Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.

Background: Neuropsychiatric symptoms (NPS) occur frequently in residents of long-term care institutions. The aim of this study was to review the literature systematically on the course of NPS in residents with dementia in long-term care institutions.

Methods: A systematic literature search was conducted using Medline, PsychInfo, Embase and Cinahl. Search terms included “dementia”, “long-term care institutions”, “NPS”, “longitudinal”, and additional related terms. All titles and abstracts were independently assessed for inclusion and for methodological quality by two researchers, and the full texts of relevant papers were retrieved. Inclusion criteria were: dementia diagnosis, long-term care institutions, NPS, and longitudinal design.

Results: The literature search revealed 1982 papers of which 18 met the inclusion criteria. The patients were predominately female and aged 75 years and over. The follow-up period ranged from three months to one year. The number of assessments ranged from two to five, and 12 different assessment instruments were used to study NPS. Aberrant motor behavior, depression, anxiety, and euphoria showed decline over time, and psychosis remained constant whereas apathy, agitation, irritability, and disinhibition increased over time. All symptoms showed specific intermittent courses. The methodological quality of the literature was limited by the small sample sizes, short follow-up periods, and lack of comprehensive neuropsychiatric assessment instruments.

Conclusions: In the reviewed studies, NPS in institutionalized residents with dementia showed a heterogeneous course, although methodological limitations and the diversity of the studies call for caution in interpretation. Future research should focus on large prospective cohort studies with institutionalized residents with dementia, examining a wide range of NPS.

Background: Older prisoners are a minority within the prison population but their numbers are increasing at a greater rate than any other age group. The mental health of younger prisoners has been well researched but this is not the case for older inmates. The aim of this paper is to provide a review of the existing literature on the mental health of older prisoners.

Methods: Relevant papers were identified through database searches and an examination of cited references in the selected papers. The literature was divided into different sections in order to examine the contributing factors and rates of mental illness in older prisoners.

Results: The first section looks at demographic factors relevant to older prisoners. Subsequent sections examine psychosocial factors, environmental factors and physical health factors that may have a detrimental effect on mental health. The final sections look at the prevalence of mental illness in older offenders before and after sentencing.

Conclusions: Mental illness in older prisoners is a result of complex interactions between numerous individual and environmental factors. It currently remains poorly researched and service provision for older prisoners with mental illness is poorly developed. Further research is needed, with a particular focus on the different groups of older prisoners and the most beneficial service models, because the number of older prisoners, including those with mental illness, is likely to increase in the future.

Background: Eating disorders in the elderly are often overlooked. When they occur, significant morbidity and mortality result. In this study we review all existing literature on eating disorders in the elderly and provide practical guidelines for clinicians in recognizing and managing eating disorders in the elderly.

Methods: A literature search using Medline(R), PubMed(R), Web of Knowledge(R), and PsychINFO(R) revealed 48 published cases of eating disorders in people over the age of 50 years.

Results: The mean age was 68.6 years (range 50–94), and the majority (88%) of cases were females. The majority (81%) of cases had anorexia nervosa, and 10% had bulimia nervosa. Late onset eating disorders were more common (69%) than early onset. Comorbid psychiatric conditions existed in 60%, most commonly major depression. Management with a combination of behavioral and pharmacologic interventions was most successful, although only 42% were treated successfully. Mortality was high (21%) secondary to the eating disorder and its complications.

Conclusion: Eating disorders do occur in the elderly and should be included in the differential diagnosis of unexplained weight loss in the elderly.

Background: Dementia is now a major public health issue in low- and middle-income countries, and strategies for primary prevention are needed. This study aimed to estimate the proportion of cases of dementia attributable to illiteracy, non-skilled occupation and low income, which are common, potentially modifiable social adversities that occur along the lifespan in low- and middle-income countries.

