Delirium is a cognitive disorder characterized by acute onset, fluctuating course, altered level of consciousness, inattention, disorganized thinking, disorientation, memory impairment, and perceptual and motor disturbances (American Psychiatric Association, 2000; World Health Organization, 2010). It occurs in hyperactive, hypoactive, or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006) and 70% of older long-term care residents (McCusker et al., 2011). In both settings, delirium is independently associated with poor outcomes (Siddiqi et al., 2006; McCusker et al., 2010; Witlox et al., 2010).

Background: Most people with dementia in Western societies will eventually be placed in a nursing home. This can be stressful to those with dementia and to their families. The adjustment to this new caring environment by both residents and their family caregivers and the factors that influence this are the focus of this review.

Methods: A literature search of Embase, Scopus, and Medline databases of articles published in English between 1990 and 2011 using specified search terms was performed to examine this transition. The 174 titles located were screened and reference lists hand searched resulting in the 49 relevant articles included in this review.

Results: This decision and the subsequent adjustment period is a difficult time for people with dementia and their family caregivers. Admission has been linked to increased behavioral symptoms and in particular depression and agitation, decreasing cognition, frailty, and falls in people with dementia. For caregivers, guilt, depression, feelings of failure, and continuing burden but also improvement in quality of life have been variously reported. Research to determine what influences the trajectory of these different outcomes and the prevalence of positive outcomes for people with dementia is lacking. Successful transitions may be assisted by ensuring that the person with dementia has input into decision making, orientation procedures for the person with dementia and family member prior to and on admission, a “buddy” system for new arrivals, and a person-centered approach.

Conclusions: Adjustment to admission to residential care can be difficult for people with dementia and their family caregivers. Longitudinal research examining factors influencing the adjustment can provide a basis for intervention trials to improve this transition.

Background: During the course of Alzheimer's disease (AD), cognitive processes, including language and communication, become increasingly impaired. The aim of this review was to highlight the impact of communication deficits in AD, and discuss the need for effective treatments.

Method: PubMed was searched for studies relating to language and communication in AD. The publications identified were used as a basis for the commentary in this paper. Studies relating to the clinical effectiveness of pharmacological treatment for language and communication issues were identified systematically.

Results: Communication deficits are common in AD. From the earliest disease stage, the patient's capacity for communication declines as problems develop with the use of language and all aspects of functional communication. There is a loss of the ability to communicate thoughts and needs, and it becomes increasingly difficult to interact socially and sustain personal relationships with caregivers, family, and friends. It is unsurprising that patients become frustrated at their loss of self-expression, and studies have demonstrated that impaired communication is strongly linked with the development of significant behavioral concerns. Overall, poor communication contributes to caregiver strain, and adds notably to the burden of disease. Clinical data and post-hoc analyses provide preliminary indications that anti-AD therapies (memantine and the cholinesterase inhibitors, ChEIs) and non-pharmacological cognitive–linguistic stimulation techniques may be helpful in addressing communication difficulties.

Conclusions: The capacity to treat or slow the progression of communication deficits in AD would prolong patient independence, and have a profound impact on the quality of life of patients and caregivers. The use of pharmacological (anti-AD therapies) and non-pharmacological (cognitive–linguistic stimulation) treatments may be useful management methods and warrant further investigation.

Background: Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium.

Methods: The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium.

Results: Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2).

Conclusion: The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.

Background: An intermediate care unit opened in 2008 aiming to relieve pressure on beds in the local general hospital. Its goal was to provide rehabilitation for people recovering from physical illness who had coexisting psychiatric symptoms, including from delirium, but for whom assessment suggested that discharge home might be achieved. As an experimental unit, it warranted evaluation. We aimed to identify clinical factors associated with higher rates of discharge of the patients to their own homes.

Methods: A naturalistic retrospective exploratory cohort study of 100 consecutive admissions to the intermediate care unit. A backward logistic regression analysis was performed.

Results: Discharge home was associated with better scores on the Barthel Index of Activities of Daily Living at the time of discharge, a shorter duration of stay, and a psychiatric diagnosis other than delirium.

Conclusions: At the time of pre-admission assessment, clinical factors which were likely to predict discharge home were unclear, suggesting a need for further studies to determine who might best benefit from this sort of intermediate care placement.

