Psychogeriatrics began as an extension of psychiatry, with an emphasis on the unique manifestation of psychiatric disorders in the elderly. Early in the history of psychogeriatrics there was an emphasis on late-onset or late-enduring depression; paraphrenia and late-onset psychotic disorders; the late-life phases of schizophrenia; and anxiety and substance abuse disorders in the elderly. Growing recognition of the increasing frequency of Alzheimer's disease (AD) in the course of aging and the high prevalence of behavioral disturbances in patients with AD led psychogeriatricians to study the diagnosis and management of this disorder.

In order to conceptually define quality of life (QOL) in dementia, the literature on QOL in the elderly population, in chronic disease and in dementia was studied. Dementia is a progressive, age-related, chronic condition and to avoid omissions within the dementia-specific concept of QOL, a broad orientation was the preferred approach in this literature study. Adaptation is a major outcome in studies investigating interventions aimed at improving QOL in chronic conditions, but to date, it has not been used in the definition of QOL. It is argued that adaptation is an important indication of QOL in people with chronic diseases and therefore also in dementia. Some crucial issues in assessing dementia-related QOL that are relevant to clarify the continuing debate on whether QOL, particularly in dementia, can be measured at all, are discussed. Then the following conceptual definition is offered: dementia-specific QOL is the multidimensional evaluation of the person–environment system of the individual, in terms of adaptation to the perceived consequences of the dementia.

Studies on laypersons' beliefs and knowledge about mental disorders have proliferated in recent years. However, attention has been focused mainly on depression and schizophrenia and on young adults. The aim of this paper is to summarize research in the area, and to discuss the need to expand research in the elderly population. The unique characteristics of older persons in terms of the prevalence and type of mental disorders, especially Alzheimer's disease (AD) and other dementias, as well as in terms of their being victims of “double jeopardy” require special attention and research. The present review has three main objectives. First, it summarizes the findings of studies examining different aspects of mental health literacy. Second, the importance of age in the study of mental health literacy is discussed. Third, findings of the few studies examining laypersons' beliefs in the area of AD are presented. Finally, research directions are suggested with special emphasis on the importance of geriatric mental health and mental health literacy.

Background: There is doubt about the value of training in dementia care in U.K. nursing homes. We decided to estimate the association between nursing staff's attitudes to dementia and dementia care and their recognition of cognitive impairment in residents and other indicators of care practice in nonspecialist nursing homes derived from a probability sample of 445 residents in South-East England, and to relate this to previous training.

Methods: Prospective survey. The most senior nurse on duty was interviewed about each resident sampled, about their own training and experience, their attitude to restriction of egress and covert medication use, and asked to complete the Attitudes to Dementia Questionnaire (ADQ) and the dementia Care Styles Questionnaire (CSQ). Nurses were also asked about care practices in relation to restriction of egress and covert medication use in the home. Residents were interviewed using the Mini-mental State Examination (MMSE).

Results: One hundred and fifty-eight nurses were interviewed. Increased person-centered attitudes seem to be associated with better recognition of cognitive impairment independent of training and experience. The espousal of restrictive practices was also associated with better recognition, but only when analysis included nurses reporting on only one impaired resident.

Conclusions: More person-centered attitudes are associated with better recognition of cognitive impairment, despite perverse U.K. regulatory incentives; the need for training and support in developing person-centered dementia care for staff in “non-Elderly Mentally Infirm” (“non-EMI”) care homes is supported by these results.

Background: A variety of interventions are available to support the caregivers of dementia patients. For the purposes of service planning, we developed an instrument to assess the needs of these caregivers and to determine whether needs are met. The reliability and validity of this new instrument was also investigated.

Methods: The development of the Carers' Needs Assessment for Dementia (CNA-D), was based on in-depth interviews and a focus group. The combined inter-rater and test–retest reliability was investigated among 45 dementia caregivers. Correlations of the CNA-D with the Zarit Burden Inventory were used to analyze concurrent validity. Content validity was investigated by performing a separate survey among 40 caregivers and 40 professionals.