Methods: This report is based on data from the São Paulo Ageing & Health Study (SPAH) study (N = 2003). All individuals aged 65 years and older residing within pre-defined socially deprived areas of the city of São Paulo, Brazil, were included. The outcome of interest was prevalent dementia. Indicators of socioeconomic position (SEP) were literacy (distal indicator), highest occupational attainment (intermediate indicator), and monthly personal income (proximal indicator). We estimated the proportion of prevalent dementia attributable to each SEP indicator (illiteracy, non-skilled occupations and low income) by calculating their population attributable fractions (PAF).

Results: Dementia was more prevalent amongst participants who were illiterate, had non-skilled occupations and lower income. Illiteracy, poor occupational achievement and low income accounted for 22.0%, 38.5% and 38.5% of the cases of dementia, respectively. There was a cumulative effect of socioeconomic adversities during the lifespan, and nearly 50% of the prevalence of dementia could be potentially attributed to the combination of two or three of the socioeconomic adversities investigated.

Conclusions: Public policies aimed at improving education, occupational skills and income could potentially have a role in primary prevention of dementia. Governments should address this issue in a purposeful and systematic way.

Background: Differential diagnosis implies identifying shared and divergent characteristics between clinical states. Clinical work with older adults demands not only the knowledge of nosological features associated with differential diagnosis, but also recognition of idiosyncratic factors associated with this population. Several factors can interfere with an accurate diagnosis of specific phobia in older cohorts. The goal of this paper is to review criteria for specific phobia and its differential diagnosis with panic disorder, agoraphobia, post-traumatic stress disorder and obsessive compulsive disorder, while stressing the specific factors associated with aging.

Methods: A literature search regarding specific phobia in older adults was carried out using PubMed. Relevant articles were selected and scanned for further pertinent references. In addition, relevant references related to differential diagnosis and assessment were used.

Results: Etiologic factors, specificity of feared stimulus or situation, fear predictability and the nature of phobic situations are key points to be assessed when implementing a differential diagnosis of specific phobia.

Conclusions: First, age-related sensory impairments are common and interfere both with information processing and communication. Second, medical illnesses create symptoms that might cause, interfere with, or mimic anxiety. Third, cohort effects might result in underreporting, through the inability to communicate or recognize anxiety symptoms, misattributing them to physical conditions. Finally, diagnostic criteria and screening instruments were usually developed using younger samples and are therefore not adapted to the functional and behavioral characteristics of older samples.

Background: Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams.

Methods: A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes.

Results: 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories.

Conclusions: The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Background: The concept of benign senescent forgetfulness (BSF) was introduced in 1958 by V. A. Kral, consultant neuropsychiatrist to the Montreal Hebrew Old People's and Sheltering Home (hereafter the Home). BSF was criticized and mild cognitive impairment (MCI) was adopted years later. In this paper I argue that a notion of MCI also originated with Kral.

Methods: A historical review was undertaken of the Canadian Jewish Congress archives in Montreal, Kral's biography and his publications, as well as relevant literature. A discussion was held with one of Kral's collaborators.

Results: In the mid-1950s the administration of the Home sought research-derived recommendations to improve residents’ conditions. In an initial survey, based on a meticulous neuropsychiatric examination, Kral departed from contemporaneous psychiatric nosology and suggested other criteria in order to classify the home's population. He classified one of the five groups, consisting of subjects with mild memory dysfunction, as having BSF. In his next survey, Kral included psychological tests in addition to clinical assessment and focused on the elderly people who were well preserved (good personal and social functioning). This sample was subdivided into four subgroups, including BSF and incipient amnestic syndrome (IAS). The findings revealed: well-preserved aged people; normal (dull) level of general intelligence; subnormal performance of specific memory and perceptual/organization tests; and no significant signs of malignant amnestic syndrome. This construct is very similar to that of MCI, which is widely used today.

Conclusions: The interaction between Kral and a particular home for the elderly at a particular moment in its history gave rise to the concept of BSF, and a notion of what we now call MCI emerged.