Background: There are limited data on the impacts of alcohol use in older adults. We aimed to evaluate self-reported hospital admissions and falls against current Australian alcohol consumption guidelines.

Methods: We conducted a longitudinal analysis of data from five Australian cohort studies. The study comprised 16,785 people aged 65 years or older at baseline. Alcohol consumption was categorized using Australian guidelines in standard (10 g) drinks per day as “abstinent,” “low-risk” (>0 ≤2), “long-term risk” (>2 ≤4), or “short-term risk” (>4). Separate generalized estimating equations for men and women, controlling for key demographic, and health variables (depression, diabetes, circulatory and musculoskeletal conditions) were used to examine the relationship of alcohol consumption with hospitalization and falls against a reference category of low-risk consumption.

Results: Most participants were in the low (10,369, 62%) or abstinent (5,488, 33%) categories. Among women, all alcohol groups had greater odds of admission than low-risk users; among men, only the abstinent group had increased odds. For both genders, depression, diabetes, circulatory and musculoskeletal conditions all increased the odds of admission. For both genders, the unadjusted model showed that abstainers had increased odds of falling, with depression, diabetes, and for women, musculoskeletal conditions also associated with falls in the adjusted model.

Conclusion: These outcomes suggest that older women in particular could benefit from targeted alcohol consumption messages or interventions. In relation to falls, other health conditions appear better targets for intervention than alcohol use.

Background: While venous thromboembolism (VTE) risk assessment and prophylaxis is well established for medical and surgical in-patients, there is a paucity of evidence, and therefore guidelines, in this area for psychogeriatric in-patients. We wished to determine VTE incidence, risk, and use of prophylaxis, in a psychogeriatric in-patient population.

Methods: Retrospective audit of consecutive psychogeriatric patients aged 65 years and over admitted to Bankstown Hospital over a 3-year period, 2007–2009. Using an adapted VTE risk scoring system, patients were assigned as low, medium, or high VTE risk.

Results: A total of 192 patients were included in the study. Mean age was 79.1 ± 7.0 years. Out of the total, 55.2% of patients had diagnosis of dementia, and 33.3% had depression. Overall, 81.8% (157/192) were assessed as low risk, and 18.2% (35/192) as medium risk. Also, 16.7% (32/192) received VTE prophylaxis.

Four new VTE events occurred in medium-risk group, and one in low-risk group (p = 0.004). Overall VTE incidence was 10.5/10,000 patient-days, but 44.2 per 10,000 in medium-risk group. VTE risk score was predictive of VTE events – IRR 6.02 (95% Confidence Intervals (CI) = 1.76–20.7, p = 0.004) for every one-point increment in risk. Depression was associated with significantly higher VTE occurrence (6.3% in those with diagnosis vs. 0.8% without, p = 0.043).

Conclusion: Using a VTE risk scoring system adapted for psychogeriatric in-patients, those assessed to be at medium risk had a significantly increased rate of VTE. On this basis, we would recommend VTE prophylaxis be prescribed for psychogeriatric in-patients assessed to be at medium and high level of risk.

Background: Agitation and aggression in Alzheimer's disease (AD) are amongst the most serious of neuropsychiatric symptoms, and contribute to poor outcomes and worse quality of life. Previous studies have suggested a benefit for memantine on agitation and aggression, but none have examined its efficacy in community-dwelling patients with significant agitation and aggression at baseline, utilizing these behaviors as a primary outcome measure.

Methods: Patients with moderate-to-severe AD with Neuropsychiatric Inventory (NPI) total score ≥13 and NPI agitation/aggression score ≥1 were randomized to placebo or 20-mg memantine in a double-blind, 24-week trial. Co-primary outcome measures were behavior, measured by total NPI score, and cognition, using the Severe Impairment Battery (SIB). Secondary outcome measures included global assessment, function and other measures of behavior. This trial was registered as Clinicaltrials.gov: NCT00857649.

Results: A total of 369 patients (average age = 75, average MMSE = 12) were randomized to placebo or memantine. The study was prematurely terminated due to recruitment problems. There were no statistically significant differences between memantine and placebo in mean change from baseline in NPI, SIB, or any of the secondary outcome measures. Behavior improved in both groups (total NPI change scores −3.90 ± 1.24 for memantine and −5.13 ± 1.23 for placebo). Memantine was generally well tolerated and patient retention in both treatment arms was good.