Results: The CNA-D is a semi-structured research interview including 18 problem areas. For each problem area, the CNA-D offers several possible interventions. The relevance of the problem areas and the interventions (content validity) was confirmed by most of the study participants. Significant positive associations were found between the total score of the Zarit Burden Inventory and the number of problems and the number of unmet needs according to the CNA-D. The agreement between the interviewers was “excellent” (κ above 0.75) in 73.7% of the problem areas and in 69.9% of the interventions.

Conclusions: The CNA-D is a valid and reliable instrument for comprehensively assessing the needs of dementia caregivers.

Background: Dementia among nursing home residents is often accompanied by high care dependency and behavioral disturbances, resulting in an increased workload for the caregivers. Snoezelen, integrated into 24-hour dementia care, is an approach that might improve the quality of working life of dementia caregivers. This study aims to investigate the effectiveness of integrated snoezelen on work-related outcomes (workload and psychological outcomes) of caregivers in psychogeriatric nursing homes.

Methods: A quasi-experimental pre- and post-test design was used, comparing six psychogeriatric wards that implemented snoezelen in 24-hour care to six control wards that continued giving usual care. One hundred and twenty-nine Certified Nursing Assistants (CNAs) were included in the pre-test and 127 CNAs in the post-test. The six intervention wards received a 4-day in-house training program. The intervention further consisted of implementation activities on the ward (e.g. stimulus preference screening, workgroup), three in-house follow-up meetings and two general meetings. Measurements on workload, perceived problems, stress reactions, job satisfaction and burnout were performed at baseline and after 18 months.

Results: A significant treatment effect in favor of the experimental group was found for time pressure, perceived problems, stress reactions and emotional exhaustion. CNAs of the experimental group also improved on their overall job satisfaction score. In particular, they were more satisfied with the quality of care and with their contact with residents.

Conclusion: The implementation of snoezelen improved the quality of the working life of dementia caregivers.

Background and objectives: The use of risperidone or olanzapine to treat behavioral problems associated with dementia is no longer recommended in the U.K. because of the increased risk of cerebrovascular adverse effects (CVAEs) and/or mortality. To evaluate the risks and benefits of antipsychotics, we measured the rate of mortality in patients with dementia, Alzheimer's disease (AD) and vascular/mixed dementia and compared mortality rates between those who had received antipsychotics and those who had not received antipsychotics.

Methods: A total of 273 subjects were assessed at baseline, 6 months and 12 months using a 1-year prospective follow-up design. Mortality rates between groups were compared using a Kaplan–Meier curve and log-rank statistics. Relative risks (RRs) were examined by the Cox proportional-hazards model.

Results: The overall 1-year mortality rate in dementia was 23.8%. The mortality rate in those who had not received antipsychotics (26.8%) was higher than that in those who had received antipsychotics (20.6%). RR and 95% confidence interval (CI) of mortality, when we compared those who had not received antipsychotics with those who had received antipsychotics, was 1.277 (95% CI 1.134–1.437) after controlling for age, severity of dementia, medical comorbidities, cognitive impairment (measured by the Korean version of the Mini-mental State Examination (MMSE)) and behavioral and psychological symptoms of dementia (BPSD), measured by the Behavioral Pathology in Alzheimer's Disease Rating Scale, Korean version (BEHAVE-AD-K). When those who had not received antipsychotics were compared with those who had received both risperidone and haloperidol, RR (95% CI) was 1.225 (1.101–1.364).

Conclusion: This study does not support reports that antipsychotics increase mortality in dementia.

Background: Complaints of sleep disturbance are common in elderly individuals. The quality of life (QOL) for people who have insomnia is thought to be worse than for those who do not have insomnia. In this study we investigated the influence of disturbed sleep on morale in elderly people who live independently.