Background: Cognitive training (CT) may be effective as a therapeutic strategy to prevent cognitive decline in older adults. This review evaluates CT as a preventive tool at various stages of a prevention hierarchy with specific reference to healthy older adults, “at risk” and clinical populations. It also considers the underlying mechanism of CT, namely that which suggests that CT acts via promoting neuroplasticity.

Methods: Evidence for CT in healthy, “at risk” and clinical populations has been systematically reviewed elsewhere. This review re-examines several studies in each group to clarify the potential of CT as a preventive technique, with a key focus on the secondary level of prevention.

Results: Studies in healthy older adults and those with mild cognitive impairment are largely positive and suggest that CT has the potential to improve cognition. However, findings in relation to Alzheimer's disease are mixed. Limitations of existing research include diverse methodologies and CT programs, small samples, insufficient focus on functional outcomes, sustainability and generalization of effects and the need for imaging data to delineate mechanisms of change. Additionally, there is limited data on those with late-life depression, despite this being an independent risk factor for dementia.

Conclusions: CT offers promise as a preventive therapeutic technique in healthy older adults and particularly as a secondary prevention method for “at risk” groups. Future investigations need to focus on methodological constraints and delineating possible neuroplastic mechanisms of action. Nonetheless, CT programs may represent a viable, non-pharmacological early intervention strategy, as they are easily-implemented, engaging and promote social interaction in group settings.

Background: The IPA Taskforce on Mental Health Issues in Long-Term Care Homes seeks to improve mental health care in long-term care (LTC) homes. The aim of this paper is to provide recommendations on comprehensive assessment of depression and behavioral problems in order to further stimulate countries and professionals to enhance their quality of care.

Methods: Existing guidelines on comprehensive assessment of depression or behavioral problems in nursing home (NH) patients or patients residing in LTC homes were collected and a literature review was carried out to search for recent evidence.

Results: Five guidelines from several countries all over the world and two additional papers were included in this paper as a starting point for the recommendations. Comprehensive assessment of depression in LTC homes consists of a two-step screening procedure: an investigation to identify factors that influence the symptoms, followed by a formal diagnosis of depression according to DSM-IV-TR or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease in cases of dementia. Comprehensive assessment of behavioral problems encompasses three steps: description and clarification of the behavior, additional investigation, and assessment of probable causes of the behavior. The procedure starts in the case of moderate behavioral problems.

Conclusion: The recommendations given in this paper provide a useful guide to professional workers in the LTC sector, but clinical judgment and the consideration of the unique aspects of individual residents and their situations is necessary for an optimal assessment of depression and behavioral problems. The recommendations should not be rigidly applied and implementation will differ from country to country.

Background: This study evaluated a multi-faceted, interdisciplinary intervention to reduce the use of benzodiazepines and antipsychotics in nursing homes – the “RedUSe” (Reducing Use of Sedatives) project.

Methods: The RedUSe project was a controlled trial conducted in 25 nursing homes in Tasmania, with 13 intervention and 12 control homes. A series of pharmacist-led strategies were provided to intervention homes including two medication audit and feedback cycles, educational sessions for staff and an interdisciplinary sedative review. Data on psychotropic drug use at each nursing home were collected utilizing a customized computer program at baseline, 12 and 26 weeks. The RedUSe project was registered as a controlled trial at the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12608000221358.

Results: For each measure, an average of 1591 residents were audited. Over the six-month trial, there was a significant reduction in the percentage of intervention home residents regularly taking benzodiazepines (31.8% to 26.9%, p < 0.005) and antipsychotics (20.3% to 18.6%, p < 0.05), whereas control home psychotropic use did not alter significantly. For residents taking benzodiazepines and antipsychotics at baseline, there were significantly more dose reductions/cessations in intervention homes than in control homes (benzodiazepines: 39.6% vs. 17.6%, p < 0.0001; antipsychotics: 36.9% vs. 20.9%, p < 0.01).