Conclusions: The study failed to show the superiority of memantine in this sample of patients with moderate-to-severe AD with significant baseline agitation and aggression. Methodological limitations could have contributed to these results.

Background: Functional impairment is a core symptom of Alzheimer's disease (AD) often measured by loss of ability to perform activities of daily living (ADL). The objective is to describe the progressive loss of specific ADL functional capabilities expressed by AD patients’ cognitive ability.

Methods: Data are from ELN-AIP-901, an observational study of cognitive progression in participants aged 50–85 with AD (n = 196), mild cognitive impairment (n = 70), or cognitively normal (n = 75). Participants were evaluated using the Mini-Mental Status Exam (MMSE) and the Disability Assessment for Dementia (DAD) every six months for ≤2 years. Hierarchical regression was used to estimate annual change in DAD and MMSE; first, by individuals’ rate of change using linear regression, then controlling for baseline diagnosis.

Results: Over a two-year period, in AD participants, a 1-point change in MMSE was associated with a 3-point change in DAD (2.79, 95% CI: 1.97–3.63); DAD items within the finance, medication, and outings subdomains were impacted earlier than other subdomains; a hierarchy of functional impairment was observed, with instrumental ADL generally impaired prior to basic ADL.

Conclusions: ADL are impacted in a progressive and hierarchical manner associated with cognitive decline, but substantial variability remains among individuals, as well as in the relative order of items affected.

Background: A consensus on the brain dysfunction(s) underlying the delusions of Alzheimer's Dementia (AD) remains to be achieved. The aim of the present study was to test the hypothesis that content-based categorization of delusional ideas manifests as dysfunction of category-specific brain regions.

Methods: Fifty-nine consecutive first-visit AD outpatients underwent Single Photon Emission Computed Tomography (SPECT), Mini-Mental State Examination, and Behavioral Pathology in Alzheimer's Disease Frequency-Weighted Severity scale (BEHAVE-AD-FW) to assess cerebral blood flow (CBF), cognitive function, and delusion, respectively. SPECT images were analyzed by SPM5.

Results: CBF decreased at the temporal poles and right inferior temporal gyrus in “delusion of theft,” at the temporal poles in “suspiciousness/paranoia,” at the right parahippocampal gyrus and insula in “abandonment,” and at the right amygdala in “Residence is not home.”

Conclusions: Our findings offer a perspective on the discrete categories of the pathological thoughts of AD patients that have previously been lumped together as “delusions.” Dysfunction of the temporal poles may be associated with a socioemotional deterioration that may include pathological suspiciousness. Delusion of theft may be a manifestation of socioemotional deterioration and poor insight. Emotional factors may be essential for delusions of abandonment and “not home.”

Background: Exercising choice and control over decisions is central to quality of life. The Mental Capacity Act 2005 (England and Wales) provides a legal framework to safeguard the rights of people with dementia to make their own decisions for as long as possible. The impact of this on long-term planning has been investigated; everyday decision-making in people's own homes remains unexplored.

Methods: Using a phenomenological approach, we interviewed 12 dyads (one person with dementia + one carer) four times over one year to ascertain experience of decision-making, how decisions were negotiated, and how dynamics changed. Qualitative interviews were conducted in people's own homes, and thematic analysis was applied to transcripts.

Results: Respecting autonomy, decision-specificity and best interests underlay most everyday decisions in this sample. Over time, dyads transitioned from supported decision-making, where person with dementia and carer made decisions together, to substituted decision-making, where carers took over much decision-making. Points along this continuum represented carers’ active involvement in retaining their relative's engagement through providing cues, reducing options, using retrospective information, and using the best interests principle. Long-term spouse carers seemed most equipped to make substitute decisions for their spouses; adult children and friend carers struggled with this.

Conclusions: Carers may gradually take on decision-making for people with dementia. This can bring with it added stresses, such as determining their relative's decision-making capacity and weighing up what is in their best interests. Practitioners and support services should provide timely advice to carers and people with dementia around everyday decision-making, and be mindful how abilities may change.

