Nutritional biochemistry is not a subject with which most psychiatrists, psychologists, and psychopharmacologists are familiar. A stream of recent epidemiological studies and clinical trials, however, indicates that understanding of nutritional biochemistry is soon going to be essential for anyone working with mentally ill patients. Those who are tempted to dismiss this statement as airy-fairy holistic nonsense will benefit from reading some recent issues of the American Journal of Psychiatry, British Journal of Psychiatry, Archives of General Psychiatry, Schizophrenia Research, Journal of Affective Disorders, and New England Journal of Medicine.

Aims and Background: The International Psychogeriatric Association (IPA) aims to improve the mental health care of older people globally. With regard to depression, a number of key publications over the past decade have highlighted areas of progress and areas requiring further research. In order to help clarify what progress has been made, the author conducted a literature review of original research subsequent to three recent major reviews. Method: A literature search of four databases over the period 1998—October 2001. Publications with an abstract in English were studied to ascertain number of relevant publications; type of research methodology; topics; and where the research originated. Results: A total of 1,002 publications meeting predifined criteria were located. Fifty-nine percent were crossectional studies; less than 10% were randomized controlled studies. The most common themes were depression with comorbidity and etiology, accounting for almost half the papers, with stroke and Parkinson's disease the most frequently researched comorbid medical disorders, although interest in Alzheimer's disease, heart disease, hip fracture, and chronic lung disease appears to be increasing. There were comparatively few studies of psychological and psychosocial interventions. A quarter of the publications concerned major depressive disorder. There were striking variations in the origin of publications with two regions, North America and Northern Europe, accounting for two thirds of all publications but only 13.7% of the world's population aged 65 and over. Conclusions: Progress is being made but it might occur more rapidly and with greater scope with more international and cross-center collaboration.

Researchers have suggested that educational attainment and occupational status—indicators of cognitive and/or neurologic “reserve”—can help persons compensate for clinical manifestations of Alzheimer's disease (AD), such as the rates of cognitive and functional decline. The effects of educational attainment on rates of decline could be “direct” (independent of occupational status), “indirect” (working through occupational status), or both. We used multilevel analysis for repeated measures to study the effects of educational attainment and occupational status on rates of decline in cognition (Mini-Mental State Examination, MMSE) and function (Cleveland Scale for Activities of Daily Living). Subject included persons with “probable” or “possible” AD, drawn from our Alzheimer's Disease Research Center registry (N = 482 in the analysis of cognitive decline, and N = 450 in the analysis of functional decline). When controlling for year of birth, gender, ethinicity, and duration of illness, we found that there was an inverse relationship between number of years of education and rate of decline in MMSE, but effects of occupational status were not significant. This implies a “direct” effect of education on decline in MMSE, but no “indirect” effect through occupational status. Neither educational attainment nor occupational status affected rate of decline in functional ability. We conclude that education slows the rate of cognitive decline in persons with AD, but not through its impact on occupational status. Thus the protective effects of reserve may be established early in life, before people enter the workforce.

Background and Objective: The pathophysiology and the neurobiology of the behavioral disturbances in Alzheimer's disease (AD) are far from understood. The aim of the study was to assess whether delusional AD patients have a specific pattern of regional brain atrophy. Methods: The setting of the study was the outpatients facility of a memory clinic. Subjects were 41 AD patients with mild dementia severity (Mini-Mental State Exam score of 22 ± 3, range 18 to 27). Delusions were assessed with the pertinent subscale of the UCLA Neuropsychiatric Inventory (NPI). Nondelusional (n = 22) AD and delusional (n = 19) AD were defined on the basis of absence (NPI delusions subscale = 0) or presence (NPI delusions subscale = 1 or higher) of delusions. Thirteen (68%) of the delusional patients had isolated theft delusions, and 6 (32%) had theft associated with another paranoid delusion (of jealousy or persecution). None of the patients had misidentifications or other delusions of nonparanoid content. Temporal lobe and frontal lobe atrophy were assessed with linear measures (radial width of the temporal horn, rWTH, and frontal index, FI) taken from computed tomographic films. Temporal and frontal asymmetries were computed as right/left ratio of the rWTH and FI. Results: AD patients without delusions had symmetrical enlargement of both temporal (8.1 ± 3.9 vs. 8.5 ± 4.5) and frontal horns (35.8 ± 4.8 vs. 35.9 ± 4.6). On the contrary, AD with delusions showed temporal horns larger to the right (9.1 ± 3.3 vs. 7.7 ± 3.1, p = .06) and the frontal horn to the left (35.7 ± 4.3 vs. 37.5 ± 4.2, p = .02). This different pattern was confirmed with a gender-adjusted repeated measures analysis of variance model (interaction term between asymmetry and group: F1,38 = 5.5, p = .03). Discussion: AD patients with delusions are characterized by a specific pattern of frontal and temporal asymmetry of brain atrophy, whereas nondelusional patients are symmetric. Because the asymmetry pattern of the delusional patients is similar to the physiological pattern of asymmetry of individuals without dementia, the data indicate that the absence of theft delusions in the mild stage of AD rather than their presence is associated with an abnormal asymmetry pattern.