Conclusions: RedUSe led to a significant reduction in the proportion of residents in nursing homes taking benzodiazepines and antipsychotics, and a significant increase in the number of dose reductions of these agents. Our findings suggest that a multi-faceted program, coordinated through a community pharmacy, can offer an effective approach in reducing psychotropic use in nursing homes.

Background: The impairment of verbal skills of people with dementia challenges communication. The aim of this review was to study the effects of nonpharmacological interventions in residential and nursing homes on (1) communication between residents with dementia and care staff, and (2) the neuropsychiatric symptoms of residents with dementia.

Method: Pubmed, PsychInfo, Web of Science, the Cochrane Library, and reference lists from relevant publications were systematically searched to find articles about controlled interventions with communication strategies. The data collected were pooled and subjected to a meta-analysis.

Results: Nineteen intervention studies were selected for this review. They included structured and communicative “sessions at set times” for residents (e.g. life review) and communication techniques in activities of “daily care” applied by care staff (e.g. sensitivity to nonverbal communication). A meta-analysis of five set-time interventions (communication) and another meta-analysis of four set-time interventions (neuropsychiatric outcomes) found no significant overall effects. Individual set-time intervention studies report positive effects on communication when interventions are single-task sessions, like life review or one-on-one conversation. Interventions around daily care activities had positive effects on communication outcomes. Effects of both types of interventions on neuropsychiatric symptoms were divergent.

Conclusion: This review indicates that care staff can improve their communication with residents with dementia when strategies are embedded in daily care activities or interventions are single-task sessions at set times. These results offer the possibility of improving the quality of care, but not of directly reducing neuropsychiatric symptoms. More research is needed to study the effect of communication interventions on neuropsychiatric symptoms.

Background: Achieving remission in late-life depressive disorder is difficult; it is far better to prevent depression. In the last ten years there have been a number of clinical studies of the feasibility of prevention.

Methods: A limited literature review was undertaken of studies from 2000 specifically concerning the primary prevention of late-life depressive disorder or where primary prevention is a relevant secondary outcome.

Results: Selective primary prevention (targeting individuals at risk but not expressing depression) has been shown to be effective for stroke and macular degeneration but not hip fracture. It may also prove effective for the depression associated with caregiving in dementia. Emerging evidence finds effectiveness for indicated prevention (in those identified with subthreshold depression often with other risk factors such as functional limitation). Despite a number of promising risk factors (for example, diet, exercise, vascular risk factors, homocysteine and insomnia), universal prevention of late-life depression (acting to reduce the impact of risk factors at the population level) has no current evidence base, although a population approach might mitigate suicide.

Conclusion: Interventions which work in preventing late-life depression include antidepressant medication in standard doses and Problem-Solving Treatment. When integrated into a care model, such as collaborative care, prevention is feasible but more economic studies are needed.

Background: Despite a stereotype that characterizes older people as excessively anxious about their health, there is little research into this phenomenon. The present exploratory study examined: (a) whether a cohort of older adults was unduly health anxious, (b) which demographic and health factors predicted health anxiety (HA), and (c) whether an aspect of the cognitive behavioral model of HA was applicable to older adults by investigating the relationship between HA and safety behaviors.

Method: Participants were a convenience sample of adults aged over 65 and living independently in Auckland, New Zealand. Participants (104 women and 41 men) completed an anonymous self-report questionnaire measuring demographic factors, physical health and function, health anxiety, safety behaviors, and medical utilization.

Results: This cohort of adults over 65 were not unduly health anxious. Occurrence of severe HA was similar to that found in younger populations. Decreased physical function and lower education predicted scores on the HA measure. Consistent with the cognitive behavioral model, HA was a unique significant predictor of safety behaviors. HA and decreased physical function predicted medical utilization.

Conclusions: Generally low levels of HA among this cohort of older individuals challenged the pervasive stereotype of the “hypochondriacal” older person. Factors contributing to HA were similar to those reported in studies with younger cohorts. Findings provided preliminary support for the applicability of the cognitive behavioral model of HA to adults over 65. Implications of the findings and directions for future research were discussed.

