Behavioral and psychological symptoms of dementia (BPSD) frequently arise in people with Alzheimer's disease (AD) and other dementias. They cause significant distress and confer risk to the person and others, in addition to presenting a complex clinical challenge for treatment (Ballard et al., 2009b). There is good evidence for the value of first-line management strategies such as psychological interventions and treatment of concurrent medical conditions, particularly pain, which are known to be effective (Ballard et al., 2009b). However, there are limited pharmacological treatment options for severe aggression, which causes significant risk, and for other severe BPSD which do not respond to first-line approaches. The only pharmacological intervention with an adequate evidence base is the prescription of atypical antipsychotics, where 18 placebo-controlled trials have evaluated the effect of treatment over 6–12 weeks. The literature indicates modest but significant benefits in the treatment of aggression and psychosis with risperidone and aripiprazole (Cohen's d standardized effect size of 0.2), uncertain benefits with olanzapine, and no benefits with quetiapine (Ballard and Howard, 2006; Schneider et al., 2006a; Ballard et al., 2009b; Corbett et al., 2012). Unfortunately, the benefits of longer term prescribing are more limited (Schneider et al., 2006b; Ballard et al., 2008) and there have been increasing concerns regarding the potential for serious adverse outcomes, including accelerated cognitive decline, stroke, and death (Schneider et al., 2006b; Ballard et al., 2009a). There is therefore an urgent imperative to identify more effective pharmacological treatments for severe BPSD which have a better safety profile, particularly for long-term treatment and prophylaxis. Despite this urgency, there has been very little effort toward developing or evaluating potential novel therapies for the treatment of key symptoms such as aggression, psychosis, restlessness, and apathy.

The authors regret that they omitted to include an acknowledgment of financial support in the original publication. The acknowledgment should have read:

This work was funded by a grant from the Thomas Pocklington Trust.

This issue of the journal sees the publication of the 3 papers placed first, second and third in the 2005 International Psychogeriatric Association (IPA) Research Awards in Psychogeriatrics. For the first time in the history of the awards (first presented in 1989 and awarded at each biennial IPA Congress thereafter), entries were limited to junior investigators within five years of the award of their terminal degree who were at no higher than Assistant Professor/Instructor level at the time of submission. The awards were judged by a panel of four comprising Bengt Winblad (panel chair and 12th IPA Congress chair), David Ames (editor International Psychogeriatrics), John O'Brien (deputy editor International Psychogeriatrics and 12th IPA Congress Scientific Steering Committee Chair) and Joel Sadavoy (then President elect of IPA). The field comprised 11 papers from nine countries (Canada, China (including the Special Administrative region of Hong Kong), Greece, Egypt, the Netherlands, Serbia and Montenegro, Spain, Uganda and the U.S.A.) and contained several papers which in a less competitive field would have been worthy recipients of an award. In addition to the three award winning papers, in an unprecedented decision the judges approved a special citation for a fourth submission entitled “Psychiatric disorders among the elderly on non-psychiatric wards in an African setting” by Noeline Nakasujja of Uganda for “Outstanding Research Endeavors undertaken in a previously un-researched field, in the face of unusual operational challenges.”

Behavioral and psychological symptoms of dementia (BPSD) are among the most prominent and invasive features of dementia, and increasingly form a target for therapeutic intervention in this cognitively impaired population. Aggression and other behavioral symptoms of dementia (e.g., agitation, purposeless activity, wandering, pacing, psychotic symptoms) are important features of this illness, severely affect patient and caregiver quality of life, and complicate effective medical management. Behavioral symptoms have been described by caregivers as the primary predictor of caregiver burden and cause for negative feelings toward their dependents. In fact, the behavioral symptoms of dementia, particularly aggression and agitation, are the most common reason for admission to the hospital or residential care.

Although Alzheimer's original description of the dementing disorder that bears his name emphasized the prominence of troublesome and disruptive behaviors, a systematic investigation of behavioral disturbances of dementia did not begin in earnest until the 1980s. At that time, as the neuropathologic identity of presenile Alzheimer's disease and late-onset “senile dementia” was recognized, the redefinition of Alzheimer's disease abruptly increased the number of patients diagnosed with this condition. Physicians and other medical personnel working with Alzheimer's disease patients recognized both the importance of abnormal behaviors in this now large patient population and the need to describe, classify, and quantify these behaviors.

