Our journal has been a quarterly for nearly 4 years. Prior to that, it came out twice a year. Now, a quarterly can come out by season or by named month. Season proved not to work for us because of objections from colleagues in the southern hemisphere. Specifying months has been better except that the journal has been coming out late. This has annoyed our readers. Why has this been happening?

Finding genetic linkage and identifying the genes responsible for disease can revolutionize our understanding of disorders with obscure or complex etiology and pathogenesis (Weatherall, 1991). When relevant genes have been cloned, the identification of specific mutations that cause disease (Goate et al., 1991) enables molecular pathogenesis of the condition to be addressed.

With reconsideration of the role of vascular risk factors for Alzheimer's disease (AD; Gorelick et al., 1996), and with a recent Consortium to Establish a Registry for Alzheimer's Disease (CERAD) report that pure vascular dementia may be more difficult to find than has been widely assumed (Hulette et al., 1997), it is appropriate to reevaluate our understanding of so-called mixed dementia, or the dementia syndrome that arises from the combination of AD and ischemic vascular injuries. Such a reevaluation leads to potentially important lessons, an outline of which is presented here.

It is a great honor and a privilege for me to introduce the fifth biennial IPA Research Awards in Psychogeriatrics sponsored by Bayer AG. As noted, these awards are sponsored and supported by Bayer AG, and on behalf of the IPA and the psychogeriatric community, I'd like to thank Bayer for their very generous support.

Today the IPA/Bayer award is bestowed for the fifth time. On behalf of Bayer, I would like to thank the participants, who by their sheer number and level of scientific quality have made this contest a real success. Bayer also thanks IPA and particularly Fern Finkel for providing the corporate and organizational framework for the award. In times of tighter budgets, this very much encourages Bayer to continue its commitment to sponsor the award. Let me reflect briefly about the rationale for this commitment.

Subcortical hyperintensities are easily visualized areas of signal abnormality that are seen on T2-weighted magnetic resonance imaging (MRI). Characteristically they occur in the white matter of the brain and are more common in elderly people. In depression, little is known of the clinical significance of subcortical hyperintensities or their contribution to the prognosis. Fifty-eight consecutive patients with DSM-III-R depression and an age range of 65 to 85 years were prospectively collected from an old-age psychiatry service. Response to treatment was assessed with a clinical global outcome measure. A neuropsychology battery was completed on all patients after treatment. Forty-four patients completed MRI scanning. The scans were scored using a regional rating system for hyperintensities. Forty-eight percent of patients had a favorable response to treatment on the clinical global outcome scale. Poor outcome was associated with female sex (p = .07), poor physical health (p = .040), diabetes (p = .018), psychosis (p = .026), and an early age at onset of first episode of depression (p = .036). Even after adjustment for confounding effects, there were significant neuropsychological associations with the regional hyperintensities. Distribution in the periventricular area correlated with delayed recall after distraction (p = .025), and punctate lesions in the basal ganglia correlated with impaired category production (p = .020). Pontine reticular formation hyperintensities were related to impaired psychomotor speed (p = 0.04). Location in the frontal deep-white matter (p = .024), basal ganglia (p = .03), and pontine reticular formation (p = .02) was associated with a poor acute response to treatment. However, the response to treatment was not related to total cerebral white-matter hyperintensity load. A logistic regression equation included all the significant prognostic features and found four independent predictors of poor outcome: More than five punctate lesions of the basal ganglia, diabetes, lower mean arterial pressure, and hyperintensity of the pontine reticular formation significantly predicted outcome. These four factors correctly predicted 95.6% of patients with a poor outcome and 85.7% with a favorable outcome. In late-life depression, subcortical hyperintensities are common. Lesions in the cerebral white matter are predominantly associated with memory disturbance, and those in deeper infratentorial areas, with psychomotor slowing and executive deficits. Total white-matter load has no prognostic value, and although some subcortical regions are associated with poor response, individually they have little specificity. However, a combination of involvement in three areas (basal ganglia, pons, and frontal lobe) is clinically relevant and predicts outcome with great accuracy (91%). Patients with lesions in the basal ganglia and deep white matter had an especially poor response to pharmacotherapy.

Reductions in healthcare spending and current demographic trends will result in increasing demands to care for aging relatives, especially those with cognitive impairment (e.g., Alzheimer's disease). Taking care of older individuals with cognitive impairment can be very challenging and burdensome. Caregiver burden is associated with negative outcomes such as caregiver depression and increased likelihood of patient institutionalization. One hundred eleven patients and their spousal caregivers were studied using a pre-post design. All subjects received a comprehensive medical intervention that included medical management of patients' problems and education of caregivers. We examined changes in patients' function and caregiver burden. At follow-up, patients' cognition and independence in activities of daily living had continued to deteriorate whereas their mood was improved. Regression analyses showed that changes in caregiver burden were positively associated with changes in the frequency of dysfunctional behaviors but not with changes in cognition. Gender was also related to changes in caregiver burden; male caregivers were more likely than female caregivers to report reductions in burden at follow-up. These data suggest medical interventions may provide some relief to caregivers of cognitively impaired older patients, but more research is required to identify the causal agents of this effect.