Background: Although studies indicate that community-dwelling elderly have a lower prevalence of major depression compared with younger age groups, prevalence estimates in Brazil show that clinically significant depressive symptoms (CSDS) and depression are frequent in the older population. However, a systematic review and meta-analysis of prevalence of and factors associated with depressive disorders and symptoms in elderly Brazilians has not previously been reported. The aims were (i) to perform a survey of studies dating from 1991 to 2009 on the prevalence of depressive disorders and CSDS in elderly Brazilians residing in the community; (ii) to determine depression prevalence and identify associated factors; and (iii) develop a meta-analysis to indicate the combined prevalence and the influence of gender on depressive morbidity in this population.

Methods: Studies were selected from articles dated between January 1991 and May 2009, extracted from Medline, LILACS and SciELO databases.

Results: A total of 17 studies were found, 13 with CSDS, 1 with major depression alone and 3 with major depression and dysthymia, involving the evaluation of 15,491 elderly people. The average age of participants varied between 66.5 and 84.0 years. Prevalence rates of 7.0% for major depression, 26.0% for CSDS, and 3.3% for dysthymia were found. The odds ratios for major depression and CSDS were greater among women. There was a significant association between major depression or CSDS and cardiovascular diseases.

Conclusion: The review indicates greater prevalence of both major depression and CSDS compared to rates reported in the international literature, while the prevalence of dysthymia was found to be similar. The high prevalence of CSDS and its significant association with cardiovascular diseases reinforces the importance of evaluating subthreshold depressive symptoms in the elderly in the community.

From antiquity the term “dementia” has denoted a state of severe acquired intellectual deterioration which significantly interferes with the fulfillment of personal, social or occupational roles, and makes the individual dependent on care and supervision by others. The medical concept of dementia refers to a pattern of cognitive and behavioral symptoms which typically arises from chronic and often progressive brain diseases. The quantitative expression of this pattern shows broad variability, and some patients fall within the boundaries of the concept whose intellectual and functional abilities are only mildly impaired. On the other hand, the concept currently has an unduly narrow qualitative bandwidth, because it is modeled after the subtype which occurs in Alzheimer's disease but does not represent a good fit for other important subtypes. In the authors’ view, the concept of dementia should be retained despite its limitations, since it has an important role in directing the physician's attention to a certain group of underlying pathologies. This diagnostic role of the concept will remain important in primary care even if biological indicators for one or several etiologies will become part of the diagnostic routine in research units in the future. The medical construct has further value since it entitles patients to medical treatment, social assistance and legal protection. Although in our opinion the concept of dementia does not need to be replaced, upcoming revisions of the psychiatric classification systems will have to reframe it by emphasizing the heterogeneity of the psychopathological symptom pattern. In view of the increasing importance of early diagnosis and treatment, however, the term “dementia”, which literally means “absence of mind”, is no longer an appropriate and timely designation for the broad range of cognitive and behavioral limitations covered by the concept. It should be renamed, using a terminology which accommodates scientific advance and meets the requirements of medical communication while preserving the benefits for patients and their families.

Background: The prevalence of mental disorders in long-term care (LTC) homes is high, but quality and availability of mental health services to assess and help in management of cases have been criticized.

Method: Literature concerning mental health problems in LTC homes was reviewed, especially regarding models of mental health service delivery and factors that affect development, persistence and reduction of symptoms and distress.

Results: The advantages of consultation-liaison arrangements and of telepsychiatry were noted. Discussions led to development of recommendations aimed at improving mental health expertise and provision of assessment and intervention services in LTC homes in diverse countries. Prompt recognition of mental health problems among residents is required, with availability of a team working within the facility to deal with these problems. Commonly such multidisciplinary teams are formed by facility staff linking with visiting mental health professionals or services. Quality of care is also affected by the organization, attitudes and education within LTC facilities.

