In 1974 one of us attended a lecture on aging by the Nobel prize winning immunologist, Sir Macfarlane Burnet. Burnet indicated that oxidative stress was central to the aging process, and that interventions to ameliorate this process should prolong the human lifespan and diminish the incidence of age-related diseases, one of the most important of which is, of course, Alzheimer's disease (AD). A decade after this lecture was given, Burnet died of rectal carcinoma – a typical age-related disease. Thirty three years on, has the field advanced at all?

Since the first human application of electroconvulsive therapy (ECT) by Cerletti and Bini in 1938 (Endler, 1988), its history has been replete with examples of both successes and failures. The failures have been related not only to adverse effects but also to the use of ECT at various times without appropriate clinical indications. Acknowledging that ECT has been misused and abused in the past, professional organizations have made strenuous efforts to develop guidelines for its proper use (American Psychiatric Association, 2001). However, persisting stereotypes have fostered fear and distrust in patients and their families, as well as in the general public and popular media (Brewis, 2001), sometimes resulting in reduced access to ECT.

Older patients hospitalized with major depression in the U.S.A. are more likely to be treated with electroconvulsive therapy (ECT) than younger patients (Olfson et al., 1998; Thompson et al., 1994). Concerns have been expressed that ECT may be “overused” in these older patients, who may be especially sensitive to its physical and cognitive adverse effects. We selectively review the evidence on this issue, addressing several questions that are important for clinicians who treat older depressed patients. While ECT is used in other geriatric syndromes (e.g., depression in Parkinson's disease, bipolar depression, etc.), we focus exclusively on non-bipolar major depression because there is almost no published evidence relevant to these other conditions.

Regrettably, psychological treatments are often overlooked in the management of severe late-life depression while ECT is favored, even though it is more likely to be harmful and its evidence base is slim. This is of little surprise given that psychiatrists are often guilty of overlooking potentially beneficial psychosocial interventions preferring more familiar biological treatments. This position is unacceptable: depressed older adults deserve access to a whole range or interventions in order to maximize benefits and choice.

Electroconvulsive therapy (ECT) is one of the oldest interventions in psychiatry. Like many aging celebrity rock-stars of the 1960s, ECT has outlived critics who predicted its early demise and in fact continues to create a bigger bang than it did at inception (http://www.rollingstones.com/abiggerbang/). ECT owes its longevity largely to a series of well-conducted trials since the 1970s that secured its endorsement by special committees and task forces of national associations (American Psychiatric Association, 2001; Royal College of Psychiatrists, 1995), and guideline developers (Bauer et al., 2002; Fochtmann and Gelenberg, 2005; Kennedy et al., 2001; NICE, 2003).

The articles in this debate address two separate but overlapping questions regarding the management of severe depression in older adults: (1) Is electroconvulsive therapy (ECT) an efficacious and safe treatment, and (2) What is the role of psychotherapy? That the first question is asked at all may come as a surprise to the many practitioners of geriatric psychiatry who consider ECT to be an indispensable part of their therapeutic tool kit. Yet, Wilkinson argues that the evidence supporting the efficacy of ECT in the elderly is “sparse” and derived from studies that are “of poor quality.” He provocatively states that psychotherapy “is at least as important as ECT” in the management of severe late-life depression, and advocates the more widespread use of psychotherapy to treat severe depression in older adults, including individuals admitted to psychiatric inpatient units. There are two issues here. First, what is severe depression? Second, what constitutes sufficient evidence to support the use of ECT or psychotherapy in severe depression in late life?

Background: Referrals to clinical services of people living in severe domestic squalor are not uncommon. It is timely to review literature concerning and discussing such cases.

Method: Using Medline, Psychinfo, Embase, CINAHL and reference lists from relevant publications, literature referring to over 1100 cases was identified and then reviewed.

Results: Half of those described as living in severe squalor are elderly. Outcomes of intervention are often poor. People living in severe squalor are most commonly diagnosed as having dementia, alcoholism or schizophrenia, though personality problems are evident in a high proportion. There is evidence to suggest that neglect of hygiene and of attention to cleanliness of accommodation may be largely attributable to frontal lobe changes. The review also revealed a second body of literature, not often cited in papers focussed on unclean living conditions and published in psychiatric or medical journals, that concludes that hoarding is most commonly due to obsessive-compulsive disorder (OCD). Accumulation of rubbish is described in over half of the case reports on severe domestic squalor, but it is suggested that this should only be called hoarding if it results from purposeful collection of items. Lack of impulse control may contribute to collecting behavior, resulting in reduction in living space if there is also a failure to discard.

Conclusions: There is a need for further studies, using standardized ratings of living conditions, investigating and trying to understand the complex interplay of triggers and vulnerabilities, exploring how best to intervene and examining outcomes of interventions.

Background: Old age psychiatry as a clinical specialty emerged in the 1970s and modern, open-access multidisciplinary services started in the mid-1980s in South London. There are few accounts of referrals to old age psychiatry services and no quantitative accounts of the referral patterns to such teams. We report on the first 10,000 patients newly referred to the first such service in the world.