Background: Connecting willing patients with dementia to suitable clinical research studies has been historically challenging. The United Kingdom Dementia and Neurodegenerative Research Network (DeNDRoN) was established to link patients into high-quality studies. One component is DemReg, a register of dementia patients and their carers who have agreed to be approached regarding future research studies. The limited literature highlights the predominance of altruism mediating research register participation. The objective of this study was to understand the motivations of patients and carers to participate in DemReg.

Methods: There were 107 participants in the study, interviewed using a questionnaire to determine which factors were important in their decision to be on the register. The study compared the proportion of the altruistic motivations articulated with the proportion of the other answers offered.

Results: The two most important motivators for registering on DemReg were to help others (44%; p < 0.001) or themselves (29%; p < 0.001) and altruistic motives took precedence over those for personal benefit. Participants were not motivated by the prospect of payment or by concern that they would be letting down their clinician if they did not register.

Conclusions: There are currently major projects within the United Kingdom to increase the number of patients on dementia registers and to further involvement in dementia research. This study, to the best of our knowledge, is the first to assess the motivations of patients and carers for joining a dementia research register in the United Kingdom, and the findings highlight the importance of altruistic motives.

Background: Caring for a relative with dementia has been associated with high levels of psychological morbidity in carers. Sense of coherence is an important resource of successful coping with caregiving. The purpose of the present study was to examine the relationship between stress associated with caregiving, sense of coherence, and self-reported depression and anxiety in family carers of people with dementia. We hypothesized that carers reporting high levels of anxiety and depression will report low levels of coherence, and that the relationship between caregiver stress and affective symptoms will be mediated by sense of coherence.

Methods: A total of 170 carers of people with dementia took part in the present study. Family carers completed the Sense of Coherence Scale, the Relative Stress Scale, and the Hospital Anxiety and Depression Scale. A series of multiple linear regressions were conducted to examine the relationship between stress related to caregiving, caregiver anxiety and depression, and whether sense of coherence mediated this relationship.

Results: Self-reported anxiety and depression were associated with low levels of sense of coherence. Sense of coherence mediated the relationship between burden and self-reported depressive effect and anxiety symptoms.

Conclusions: Carers reporting high levels of anxiety and depression are more likely to report low levels of sense of coherence. The relationship between stress related to caregiving and depressive symptoms is mediated by carers’ self-reported sense of coherence. Future psychotherapeutic intervention studies in family carers of people with dementia may incorporate strategies that specifically target sense of coherence.

Background: Previous research has shown that healthy behaviors, such as regular physical exercise, a nutritious diet, and not smoking, are associated with a lower risk for Alzheimer's disease and dementia. However, less is known about the potential link between healthy behaviors and mild memory symptoms that may precede dementia in different age groups.

Methods: A daily telephone survey (Gallup-Healthways Well-Being Index) of US residents yielded a random sample of 18,552 respondents ranging in age from 18 to 99 years, including 4,423 younger (age 18–39 years), 6,356 middle-aged (40–59 years), and 7,773 older (60–99 years) adults. The questionnaire included demographic information and the Healthy Behavior Index (questions on smoking, eating habits, and frequency of exercise). General linear models and logistic regressions were used in the analysis.

Results: Older adults were more likely to report healthy behaviors than were middle-aged and younger adults. Reports of memory problems increased with age (14% of younger, 22% of middle-aged, and 26% of older adults) and were inversely related to the Healthy Behavior Index. Reports of healthy eating were associated with better memory self-reports regardless of age, while not smoking was associated with better memory reports in the younger and middle-aged and reported regular exercise with better memory in the middle-aged and older groups.

Conclusions: These findings indicate a relationship between reports of healthy behaviors and better self-perceived memory abilities throughout adult life, suggesting that lifestyle behavior habits may protect brain health and possibly delay the onset of memory symptoms as people age.

Background: The study of exceptionally long-living individuals can inform us about the determinants of successful aging. There are few population-based studies of centenarians and near-centenarians internationally, but none in Australia.

Methods: Individuals 95 years and older were recruited from seven electoral districts in Sydney using the electoral roll, Medicare lists, and multiple other strategies to obtain a representative sample. Physical and mental health and cognitive status were assessed using standard instruments in multiple sessions, with assessments individually adapted. An informant was interviewed, and participants were invited to donate a blood sample, undergo an MRI scan, and enrol into the brain donation program.