This article describes the met and ummet needs of elderly residents of nursing care (NC) and residential care (RC) settings. Thirty-four residents of an RC home and 40 residents of two NC settings were assessed. Each resident and a respective staff member were interviewed using the Camberwell Assessment of Need for the Elderly (CANE) to indicate the resident's current met and unmet needs. The Clifton Assessment Procedure for the Elderly–Behaviour Rating Scale (CAPE-BRS) was completed by the staff member to indicate the participant's current level of dependency. In addition, the Mini-Mental State Examination was administered to participants and DSM-IV diagnosis was recorded. A high number of needs were found in both RC and NC settings, the level of dependency being proportional to level of need. There was a core set of needs in both samples related to difficulties with accommodation, food preparation, and self-care. Both NC and RC homes were meeting these needs; however, RC residents had a significantly greater level of unmet need for suitable daytime activities. The greatest predictor of type of setting was gender and there were significantly more females in RC. Controlling for gender, participants in NC had greater levels of dependency, particularly problems with apathy and social skills, as measured on the CAPE-BRS. It is possible that the greater level of social needs in NC residents had led to their placement in the more specialized NC settings. On the other hand, NC settings may be left caring for a group of residents that, because of their specific needs, have been difficult to place into RC. These findings have clinical implications for the future development of continuing care for the elderly. This study also highlighted that there is a substantial need for specialist services to address the unmet needs in these two types of continuing-care settings, such as interventions for social disturbances in NC and suitable daytime activities in RC. The CANE is a useful instrument to evaluate such needs in long-term-care settings.

Objective: This subanalysis of a large, double-blind, placebo-controlled trial examined the prevalence of behavioral symptoms in moderate to severe Alzheimer's disease (AD), and the effect of treatment with donepezil. Methods: Two hundred ninety patients with moderate to severe AD (standardized Mini-Mental State Examination scores 5–17) were randomized to receive 24 weeks of once-daily doses of donepezil 5 mg/day for 28 days, and 10 mg/day thereafter per the clinician's judgment (n = 144), or placebo (n = 146). The outcome measure of interest was the 12-item Neuropsychiaric Inventory (NPI). Results: Baseline demographics were similar between the treatment groups. Least squares mean (± SE) baseline NPI 12-item total scores were 19.55 ± 1.48 and 19.30 ± 1.45, respectively. At baseline, the most common symptoms were apathy/indifference (67%), aberrant motor behavior (53%), depression/dysphoria (52%), anxiety (49%), and agitation/aggression (45%). NPI individual item change from baseline scores at Week 24 using a last observation carried forward (LOCF) analysis showed benefits with donepezil treatment compared with placebo for all items, with significant treatment differences for depression/dysphoria, anxiety, and apathy/indifference (p < .05). Symptoms present at baseline that improved significantly for donepezil- compared with placebo-treated patients at Week 24 LOCF included anxiety, apathy/indifference, and irritability/lability (p < .05). When patients who were not receiving psychoactive medications at baseline were analyzed separately, significant improvements in NPI 12-item total score were observed with donepezil compared with placebo at most visits and at Week 24 LOCF (p < .05). Conclusions: Behavioral symptoms of the magnitude observed in this moderate to severe AD population improved with donepezil.

The aim of this study was to describe the epidemiological features of agitation and aggressiveness in elderly individuals living in French nursing and retirement homes in the year 2000. Data were collected on the type, time of onset, and duration of symptoms, medical evaluation and treatment, and medical and psychiatric comorbidities of the elderly patients. The most frequently reported behavior was verbal aggressiveness and the least reported behavior was physical aggressiveness. A triggering factor initiating the symptoms of agitation or aggressiveness was reported in 61% of the cases. In 61% of the study population, there were several morbidities reported as caused by the agitated or aggressive behavior (anorexia, weight loss, dehydration). A specialist was consulted for nearly half of the agitated or aggressive patients. For 55% of the patients, a new medication regimen was started or the administration of previous medications was modified, the most frequently prescribed drugs being antipsychotics. The results of our study and others show that agitation and aggression have a substantial impact on the lives of the elderly population, as well as on the lives of their family members and caretakers.