Methods: A survey of the necessity of public nursing care for all those aged over 65 years was performed in Kumamoto city, Japan. Three hundred subjects from the elderly population living at home without special care were sampled at random and they filled out a questionnaire regarding sleep, psychiatric symptoms and attitudes towards their own aging.

Results: A logistic regression analysis found psychiatric symptoms and problems keeping awake to be independently related to a negative attitude towards one's own aging. Neither sleep, sex nor age demonstrated any relationship with the negative attitudes of elderly individuals.

Conclusion: Excessive daytime sleepiness is related to poor morale regardless of both the quality and quantity of sleep and psychiatric symptoms.

Background: Although most people with dementia experience an insidious onset of symptoms, in some cases onset can be acute. The importance of acute onset is unclear. Some reports suggest that it portends a worse course.

Methods: We performed a secondary analysis of the clinical examination cohort (n=2914) of the Canadian Study of Health and Aging (CSHA). We defined “acute onset of dementia” from the Cambridge Examination for Mental Disorders in the Elderly (CAMDEX) questionnaire, conducted with an informant. People with dementia of acute onset were compared to those with dementia of insidious onset for development of adverse outcomes of death and institutionalization over 5years.

Results: Of the 1132 people who had dementia, 130 (11.5%) met criteria for acute onset. Compared with gradual-onset dementia patients, those with acute-onset dementia were more often men (42% vs. 30%, p<0.05), resided in nursing homes (75% vs. 63%, p<0.05), had vascular risk factors (72% vs. 47%, p<0.05), and a Hachinski Ischemia Scale (HIS) score ≥7 (64% vs. 19%, p<0.05). More patients with dementia of acute onset than gradual onset were diagnosed with vascular dementia (55% vs. 13%; p<0.05). Adjusted hazard ratios (HRs) for survival and institutionalization in the acute-onset group were 0.93 [95% confidence interval (CI) 0.7–1.2] and 0.76 (95% CI 0.4–1.3), respectively, compared with the gradual-onset group.

Conclusions: People with acute-onset dementia had more vascular risk factors than those with gradual-onset dementia across all dementia diagnoses, and lower risks of institutionalization but worse survival. Routine inquiry about the onset of dementia might help to better clarify prognoses in patients with dementia.

Objective: To develop and validate an Instrumental Activities of Daily Living Scale for elderly people (IADL-E) to use in conjunction with cognitive screening tests for dementia in an educationally and socioculturally heterogeneous population.

Method: Eleven IADL items were selected and weighted for major factors causing heterogeneity in the population – gender, education, social (rural/urban) setting and age. Each item was rated for its applicability (yes/no), degree of disability (scored from 0 to 2) and causative impairment (cognitive and/or physical). From this a composite index of cognitive (CDI) or physical (PDI) disability was derived. Validation was performed retrospectively on 240 subjects: 135 without and 105 with dementia by DSM-IV.

Results: The IADL-E had a high internal consistency (α=0.95). The area under the receiver operating characteristic (ROC) curve was 0.97 (CI=0.94−0.99). A cutoff score of 16 on CDI provided a sensitivity of 0.91, specificity 0.99 and positive predictive value 0.76 (at 5% base rate). IADL-E correlated highly with clinical (DSM-IV, κ=0.89), functional (CDR, 0.82) and cognitive (Mini-mental Status Examination, MMSE, 0.74) diagnoses. It showed good responsiveness, with the change on CDI over a median of 23 months correlating significantly with that on MMSE (coefficient=−0.382, CI=−0.667 to −0.098; p=0.009). Individual items had good interrater and test–retest reliability.

Conclusions: The IADL-E is a reliable, sensitive and responsive scale of functional abilities useful in dementia screening in a socioculturally heterogeneous population.

Background: The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high, and it has been shown previously that people with such symptoms have poorer health outcomes. This study was designed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth, Western Australia. We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls.