Results: Preliminary data on the first 200 participants are reported. Mean age was 97.4 years (range 95–106), with 29.5% being men, and 58.5% living in a private dwelling. Rates of heart disease and diabetes were lower than in octogenarians, but hearing and visual deficits were common. The mean mini-mental state examination (MMSE) score was 21.1, with men performing better. Rates of psychological distress were low and satisfaction with life high (mean 5.91 out of a maximum of 7); 54% scored <24 on MMSE; 39.5% were impaired on both MMSE and a functional measure; and 20% had previous diagnosis of dementia.

Conclusions: This is a preliminary report describing the methodology of the study. It provides further evidence that dementia is not inevitable at this age and independent living is common. The study provides an excellent resource to determine the genetic and environmental contributions to long and successful cognitive aging.

Background: Post-traumatic stress disorder (PTSD) is a severe anxiety disorder whose symptoms include re-experiencing, avoidance, and hyperarousal after a particularly intense event. In view of the aging of the population, increased clinical knowledge is required for better understanding of PTSD in the elderly. Extending previous research in this field in adults and children, the aim of our study was to assess the utility of peri-traumatic dissociation and distress as a predictor of PTSD in the elderly.

Methods: A prospective longitudinal study was conducted in a consecutive cohort of subjects aged 65 years and over admitted to emergency departments after a physical assault or a road traffic accident. Peri-traumatic responses of distress and of dissociation were measured. One, 6, and 12 months after trauma exposure, PTSD symptoms and diagnosis were assessed using both a dimensional and a semistructured interview.

Results: Thirty-nine male and female participants with an average age of 72.4 years were recruited. Mixed model regression analyses did not detect a significant effect of age, sex, nor time. Significant associations were detected between peri-traumatic distress and the self-report PTSD Checklist (p = 0.008), as well as the Clinician-administered PTSD scale (p = 0.03). No association was detected between peri-traumatic dissociation and PTSD.

Conclusions: Peri-traumatic distress predicts PTSD symptoms and diagnosis in the elderly, thereby suggesting its systematic evaluation at the emergency department would be a worthwhile thing to do.

Background: This study was to examine culturally based factors as potential predictors of depressive symptoms in older Taiwanese adults living in eight long-term care institutions in southern Taiwan.

Method: A cross-sectional, exploratory design study was used with a purposive sample of 156 participants with a mean age of 79.80 ± 7.14 years. Measurements included filial responsibility expectation questions, two questions about degrees of acceptance of institutionalization, Perceived Stress Scale, Self-Transcendence Scale, and Geriatric Depression Scale.

Results: An elder's willingness to be institutionalized, an elder's willingness to remain institutionalized, perceived stress, and self-transcendence were significantly associated with depressive symptoms (r = –0.35; –0.49; 0.60; and –0.67, respectively). Although no evidence for the relationship between filial responsibility and depressive symptoms was found in this study, there was evidence that filial responsibility was highly valued. Self-transcendence was the strongest predictor of depressive symptoms, accounting for 45% of the variance.

Conclusion: These findings provide insight into the cultural factors associated with depressive symptoms and support the need of timely interventions for institutionalized Taiwanese elderly population.

Background: The provision of mental health care for older people will become increasingly important with rising demand related to global demographic changes. This project aimed to identify changes in work patterns of UK consultant old age psychiatrists between 1993 and 2012.

Method: A link to an online questionnaire was circulated to consultant old age psychiatrists through the Faculty of Old Age Psychiatry, Royal College of Psychiatrists.

Results: In all 210 usable responses were received. On the survey day 71% of old age psychiatrists arrived at work before 9 am, and 40% left work after 6 pm. Over one-third (35%) worked for another hour or more at home. The range of activities was broader than previously reported. Administrative activity was undertaken by over 60% and acute ward work by only 26%. Few consultants reported time in long-stay care or day hospitals. Outpatient activity included Memory Clinics and Health Center Clinics. The main stressors reported by consultants were lack of resources and pressures from management-imposed, financially driven service changes. Relationships with people at work (including patients and their families) and outside work were the main identified support.

Conclusions: Consultants’ working hours have changed little since 1997, but the range and emphases of activities have changed. Changes in service organization are stressful and consultants are supported by relationships with colleagues and patients. Work patterns are changing in response to demands and constraints on the specialty. Research is needed into service design and work patterns, which can provide humane care in the current economic climate.