Neuropsychological testing provides an important adjunct to diagnosis and prognosis in geriatric assessment, which has become of increasing importance in light of the rising prevalence of neuropsychiatric disorders for which no specific biological marker is presently available. Neuropsychological testing itself involves the observation of an individual's behavior in relation to a given stimulus selected for its likelihood to provoke an abnormal response in the face of damage to a specific neuroanatomical structure. The theoretical basis of neuropsychological assessment is derived both from cognitive psychology, which deals with the development of cognitive tests for the demonstration of theoretical models of cognitive functioning, and also from behavioral neurology, which aims at the classification of normal and pathological responses to cognitive stimuli with a view to screening central nervous system disorder.

The next millennium looms, bright and pristine, ours for the asking. Sounds good, although sour notes have already chimed. The millennium, it is said, starts 2000/2001 and not 1999/2000; Y2K is going to start with a computer-driven catastrophe; on CNN this morning it was reported that three airlines, including Virgin Atlantic airlines, had decided not to fly at New Year.

In the last 50 years there has been both extraordinary and extraordinarily little progress in geriatric psychiatry, depending on the perspective from which the topic is viewed. In developed countries there has been a slow recognition of the emergence of the particular issues raised by aging populations. This has accelerated in the last few years, with the acknowledgment of the importance of the topic area in funding initiatives such as the European Union Framework V. In tandem with such developments has come the realization that aging populations, and their challenges, are not limited to the developed world, but also to developing countries that are experiencing demographic transition at much greater speed. Among the key areas of the impact of aging populations is health, and particularly mental health.

Assessment of progress in geriatric psychiatry in Canada is a difficult task. There are no good and easily accessible measures; the process of assessment is influenced by personal values and emotions; to a large extent, progress in geriatric psychiatry defies national and even subspecialty boundaries. Difficulties notwithstanding, I have attempted a brief, dispassionate assessment that focuses on training, personnel, services, professional organizations, and research activity.

CLASSIFICATION, CLINICOPATHOLOGICAL CORRELATIONS, AND FUNCTIONAL-ORGANIC OVERLAP In this millennial issue, I shall recall some of the issues in the psychiatry of old age that were current in England half a century ago, based on my experiences at the Maudsley Hospital, Graylingwell, Stockholm, and Newcastle. In 1946, Aubrey Lewis, then Professor of Psychiatry at the Maudsley Hospital, lamented that while the numbers of old people being admitted to mental hospitals had steadily increased, the clinical psychiatry of old age was neglected (Lewis, 1946). Classification was in a state of confusion. Senile and vascular degenerations characterized the aging brain, and though affective and paranoid states occurred, they were widely regarded as depressive and paranoid forms of senile psychosis and not clearly distinguished from purely functional states. In the presence of degenerative changes in the brains of normal old people and the apparent lack of a clear quantitative relationship between clinical severity and neuropathology, the presence or absence of symptoms was determined by the premorbid personality and the ability to resist the effects of the cerebral changes (Rothschild, 1937).

I have chosen the 30 years, 1969–1999, for this article, because this represents my psychiatric career from entry into the training scheme at the Maudsley Hospital to being current head of the old-age group at the Institute of Psychiatry. What becomes apparent, on looking back, is that the developments at this campus, which contains a psychiatric teaching hospital and a postgraduate research institute, reflect those in the UK over that time. In many areas, the lead has come from here. These activities will be reviewed and some challenges for the next decade proposed. The latter will be personal, from a researcher with an epidemiological/public health perspective.

During the late 19th and early 20th centuries, elderly individuals with severe mental illness living in the United States were cared for in state-run facilities that went by various names (asylums, psychopathic hospitals, state hospitals, state mental hospitals, and medical centers). Since the beginning of the 20th century, approximately 20% of patients in state hospital facilities had brain diseases such as dementia, usually complicated by behavioral disorder.

Prior studies have identified that quality of social functioning is strongly associated with both physical and cognitive recovery from stroke as well as with the existence of depression. This study was undertaken to identify the specific elements of social functioning that are related to depression and impaired recovery and to determine whether these elements are different between acute and chronic periods following stroke. There were 50 patients with acute stroke who were assessed in the hospital and at short-term (3- or 6-month) and long-term (12- or 24-month) follow-up. An impaired relationship with the patient's “closest other” prior to the stroke and limited social activities were both associated with depression immediately after the stroke as well as with depression at long-term follow-up. An impaired relationship with the closest other prior to the stroke was also associated with impaired recovery in activities of daily living and cognitive recovery at long-term follow-up. Fears of economic stability and limited social activity were associated with depression at short-term follow-up whereas loss of job or job satisfaction was associated with depression at long-term follow-up. These findings suggest that during the first few weeks following stroke, social supports and contact are essential needs for patients, whereas during the chronic period, other factors such as financial security, adequacy of living arrangements, and loss of job satisfaction also become important. Future research should examine the effect of enhanced social support on poststroke depression and physical and cognitive recovery.

Background: Ommoord District residents of Rotterdam, The Netherlands, age 55 and older, completed a two-stage interview to assess the risk factors for chronic disease and disability. Methods: In the in-home Stage I interview (N = 7,983), demographic data and medical history were collected by a trained lay interviewer. During Stage II, a physician interview and examination were conducted at the study center. Subjects (N = 7,129) were asked about their history of psychiatric disorders and 6,596 responded. Results: The lifetime prevalence of self-reported psychiatric disorders was 5.44% for unipolar and bipolar depressive disorders combined, 0.27% for psychotic disorders, 0.08% for alcoholism, 0.05% for drug addiction, and 3.71% for other diagnoses. Residents reporting a psychiatric diagnosis of depression were more likely to be currently taking an antidepressant medication (p < .001) and an antipsychotic medication (p < .0001), to be in current outpatient treatment (p < .001), to have been hospitalized for psychiatric illness (p < .001), to have undergone electroconvulsive treatments (p < .001), and to report a history of having made suicide attempts (p < .001). Conclusion: The self-reported lifetime prevalence of affective disorders was similar to the rates found in the Stirling County Study (Canada) and the Epidemiologic Catchment Area Survey (United States). The lower prevalence rates of the other psychiatric disorders may reflect underreporting or an age cohort effect, or may be due to the nonresponse bias.