The wish to die in elderly persons is currently under debate. Experts are questioning whether it is natural for these individuals to show a wish to die, whether the right to eventually kill oneself should be respected, or whether suicidal intentions in old age are expressions of mental disorders that need intensive, professional care. A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview Geriatric Mental State Examination-Version A (GMS-A) and several self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R criteria and by clinical judgment. The goal of the study was to find examples of “pathology-free wishes to kill oneself.” A total of 115 out of 516 very old (70 to 105 years) persons, which represents 21.1% of the community population, said at the time of investigation that they wanted to die or felt life was not worth living (Hamilton Depression Rating Scale [HAMD] score 1, 2, or 3). Forty-three very old persons (6% of the community population) had the wish to be dead according to the HAMD or the GMS-A, and 11 persons (2% of the community population) had suicidal intentions. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as having psychiatric disorders and half to three quarters showed symptoms fulfilling the criteria of at least one specified psychiatric diagnosis. Acute suicidal intentions were in all cases associated with at least one specified diagnosis according to DSM-III-R. Thirteen persons out of 54 who actually wanted to die (GMS-A category 4, 5, 6 or HAMD category 2, 3) did not fulfill criteria for specified diagnoses. Seven individuals showed scores in self-rating and observer-rating scales that speak for mental disorders apart from pure suicidality. Six remaining persons are described in greater detail in short case vignettes. They showed either mild but chronic psychiatric disorders, fluctuating courses, or an atypical phenomenology of psychiatric disorders. The results of this study strongly suggest that the wish to be dead in the very old is most probable, and suicidal intentions are definitely associated with psychiatric disorders.

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longer-term cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

Many efforts have been made to trace the causes of Alzheimer's disease (AD). There are, however, many points of controversy among reports from the same country as well as among reports from different countries. The current study is a case-control study to determine the risk factors in the development of AD in Greece. Sixty-five patients with AD and 69 age-matched controls were examined. All patients with AD fulfilled the DSM-IV criteria for AD and NINCDS-ADRDA criteria for probable AD. Demographic characteristics such as gender, current marital status, who he/she is living with, education, main place of residence in childhood, adulthood, and late life, occupational hazards, patient's medical history (history of diabetes mellitus and hypertension), life habits like alcohol consumption and smoking, and a history of head trauma, heart attack, stroke, parkinsonism, or depression were collected from the subject or from an informant. A family history of selected diseases (hypertension, diabetes mellitus, dementia, Parkinson's disease, Down's syndrome, stroke) was also elicited. Ages of father and mother at birth were also recorded. Chi-square test, Kruskal-Wallis analysis of variance, cluster analysis, and logistic regression analysis were used for statistical analysis. The results (chi-square test) showed a statistically significant difference between patients with dementia of the Alzheimer type and controls as far as marital status (p = .04), the subject's history of major depressive episode (p = .02), and family history of dementia (p = .002) were concerned. Logistic regression analysis results produced a complex model of family aggregation of dementia, with patients with a history of depression and family history of dementia having an up to seven times higher risk of developing AD. These findings, especially a family history of dementia, are consistent with most of the literature.

The heterogeneity in severe mental illnesses means that although some persons exhibit a chronic course in later life, others may recover for long periods or have episodes throughout the lifespan. The challenge to mental health providers is to identify those people most at risk for a chronic or relapsing course in later life. Data described here come from a prospective study of course and adjustment in severe mental illness for persons over age 40. The sample of 313 people, residing in the community and both in treatment and not in treatment, is unique. Six 8-month course patterns were identified; nearly one third of the participants had course patterns that were unstable, and one third were well across the 8 months. Older participants were more stable and less depressed, but otherwise were very similar to those in middle age. Demographic and history variables that predict long-term outcomes were not useful for predicting short-term recovery or relapse.

The purpose of this study was to obtain information about the prevalence of depressive symptoms in a representative sample of elderly subjects aged 85 years and over. The study was carried out as a population-based interview study in the City of Vantaa in Finland. The Zung Depression Status Inventory (DSI) was used to evaluate various depressive symptoms in this study population. The DSI scores range from 20 to 80; the higher the score, the more severe the disturbance. In subjects interviewed (n = 467, 362 women, 105 men), the prevalence estimates of depression with cutoff scores used in earlier studies (40 and 48) were very low: 5.2% and 1.1%. Also, the mean DSI score (SD) was very low, 27.9 (6.4). The scores tended to decrease with age, although the differences were not statistically significant. The DSI means were 28.0 (6.1) for women and 27.3 (7.2) for men (p = .0349). Women had a greater risk of being classified as depressed on the DSI (odds ratio: 1.60, 95% confidence interval: 1.00-2.57, p = .049). Feelings of emptiness, personal devaluation, and depressive mood were the most common depressive symptoms. In conclusion, the present population-based study shows that subjective experience of depression is very rare in Finnish people aged 85+. Our results suggest that optimistic mood might give some protection against death.