Aggressive and violent behavior is a problem throughout healthcare services (Behar et al., 2008). The incidence of such acts is known to be over two and half times greater in mental health settings than in general hospital environments (National Audit Office, 2003). All types of aggression may have negative physical and psychological consequences for the victim, and therefore none ought not to be overlooked. However, one particularly serious feature is physical assault, which may result in a physical injury to the victim, although reported levels are relatively low (Stubbs et al., 2009). Physical assault may also affect the psychological, emotional and spiritual well-being of health staff and a minority may go on to develop post-traumatic stress type symptoms (Needham et al., 2005). Indeed, these symptoms may last longer than the original physical injury itself (Needham et al., 2005).

Drugs with a short elimination half-life should display fewer side effects than longer acting drugs in the treatment of sleep disturbances due to their smaller tendency to accumulate, especially in the elderly. This hypothesis could be confirmed in a double blind study of zopiclone versus flurazepam.

The premise underlying the implementation of any intervention aimed at changing behavioral or other symptoms of Alzheimer's disease (AD) is that the change will be beneficial in some manner for the patient and the benefits will outweigh any negative consequences that may simultaneously result from the intervention. Consequently, the ultimate task of investigators studying the impact of proposed interventions is to identify and measure the benefit that stems from the intervention, as well as any negative effects. When interventions are intended to create organic changes, as is traditionally true with pharmacologic interventions, the identification of relevant outcomes is made relatively simple through indicators of organic functioning. However, when intended changes are behavioral, the identification of appropriate outcomes is far more complex. An individual's behavior ultimately has an impact on all the actors within his or her social setting, directly or indirectly. Furthermore, changes in an individual's behavior may have an impact on other persons in such a way that these secondary changes feed back to further influence the initial target individual. Hence, it is likely that the most appropriate study designs for assessing the impact of interventions aimed at behavioral problems will include multiple outcome measures for multiple actors.

Within our workshop we discussed neuropathological assessments in different cultures and countries, evaluation of dementia type, and availability of autopsy. We agreed that evaluation of dementia cases should not be limited to the use of diagnostic criteria; but neuropathologic assessment should be utilized where appropriate. We agreed that it is vital to communicate this concept to general practitioners (GPs) and physicians working in nursing homes, where there is often a high proportion of dementia patients. When neuropathologic assessments are conducted correctly, they provide both quantitative and qualitative information about cell and tissue damage. The assessment should preferably be performed by a neuropathologist in order that a diagnosis plus an estimation of disease severity and extent can be made.

Alcohol-related dementia (ARD) is a controversial concept. Alcohol-related brain damage (ARBD) is a term used to cover a spectrum of conditions and disorders: this includes alcohol-related dementia, Korsakoff's syndrome, Wernicke's encephalopathy, alcohol-related brain injury, and alcohol amnesic syndrome. In other words, these are the conditions that have been induced by chronic alcohol consumption, resulting in some degree of brain damage. The prevalence data are varied.

Background: Suicide rates are higher in the over 65s than in younger adults and there is a strong link between deliberate self harm (DSH) and suicide in older people. The association between personality disorder (PD) and DSH in older adults remains uncertain. Our objective was to describe this association.

Methods: A case control study was conducted in which participants were: (i) those who had undertaken an act of DSH and (ii) a hospital-based control group drawn from a geographical contiguous population. PD was assessed using the Standardised Assessment of Personality (SAP)

Results: Seventy-seven cases of DSH were identified; 61 (79.2%) of these participants were interviewed. There were 171 potential controls identified of whom 140 (81.9%) were included. An SAP was completed in 45/61 (73.8%) of cases and 100/140 (71.4%) of controls. The mean age was 79.8 years (SD = 9, range 65–103). The crude odds ratio for the association between PD and DSH was 5.91 [(95% CI 2.3, 14.9) p<0.0001]. There was a strong interaction with age stratified at 80 years. There was no association between PD and DSH after age 80. The adjusted odds ratio for PD in the group <80 years was 20.5 [(95% CI 3, 141) p = 0.002]. Borderline and impulsive PD traits tended to be associated with an episode of DSH more than other personality types.

Conclusions: PD appears to be a strong and independent risk for an act of DSH in people aged between 65 and 80 years and should be looked for as part of any risk assessment in this population. Access to specialist services may be required to optimally manage this problem and reduce the subsequent risk of suicide.