The activities of daily living (ADL) functioning of 26 subjects with Alzheimer's disease was measured using the Assessment of Motor and Process Skills (AMPS) and family informants' Older Americans Resources and Services (OARS) Activities of Daily Living (ADL) reports. Concordance with a clinician's ratings of subjects' level of ADL functioning was achieved for 77% of the subjects based on their AMPS ADL process ability measures and for 54% for the subjects based on their family informants' OARS ADL ratings. In cases of discordance, subjects' AMPS ADL process ability measures were just as likely to overestimate (11.5%) as to underestimate (11.5%) subjects' ADL functioning. In contrast, 46% of the informants overestimated their family members' ADL functioning, and this was more likely to occur when subjects' cognitive impairment was mild.

This survey sought to determine (a) the prevalence of carer stress in patients with mild to moderate dementia, (b) whether caregiver burden was already associated with plans to institutionalize patients, and (c) which patient-related and caregiver-related variables best predicted caregiver burden. The principal caregivers of 93 Asian patients with mild to moderate dementia attending an outpatient cognitive assessment clinic were interviewed via a structured questionnaire that focused upon (a) patient-related variables such as their behavioral and functional abnormalities; and (b) caregiver-related variables such as whether they were having problems looking after the patients, the duration of their caregiving, their associated feelings of anger and/or depression, and their financial status as well as intentions to institutionalize patients. Forty-nine percent of caregivers reported problems in looking after the patients, and their perception of difficulties was significantly associated with institutionalization plans for the patients. Logistic regression analysis using a forward variable selection procedure showed two of the patients' behavioral abnormalities (repetition, agitation) and one of their functional impairments (urinary incontinence) as well as the carers' depressed feelings to be predictive of the carers' problematic status, explaining 40% of the variance. It is important that even in the early stages of dementia, the medical assessment also evaluate behavioral, functional, and social dimensions of the illness, so that appropriate interventions can be implemented to reduce caregiving burden and delay institutionalization.

We performed awake and resting electroencephalograms (EEGs) on 22 subjects with DSM-III-R schizophrenic disorder of late onset (at or after age 50 years), and compared them with the EEGs of 33 healthy community controls matched for age and gender. The EEGs were rated qualitatively and a 2-minute, artifact-free tracing from each subject was quantified manually by an experienced neurophysiologist unaware of the identity of the subject group. The only significant difference was the presence of more generalized slowing in the EEGs of schizophrenia patients, which was at least partially accounted for by the effect of neuroleptic drugs. The schizophrenic subjects did not have a greater prevalence of epileptiform disturbances or abnormal asymmetry of the EEG compared to the control group. Our study does not suggest the presence of underlying dementia in schizophrenia of late onset.

In this prospective cohort of 71 elderly patients undergoing cardiac surgery, each subject was interviewed before and after surgery to detect incident delirium using the Confusion Assessment Method (CAM), the Mini-Mental State Examination (MMSE), the Clock Test, and a health record review. The first 41 were assessed by a physician and the remaining 30 by two study nurses. Delirium was then diagnosed by a physician using DSM-III-R criteria. Delirium was present in 23 subjects (32.4%). The sensitivity of the CAM differed significantly when administered by physicians compared to nurses (1.00 vs. .13). When standard cutoffs were used, neither the MMSE nor the Clock Test were found to be sensitive markers for delirium (.30 and .09, respectively). Recognition of delirium by charting was superior in nurses compared to physicians (.83 vs. .30). We conclude that the sensitivity of markers for delirium, such as the CAM and health record documentation, is dependent on the training background of the operator.

Background: Aggressive behavior among geriatric psychiatry inpatients spontaneously declines during serial measurements over time with rating scales. Method: Evidence for decline in aggressive behavior, over a 6-week period, on a continuing-care geriatric psychiatry ward was examined with the Staff Observation Aggression Scale (SOAS) and the Rating Scale for Aggressive Behavior in the Elderly (RAGE). Results: The RAGE and all its subitems did not spontaneously decline. The total number of aggressive incidents on the SOAS, the SOAS total score, and the subitem scores, except for the SOAS results subitem, spontaneously declined after Week 4 and became established by Week 5. Conclusion: A “run in” period of at least 4 weeks may be needed in intervention studies using the SOAS to reduce contamination by spontaneous decline.

Health-related quality of life (HRQL) was investigated in 211 inhabitants of five residential homes in The Netherlands and was assessed again 1 year later. It was examined (a) if HRQL was related to the presence of specific general medical illnesses, (b) if comorbidity resulted in poorer HRQL, independent of the type of illness, and (c) if HRQL remained stable over time (1 year). We found that the illnesses we investigated contributed only little power to the prediction of HRQL, although some coefficients were significant. Comorbidity was also found to be a significant predictor of several aspects of HRQL, but did not contribute much power either. Several aspects of HRQL (bodily pain, health perceptions, and social functioning) remained stable over time, whereas other aspects (role functioning, activities of daily living) deteriorated. There was a trend indicating that mental health improves over time. Improvement and deterioration on aspects of HRQL were relatively strongly related to the scores on these aspects 1 year earlier, but not to specific illnesses or comorbidity.