Institutionalized persons with Alzheimer's disease (AD) often demonstrate nonfunctional behaviors such as resistance to dressing and washing, disturbed sleep, restlessness, homesickness, and wandering. If behavior is regarded as emanating from the person with impaired cognition interacting with his or her environment, the environment is found to have a very significant impact on retaining functional capacity. For example, studies have demonstrated how behaviors described as wandering and homesickness strongly relate to events and objects in the environment (Zingmark et al., 1993). The context or environment contributes to the success or failure of behavioral strategies. The goal in dementia care must be to have a positive impact on functional behavior. One consequence of this is that functional behavior can be altered, within limits, through environmental strategies.

The increasing prevalence of dementia with population aging has heightened interest in understanding patterns of utilization and health expenditures in persons with dementia (PWD) among policy officials, practicing physicians, and health system. While a substantial part of this interest is concerned with the high costs of care for people diagnosed with dementia (Kelley et al., 2015), less attention has been focused on the costs and consequences of missed or delayed diagnosis in those who screen positive for dementia. The article on “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” by Michalowsky and colleagues (Michalowsky et al., 2015) in this issue makes a particularly important contribution in this regard.

Background: The Kana Pick-out Test (KPT), which was developed in Japan, is suitable for evaluating frontal lobe function and screening for mild dementia. However, the neural substrates involved remain to be elucidated. The aim of the present study was to identify the regional perfusion patterns in the brain associated with performance scores on the KPT in patients with mild Alzheimer's disease (AD), using brain perfusion assessed by single photon emission computed tomography (SPECT).

Methods: Twenty AD patients with high scores on the KPT and 20 age- and sex-matched AD patients with low scores were selected from 227 consecutive Japanese patients of the Memory Clinic of Okayama University Hospital. All 40 subjects underwent brain SPECT with 99mTc-ethylcysteinate dimer, and the SPECT images were analyzed by Statistical Parametric Mapping.

Results: With the exception of KPT scores, no significant differences were found between high and low scoring groups with respect to Addenbrooke's Cognitive Examination scores, Mini-mental State Examination scores, or the depression score of the Neuropsychiatric Inventory subscale. Compared to patients with high scores on the KPT, AD patients with low scores on the KPT showed significant hypoperfusion in the left subgenual cingulate gyrus (SGC) extending to the right SGC.

Conclusions: Our results suggest that functional activity of the SGC is closely related to scores on the KPT. KPT might be a promising strategy to use in detecting early stages of AD with low SGC function.

Recent progress in the biochemical characterization of Alzheimer's disease (AD) neuropathology has led to the proposal of three hypotheses for the molecular etiology of AD. One focuses on calcium-activated neutral proteases or calpains (Nixon, 1989). Another focuses on protein phosphorylation (Saitoh & Iimoto, 1989). A third is centered on altered phospholipid metabolism (Pettegrew, 1989). Interestingly, all three hypotheses are mutually compatible, involving closely interlocking biochemical systems. Disturbances in any one of these systems might result in the same type of neuropathology, consistent with suggestions that AD could have multiple etiologies. Future investigations of the function and interrelation of these systems in the central nervous system in general and at the synaptic junction in particular are likely to have significant bearing on our understanding of AD.

A three-year follow-up of 273 participants (mean age 60 years) of the Austrian Stroke Prevention Study provides the first information on the rate, clinical predictors, and cognitive consequences of MRI white-matter lesions in elderly individuals without neuropsychiatric disease. Lesion progression was found in 17.9% of individuals over a time period of 3 years. Diastolic blood pressure and early confluent or confluent white-matter hyperintensities at baseline were the only significant predictors of white-matter hyperintensity progression. Lesion progression had no influence on the course of neuropsychologic test performance over the observational period, but the statistical power of this analysis was low.

The role of the physician is critical in the evaluation of cognitively impaired patients for two reasons: (a) The longitudinal relationship between the patient and physician provides a unique opportunity to observe changes over time, generating confidence that may encourage the patient and family to report any concerns; (b) All research in this field is geared toward the earliest possible intervention, a process made possible by early diagnosis. Preparations for interview and the interview process itself require special knowledge of dementia on the part of the evaluating physician, who must understand the potentials and problems of both the content and the process of taking a history from the demented patient and his/her caregivers.