conclusion: Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

Background: Previous studies have shown that the verbal fluency test (VFT) is a sensitive measure of cognitive dysfunction in Alzheimer's disease (AD). However, other studies have shown that the performances were significantly influenced by education in the normal elderly population. In order to examine the utility of the VFT as a tool for screening for AD, it is necessary to study the effect of education not only in the cognitively intact population but also in the population of early AD patients.

Methods: Patients with AD (n = 345) and individuals with amnestic type of mild cognitive impairment (MCI) (n = 123) were asked to generate as many words as possible belonging to a category “animal” and beginning with “か [ka]” in syllabic Japanese “kana” script. In order to determine the education effect after adjusting for age and cognitive state on the VFT performance in early stage of AD, we performed multiple regression analysis with 396 individuals including both amnestic MCI and AD.

Results: After adjusting for patients’ age, sex, and cognitive state, the years of education were significantly related to category fluency test scores, but not significantly related to letter fluency test scores.

Conclusion: Our results demonstrated that a category fluency performance reflected not only AD-specific changes but also educational background. These results suggest the limitation of using the category fluency task for screening subjects at risk for developing AD without taking subjects' educational background into consideration.

Background: The Rivermead Behavioural Memory Test (RBMT) assesses everyday memory by means of tasks which mimic daily challenges. The objective was to examine the validity of the Brazilian version of the RBMT to detect cognitive decline.

Methods: 195 older adults were diagnosed as normal controls (NC) or with mild cognitive impairment (MCI) or Alzheimer's disease (AD) by a multidisciplinary team, after participants completed clinical and neuropsychological protocols.

Results: Cronbach's α was high for the total sample for the RBMT profile (PS) and screening scores (SS) (PS = 0.91, SS = 0.87) and for the AD group (PS = 0.84, SS = 0.85), and moderate for the MCI (PS = 0.62, SS = 0.55) and NC (PS = 0.62, SS = 0.60) groups. RBMT total scores, Appointment, Pictures, Immediate and Delayed Story, Immediate and Delayed Route, Delayed Message and Date contributed to differentiate NC from MCI. ROC curve analyses indicated high accuracy to differentiate NC from AD patients, and, moderate accuracy to differentiate NC from MCI.

Conclusions: The Brazilian version of the RBMT seems to be an appropriate instrument to identify memory decline in Brazilian older adults.

Background: Anxiety has a high prevalence among individuals with dementia, and it has a significant negative impact on their functioning; yet intervention studies are lacking. We developed Peaceful Mind, a cognitive-behavioral intervention for persons with dementia. In this paper, we describe the intervention and results of an open trial evaluating the feasibility and utility of the intervention and assessment procedures.

Methods: Peaceful Mind is implemented over a period of three months in the participant's home with involvement of a caregiver or “collateral.” Dyads are followed for an additional three months via telephone. An assortment of simplified skills is offered, including self-awareness, breathing, behavioral activation, calming thoughts, and sleep skills.

Results: Nine participants were enrolled, eight completed the three-month assessment, and seven completed the six-month assessment. Overall, participants and collaterals were satisfied with the intervention and reported that they benefited in terms of anxiety, depression, and collateral distress.

Conclusions: A randomized controlled trial would help determine whether this promising new treatment has a statistically significant impact on anxiety in this population.