We report a Malay man, with underlying chronic medical illnesses, presenting with positive symptoms of schizophrenia, including Capgras syndrome (CS) at the age of 73. Physical examination and blood investigations were normal and brain CT scan showed age-related cerebral atrophy. Neuropsychological assessment showed probable right hemisphere lesions but relatively intact memory and intellectual functions. Several neuroleptics including depot injections were tried but ineffective. Positive symptoms including CS eventually improved with clozapine before his death from myocardial infarction. This case report highlights the uncommon occurrence of CS in treatment resistant schizophrenia (TRS) of very late onset and its treatment challenges.

Although there is a great emphasis on memory in the diagnosis of dementia and in the measurement of treatment response, disorders of language are an important, but sometimes neglected, feature of many dementias.

The first patient described by Alzheimer in 1907 had both progressive cognitive deterioration and prominent comorbid signs and symptoms of psychosis and agitation (Alzheimer, 1907, 1987). In this editorial, we use “psychosis” to denote delusions and hallucinations and “agitation” to denote irritability, aggression, pressured motor activity, and active resistance to necessary care. Although advances have been made in the treatment of these non-cognitive symptoms, these psychosis and agitation symptoms continued to be burdensome and costly for dementia patients, caregivers, and society. Among the pharmacologic treatments available for psychosis and agitation, antipsychotic drugs are the drug class most consistently demonstrated effective for psychosis and agitation in dementia (Lyketsos et al., 2006; APA Work Group on Alzheimer's Disease and Other Dementias et al., 2007). These are widely prescribed for these behavioral problems, but their use remains controversial and their mechanism of action unclear.

There is broad agreement that randomized controlled double-blind trials (RCTs) do reveal only small effects of the cholinesterase inhibitors donepezil, rivastigmine and galantamine in the treatment of Alzheimer's disease (AD) (Perras et al., 2005; Cummings et al., 2002; Schneider, 2004). Furthermore, it is controversial whether the small effects shown in the RCTs are reliable or due to bias. In 2005 we published a systematic review of all RCTs on cholinesterase inhibitors which came to the conclusion that the scientific basis for a general recommendation of cholinesterase inhibitors in the treatment of AD is questionable because of the methodological shortcomings of the studies (Kaduszkiewicz et al., 2005). Following numerous debates on this topic at congresses and enriched through reviews of the U.K. National Institute for Health and Clinical Excellence (NICE, 2006) and the German Institute for Quality and Efficiency in Health Care (IQWiG, 2007), we will here present our actual view on this controversy. The main part of this article focuses on the methodology of cholinesterase inhibitor trials and on the interpretation of their results. We conclude by discussing briefly the three Cochrane reviews on cholinesterase inhibitors for AD.

As people live longer, an increasing proportion of patients with schizophrenia and delusional disorder will be elderly. Little has been published on treatment response, effective treatment strategies, or the use of atypical neuroleptics in this group. This review of the literature explores documented response rate, route and dose of neuroleptic, indicators of poor response, and the use of novel drugs. Despite great variation in the neuroleptic dose ranges employed, patients with late-onset disease often continue to experience psychotic symptoms. Compliance with treatment is the most important determinant of outcome. Atypical neuroleptics are specifically indicated for patients with visual hallucinations or extrapyramidal symptoms. Elderly psychotic patients should be treated as vigorously and with as wide a range of neuroleptics as their younger counterparts. Physicians should not restrict drug doses to modest levels in all cases as long as patients are monitored frequently for the emergence of side effects.

Background: The aim of this study was to examine whether age-related differences in rates of use of complementary and alternative medicine (CAM) specifically for mental health problems parallel well-known age-related differences in use of conventional mental health services and medications.

Methods: A sample of middle-aged (45–64 years; n = 10,762), younger-old (65–74; n = 4,113) and older-old adults (75 years and older; n = 3,623) was drawn from the 2001–2002 Canadian Community Health Survey (CCHS), Cycle 1.2, Mental Health and Wellbeing. Age-related utilization rates of conventional and complementary mental health services and medications/products were calculated. Logistic regression analyses were used to examine the strength of association between age group and utilization of services and medications or products in the context of other important sociodemographic and clinical characteristics.

Results: When considered in the context of other sociodemographic and clinical characteristics, older age was positively associated with mental health-related utilization of alternative health products. Older age was not significantly associated with mental health-related consultations with CAM providers.

Conclusions: Overall, age-related patterns in mental health-related use of CAM did not directly correspond to age-related patterns in conventional mental health care utilization, suggesting different sets of predictors involved in seeking each type of care.