Conclusion: Provision of optimal mental health care in LTC settings is dependent on adequate funding, availability of expertise and education, positive and caring attitudes, recognition of needs, and supportive teamwork. The latter should include cooperative links between well-resourced and under-resourced regions.

Background: Workforce shortages to meet the mental health needs of the world's aging population are well documented. Within the field of professional geropsychology in the U.S.A., a national conference was convened in 2006 to delineate competencies for psychological practice with older adults and a training model for the field. The conference produced the Pikes Peak Model of Geropsychology Training. The Council of Professional Geropsychology Training Programs (CoPGTP) aimed to produce a competency evaluation tool to help individuals define training needs for and evaluate progress in development of the Pikes Peak professional geropsychology competencies.

Methods: A CoPGTP task force worked for one year to adapt the Pikes Peak Model geropsychology attitude, knowledge, and skill competencies into an evaluation tool for use by supervisors, students and professional psychologists at all levels of geropsychology training. The task force developed a competency rating tool, which included delineation of behavioral anchors for each of the Pikes Peak geropsychology knowledge and skill competencies and use of a developmental rating scale. Pilot testing was conducted, with 13 individuals providing feedback on the clarity and feasibility of the tool for evaluation of oneself or students.

Results: The Geropsychology Knowledge and Skills Assessment Tool, Version 1.1, is now posted on the CoPGTP website and is being used by geropsychology training programs in the U.S.A.

Conclusions: The evaluation tool has both strengths and limitations. We discuss future directions for its ongoing validation and professional use.

Background: Although advance directives may seem useful instruments in decision-making regarding incompetent patients, their validity in cases of dementia has been a much debated subject and little is known about their effectiveness in practice. This paper assesses the contribution of advance directives to decision-making in the care of people with dementia, with a special focus on non-treatment directives and directives for euthanasia.

Methods: The relevant problems from the ethical debate on advance directives in cases of dementia are summarized and we discuss how these relate to what is known from empirical research on the validity and effectiveness of advance directives in the clinical practice of dementia care.

Results: The ethical debate focuses essentially on how to respond to the current wishes of a patient with dementia if these contradict the patient's wishes contained in an advance directive. The (very limited) empirical data show that the main factors in medical decision-making in such cases is not the patient's perspective but the medical judgment of the physician and the influence of relatives. Insight into the experiences and wishes of people with dementia regarding advance directives is totally lacking in empirical research.

Conclusions: Ethics and actual practice are two “different worlds” when it comes to approaching advance directives in cases of dementia. It is clear, however, that the use of advance directives in practice remains problematic, above all in cases of advance euthanasia directives, but to a lesser extent also when non-treatment directives are involved. Although generally considered valid, their effectiveness seems marginal. Further empirical research into the (potential) value of advance directives in dementia care is recommended.

Background: No previous studies have considered elder abuse in Eastern Europe. We aimed to determine the proportion of home care workers and older people receiving care in a Romanian home care service who correctly identified elder abuse in a vignette, and who had detected elder abuse at work.

Methods: In 2009, care workers and clients of a non-government home care organization serving four areas in Romania completed the Caregiver Scenario Questionnaire to measure ability to identify abuse. We asked the professionals whether they had detected a case of abuse.

Results: 35 (100%) professionals and 79 (65.8%) older people took part. Four (11.4%) professionals had encountered a case of elder abuse, two (5.7%) in the last year. No staff and only one older person correctly identified all four abusive strategies in a vignette. Staff with more professional caregiving experience recognized fewer abusive strategies (r = −0.46, p = 0.007).

Conclusion: Rates of identification were worryingly low among all professionals, and this was more marked if they had worked longer, suggesting their experiences may have reduced their ability to detect it. Mandatory abuse training for care professionals, and strategies to support reporters of suspected abuse, could help improve the management of elder abuse in all countries.