It gives us great pleasure to announce that in 2007 and beyond International Psychogeriatrics will appear six times each year in February, April, June, August, October and December. In 2007 each issue will comprise 176 pages, and at least one supplement (to contain the abstracts for the Thirteenth Congress of the International Psychogeriatric Association (IPA)) will be published as well. This increase in publication frequency and annual number of published pages will cut the time between the online publication of accepted manuscripts as “forthcoming articles” at our website www.journals.cambridge.org/jid_IPG and their appearance in a specific issue of the journal, and also will permit the further development of innovations such as the popular “for debate” series (e.g. Ames et al., 2005) which was initiated last year. This development represents a vote of confidence in the future of the journal by both its parent association, IPA, and its publisher, Cambridge University Press, and, in consequence, IPA members and other journal subscribers will now derive markedly increased value from their subscriptions, as the number of journal pages published annually will have risen from 446 in 2002 and 2003 to 1056 in 2007, coincident with a marked improvement in the timeliness of the journal's publication dates (Ames, 2006). The number of pages to be published each year will be reviewed every 12 months, and we hope that a continuation of the recent steady rise in both number and quality of manuscript submissions (Ames, 2006) will permit further growth of the journal in future. Meanwhile, we encourage the 30% or more of subscribers who have not yet activated their online subscriptions to do so by registering at the Cambridge University Press website as advised in letters sent out by the Press at the start of August. Those subscribers who are entitled to receive hard copies of the journal will not lose this entitlement by activating their online subscriptions, and online registration brings with it the considerable advantages of early access to accepted articles and the ability to obtain pdf copies of journal content.

The field of Alzheimer's disease (AD) research is in transition. Advances in our knowledge of AD pathology are translating into improved understanding of pharmacological agents that may have benefits across the spectrum of the illness. A major focus of current research is the potential ability of cholinergic therapy to enhance function and quality of life in all patients affected by AD, from the mildest to the most advanced stages.

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.”

Meeting in Lisbon, Portugal on May 3rd 2006, the board of directors of the International Psychogeriatric Association (IPA) endorsed the recommendation of its executive that I be reappointed for a further (and final under the terms of the IPA constitution) four year term to serve as editor of International Psychogeriatrics from 1 January 2007 to 31 December 2010. I accepted this offer with delight, so unless I get fired for misconduct, drop dead or resign early, readers and authors are stuck with me until the end of the decade. As we strive to further develop and improve the journal this is an appropriate moment to reflect on what has changed since I took over at the start of 2003, report how the journal stands at present and indicate what developments may lie ahead.

When we manage our patients both they and we would like to know that the interventions we prescribe have been tested and shown to be safe and effective for the uses to which they are put. The most powerful tool to determine the utility of specific interventions in the discipline of medicine is the double-blind placebo-controlled randomized clinical trial (RCT). Some of the complex problems encountered in psychogeriatrics do not lend themselves to straightforward yes or no outcomes, and some of the multifaceted interventions developed for the management of common psychogeriatric syndromes are difficult to test using standard RCT design, especially with regard to effective blinding and appropriate control conditions (Llewellyn-Jones et al. 1999; Haynes, 1999; Ames, 1999). Nevertheless, there are specific interventions for which RCT data have been very useful in refining treatment guidelines and advice (e.g. Doody et al., 2001) and, where this is the appropriate trial design, RCTs comprise the “gold standard” by which to assess the efficacy of a treatment or “management package”.

The pathological processes that lead to Alzheimer's disease (AD) begin decades before the onset of dementia. Brain abnormalities in genetically susceptible individuals have been observed even in young adults. Patients with AD differ from normal elderly patients in brain morphology and neurochemistry. Important observations include increasing appearance of amyloid plaques and neurofibrillary tangles, progressive loss of hippocampal volume, reduced cerebral glucose utilization, inflammatory processes, glial activation, and impairment of cholinergic function with losses of nicotinic acetylcholine receptors. These changes appear to begin in the asymptomatic stages and continue as cognition and then function and behavior are disrupted. Mild cognitive impairment (MCI) may be the first cognitive manifestation of this pathogenic process moderated by ongoing compensatory neurochemical mechanisms in the cholinergic system. Recent advances in positron emission tomography imaging techniques, including the development of the Pittsburgh B compound (PIB), allow in vivo visualization of amyloid plaques. These techniques have the potential to enable brain amyloid load to be monitored over time and to be related to brain function. Emerging evidence suggests that β-amyloid may interact with nicotinic receptors. This interaction may have clinically significant downstream effects and may mediate amyloid neurotoxicity. The cholinesterase inhibitors may have multiple actions, depending on the stage of the disease, from very mild to severe.