Methods: The study was designed as a randomized, single-blinded, controlled trial. All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated randomly to the intervention or usual care group. Demographic and clinical information (including medications and use of physical restraint) was gathered systematically from all participants at baseline, and at 6 and 12 months. At each assessment, the Geriatric Depression Scale (GDS), the Health of the Nation Outcome Scales for older adults (HoNOS 65+), the Mini-mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered. Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were reviewed within a 2-week period by the Inner City Mental Health Service of Older Adults (ICMHSOA). If clinically appropriate, mental health services were introduced without the involvement of the research team.

Results: One hundred and six subjects and their next of kin consented to participate in the study (53 in each group). Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts, self-rated health, use of psychotropic or PRN medication, use of physical restraint, 12-month mortality, or mental health outcomes, as measured by the GDS-15, HoNOS 65+ and NPI (p>0.05 for all relevant outcomes).

Conclusion: Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes. More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed.

Background: Cerebrovascular disease may cause “vascular depression” (VaD). Calcium-channel blockers are presumed treatments for cerebrovascular disease and might be expected to improve depression and prevent recurrence.

Objective: To examine the efficacy and tolerability of the use of nimodipine as an augmentation of fluoxetine in the treatment of VaD.

Design: A double-blind, randomized clinical trial in which 101 patients with VaD (Alexopoulos criteria) were treated with fluoxetine at standard doses. Patients were randomized to placebo (n=51) or nimodipine (n=50). Treatment outcomes were assessed using the Hamilton Depression Rating Scale (HDRS) regularly up to 8 months after treatment initiation.

Results: Depression was reduced in 63% of patients, but those whose treatment was enhanced with nimodipine had greater improvements overall by repeated measures analysis of covariance (ANCOVA) (F(1.80)=9.76, p=0.001). In addition, a greater proportion of patients treated with fluoxetine–nimodipine (54% vs. 27%) exhibited full remission (χ2(d.f. 1)=7.3, p=0.006), with the number needed to treat (NNT) equal to 4 (95% CI 2–12). Of those experiencing full remission in the first 61 days, fewer patients on fluoxetine–nimodipine (3.7%) developed recurrence of major depression as compared to those on fluoxetine alone (35.7%) (χ2(d.f. 1)=7.56, p=0.006), NNT 3 (95% CI 2–9). Side-effects were noted in 33.3% of patients in the control group and 48% of the experimental group (χ2(d.f. 1)=2.25, p=0.133).

Conclusions: In treating VaD, augmentation of fluoxetine with nimodipine led to better treatment results and lower rates of recurrence. These findings support the argument that augmentation of antidepressant therapy might be helpful in the treatment of cerebrovascular disease, which is involved in the pathogenesis of this type of depression.

Background: Subjective cognitive complaints have been included in diagnostic concepts such as Aging-Associated Cognitive Decline (AACD) aiming to identify older adults with cognitive impairments at high risk of developing dementia. Although several studies in normal aging have found that subjective cognitive complaints are related to depressive affect and personality factors, little is known as to whether this is also true for older adults with AACD.

Methods: In 123 older adults diagnosed with AACD and 291 controls, the role of actual cognitive performance, depressive affect, neuroticism and conscientiousness in predicting subjective cognitive complaints was investigated. In separate ordinary least squares regression analyses for both groups with gender, age, years of schooling, cognitive performance, depressive affect, neuroticism and conscientiousness as predicting variables, in the control participants, gender, age, depressive affect and neuroticism were related to subjective cognitive complaints, whereas in the AACD participants only gender and neuroticism accounted for variance in subjective cognitive complaints. Testing for group differences in predictive power, revealed differential effects for gender, depressive affect and neuroticism.

Conclusions: As subjective cognitive complaints in the AACD group were related to neuroticism and gender rather than to cognitive performance, their inclusion in diagnostic concepts such as AACD should be revaluated. However, the nature of subjective cognitive complaints might be qualitatively different in persons diagnosed with AACD compared to those stated by normal older adults.