Methods: Observational study on routinely gathered data on age, gender, referral source, discipline of team member involved, diagnosis and duration of contact. Data validation was by iterative feedback to clinicians.

Results: Ten thousand patients were referred between December 1983 and March 2000. Missing data rates were low. The overall referral rate was 21.0 per 1000 population over 65 per annum, with the highest rate in those 85+ years old, in whom there was a marked rise over time. The rise in referral rate compensated for a decline in the population over 65 so that the numbers of referrals rose. Although there was a rise in the rate of referral of people with an organic diagnosis over time, this was not statistically significant. Organic patients constituted 50–60% of referrals but had shorter contact times than functional ones. Cause for concern included a low rate of referral from care homes, and a high proportion of possibly inappropriate referrals from medical and general psychiatry services. We were pleased to see no excess of such referrals from open-access sources, confirming earlier work.

Conclusions: Descriptive data on referrals and workload of the first open-access multidisciplinary old age psychiatry service have generated cause for both celebration and concern.

Background: Repeat cognitive testing is an essential diagnostic strategy to measure changes in cognition over time when following people with memory problems. Alternate forms may avert practice effects that can mimic improvements in cognition. We evaluated alternate forms of verbal fluency and logical memory (paragraph recall) tasks to evaluate their equivalence for clinical use.

Methods: Participants with mild cognitive impairment (MCI) and dementia were recruited from five outpatient memory clinics and one nursing home. Participants with normal cognition (NC) were recruited from family members or friends. Verbal fluency categories of animals, cities & towns, fruits & vegetables and first names were used. Scores were recorded for 0–30 seconds, 31–60 seconds and errors. For the logical memory task, participants were read one of three different paragraphs and then were asked to recall the story. Immediate recall and delayed recall scores were recorded. The Standardized Mini-mental State Examination, the AB Cognitive Screen and the 15-point Geriatric Depression Scale were administered as part of the assessment. Analyses were performed using means, frequency distributions, t-tests, receiver-operating characteristic curves and effect sizes.

Results: There were 46 NC participants, 45 with MCI and 55 with dementia. For verbal fluency, the mean number of animals, cities & towns, names or fruits & vegetables named in 60 seconds did not differ significantly within each cognitive group. First names was an easier category than the others: NC named 16.9–22.3 items, MCI named 11.6–14.4 items and dementia named 8.1–11.4 items. The mean number of items immediately recalled in logical memory was not significantly different for the three paragraphs. The verbal fluency task (in 60 seconds) and logical memory immediate recall were highly sensitive and specific to differences between NC and MCI (areas under the curves 0.87 and 0.76, respectively).

Conclusions: Alternate forms allow serial testing without learning bias. Verbal fluency and logical memory tasks are sensitive to early cognitive changes.

Objective: The aim of this study is to evaluate the validity and the utility of the Japanese version of the WHO-Five Well-Being Index (WHO-5-J) in the context of detecting suicidal ideation in elderly community residents.

Methods: A sample of 696 subjects aged 70 years or over who completed a set of questionnaires was examined.

Results: Cronbach's α was 0.87 and Loevinger's coefficient was 0.64. The total score was significantly correlated with the number of cohabitants, the number of physical illnesses, physical functioning, instrumental activities of daily living, and depressive symptoms. Subjects with suicidal ideation had significantly lower scores on the WHO-5-J. The receiver-operating characteristic curve analysis indicated that the scale significantly discriminated the subjects with suicidal ideation. When combined with the assessment of a lack of perceived social support (PSS), a standard cut-off criterion of “a total score ≤ 12 or answering 0 or 1 to any of the five items” more appropriately identified elderly subjects with suicidal ideation: sensitivity = 87%, specificity = 75%, negative predictive value = 99%, and positive predictive value = 10%.

Conclusions: In combination with PSS, the scale has predictive utility to detect suicidal ideation in elderly community residents.

Background: Both anxiety disorders and subclinical anxiety symptoms are related to poorer health and functioning in later life. Because worry is an important component of anxiety, the accurate measurement of worry is crucial to studying the etiology, prevention and treatment of anxiety disorders. Assessment of the trait worry has emerged as the most widely used strategy to establish the presence and extent of pathological worry. However, the Penn State Worry Questionnaire (PSWQ), the most widely used measure of the trait worry, has not been validated cross-culturally in groups outside of the U.S.A.

Methods: We tested the psychometric properties and measurement invariance of an 8 item abbreviated version of the PSWQ (PSWQ-A) in American (N = 206) and Spanish (N = 137) older adult samples.

Results: Internal consistency was high and analyses supported a unidimensional solution in both samples. Measurement invariance was tested using confirmatory factor analysis (CFA) and Rasch models. Results of the CFA suggest that measurement invariance between the samples can be assumed for women but not for men. Rasch modeling results by gender suggested that three items have different endorsability levels in the two samples, suggesting that certain items may more closely represent the construct of the trait worry in American and Spanish older adults.

Conclusions: Overall, the PSWQ-A appears appropriate for cross-cultural use, although deletion of one item (item 6) may improve the psychometric properties of the scale across different populations.

Background: Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people.

Methods: We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale.

Results: Cronbach's α for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test–retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%.

Conclusions: The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

Background: Research on young psychiatric patients suggests that a significant proportion experience trauma and, in some cases, post-traumatic stress disorder (PTSD) as a result of hospitalization. This paper focuses on the evidence of trauma and PTSD associated with admission to an aged psychiatry ward.

Methods: Fifty former patients from three Melbourne hospitals were interviewed in their own homes, using a semi-structured, open-ended questionnaire.

Results: Thirty-four percent of participants reported having felt frightened, unsafe, powerless, and undermined at some time during their hospital stay. In 24% of cases these experiences could be described as “traumatic.” None met criteria for PTSD.

Conclusion: Most of the distressing experiences reported had been re-evaluated in the light of recovery or the passage of time. Nevertheless, finding ways to reduce the occurrence of such potentially traumatic experiences is clearly desirable. The evidence from this study suggests that providing opportunities for patients with depression to spend time apart from disturbed and disruptive patients would be helpful in this regard.

Background: Cognitive impairment often occurs with geriatric depression and impairments may persist despite remission of depression. Although clinical definitions of mild cognitive impairment (MCI) have typically excluded depression, a neuropsychological model of MCI in depression has utility for identifying individuals whose cognitive impairments may persist or progress to dementia.

Methods: At baseline and 1-year follow-up, 67 geriatric patients with depression had a comprehensive clinical examination that included depression assessment and neuropsychological testing. We defined MCI by a neuropsychological algorithm and examined the odds of MCI classification at Year 1 for remitted depressed individuals with baseline MCI, and examined clinical, functional and genetic factors associated with MCI.

Results: Fifty-four percent of the sample had MCI at baseline. Odds of MCI classification at Year 1 were four times greater among patients with baseline MCI than those without. Instrumental activities of daily living were associated with MCI at Year 1, while age and APOE genotype was not.

Conclusions: These results confirm previous observations that MCI is highly prevalent among older depressed adults and that cognitive impairment occurring during acute depression may persist after depression remits. Self-reported decline in functional activities may be a marker for persistent cognitive impairment, which suggests that assessments of both neuropsychological and functional status are important prognostic factors in the evaluation of geriatric depression.

Background: Memory enhancement programs that can significantly improve actual memory performance and subjective perceptions of everyday memory in elderly people are rare. This study was designed to evaluate a new memory enhancement program incorporating principles of successful aging, designed to enhance subjective and objective everyday memory in community-dwelling old people.

Methods: Two matched groups of 20 healthy community-dwelling elderly adults were assessed on measures of objective and subjective memory performance before and after participating in a memory enhancement or active control condition.

Results: Planned multivariate analysis of variance (MANOVA) on change scores showed that participants in the memory enhancement program improved significantly on both objective and subjective measures. Specifically, greater improvement was demonstrated on a verbal paired associates task, story recall, face recognition, contentment with memory, and use of memory strategies.

Conclusions: Although a fully randomized design was not used, the results are promising, suggesting that memory training incorporating principles of successful aging can enhance memory performance in healthy old people, objectively and subjectively.

Background: Losses of γ-aminobutyric acid (GABA) have been variably demonstrated in Alzheimer's disease (AD) and may be related to the presence of behavioral and psychological symptoms of dementia (BPSD) in AD. Our objective was to assess the relationship between plasma GABA (pGABA) levels and specific BPSD in patients with severe AD.

Methods: pGABA levels and BPSD were measured in 14 institutionalized AD patients (8M/6F, mean age ± S.D. = 85.6 ± 4.5 years) with severe cognitive impairment (Mini-mental State Examination score = 4.5 ± 4.6) and prominent behavioral disturbances (Neuropsychiatric Inventory (NPI) score = 33.4 ± 23.6).

Results: pGABA was positively correlated with depression and apathy scores on the NPI and negatively correlated with age. Apathy and age were independent predictors of pGABA levels.

Conclusions: The final stages of AD are associated with GABAergic changes, which may contribute to depression and apathy in AD.

Background: The ε4 allele of apolipoprotein E (APOE) and head injury are risk factors for dementia diseases, and may act synergistically to further increase the risk. The aim of this study was to examine the association between mild head injury, APOE and dementia.

Methods: Data were obtained from the Betula prospective population-based study of aging, memory, and health. The study included 543 participants in the age range 40–85 years, free of dementia at baseline, who were followed up within a 5-year interval. Dementia was classified using DSM-IV criteria. Information on previous head injury was obtained through screening of the participants' answers to health questionnaires at baseline and at follow-up.

Results: Subjects with head injury but without APOE ε4 had no increased risk of dementia. Subjects with APOE ε4 had an increased risk and those with both APOE ε4 and head injury had the highest risk of dementia (odds ratio = 5.2).

Conclusions:APOE ε4 constitutes a risk factor for dementia, mild injury in isolation does not increase the risk, but head injury in combination with the APOE ε4 leads to increased risk of dementia.