Background: The results of studies of the association between awareness and clinical correlates in patients with dementia are inconclusive. The aims of this study were to investigate whether awareness changed during the course of dementia and to determine whether awareness was associated with certain behavioral symptoms. Specifically, it was hypothesized that relatively intact awareness was related to affective disorders.

Methods: One hundred and ninety-nine patients with dementia were included in a prospective 18-month follow-up study. Behavioral problems were assessed with the Neuropsychiatric Inventory and the Cornell Scale for Depression in Dementia. Awareness was assessed by means of the Guidelines for the Rating of Awareness Deficits.

Results: Cross-sectional analyses showed awareness to be positively associated with age, gender, education and socioeconomic status, and negatively associated with psychosis, apathy, and overall behavioral disorders at baseline. After 1 year, a higher level of awareness was related to depression and anxiety. The level of awareness at baseline also predicted depression and anxiety after 1 year. Awareness decreased during the study.

Conclusions: A higher level of awareness is associated with subsyndromal depression and anxiety, whereas lack of awareness is associated with psychosis and apathy. The level of awareness decreases as dementia progresses. Clinicians should be more alert to changes in awareness in patients with dementia because psychosocial support might help to prevent the development of affective symptoms.

In March 2005 International Psychogeriatrics published its first “For Debate” section on the topic of “should novel antipsychotics ever be used to treat the behavioral and psychological symptoms of dementia (BPSD)?” (Ames et al., 2005). Following the positive reception of this piece, we have commissioned three further debates, of which this one on mild cognitive impairment (MCI) is the first to be finished. Further For Debate articles on the effectiveness of electroconvulsive therapy in treating the depressed elderly, and the utility of neuroimaging methods in the assessment of dementia are in an advanced stage of preparation and will appear in future issues of the journal. Should any reader have suggestions for other worthwhile debate topics I urge them to contact me at [email protected] as the journal's entire editorial panel is keen to make these debates a regular journal feature.

Background: In recent years, many different forms of interventions for caregivers of people with dementia have been developed. However, their results have been, in part, inconclusive.

Methods: Meta-analysis was used to integrate the results of 127 intervention studies with dementia caregivers published or presented between 1982 and 2005.

Results: Interventions had, on average, significant but small effects on burden, depression, subjective well-being, ability/knowledge and symptoms of care recipient. Only multicomponent interventions reduced the risk for institu-tionalization. Psychoeducational interventions that require active participation of caregivers had the broadest effects. Effects of cognitive-behavioral therapy, support, counseling, daycare, training of care recipient, and multicomponent interventions were domain specific. The effect sizes varied by study chara-cteristics, such as caregiver gender and year of publication.

Conclusions: Because most interventions have domain-specific outcomes, clinicians must tailor interventions according to the specific needs of the individual caregivers. Although more recent interventions showed stronger effects, there is room for further improvements in interventions.

Mild cognitive impairment (MCI) has become a major issue in the fields of geriatrics, behavioral neurology and geriatric psychiatry. While some have embraced the construct as a step forward in understanding the prodromal stages of dementing disorders, others have assailed the concept as counterproductive and distracting. Perhaps this is appropriate, since any new proposal for the clinical characterization of impaired subjects should undergo strict scrutiny.

Background: Older adults with dementia commonly exhibit agitated behavior that puts them at risk of injury and institutionalization and is associated with caregiver stress. A range of theoretical approaches has produced numerous interventions to manage these behavior problems. This paper critically reviews the empirical literature on behavioral interventions to reduce agitation in older adults with dementia.

Method: A literature search yielded 23 articles that met inclusion criteria. These articles described interventions that targeted wandering, disruptive vocalization, physical aggression, other agitated behaviors and a combination of these behaviors. Studies are summarized individually and then evaluated.

Results: Behavioral interventions targeting agitated behavior exhibited by older adults with dementia show considerable promise. A number of methodological issues must be addressed to advance this research area. Problem areas include inconsistent use of functional assessment techniques, failure to report quantitative findings and inadequate demonstrations of experimental control.

Conclusions: The reviewed studies collectively provide evidence that warrants optimism regarding the application of behavioral principles to the management of agitation among older adults with dementia. Although the results of some studies were mixed and several studies revealed methodological shortcomings, many of them offered innovations that can be used in future, more rigorously designed, intervention studies.

Early initiation of Alzheimer's disease (AD) treatment is advantageous because it can potentially keep patients in milder stages of the disease longer than delayed treatment. Early initiation of cholinesterase inhibitor therapy is an effective intervention for mild AD. Therefore, it is critical to identify and monitor patients who are at risk for AD and to initiate treatment once AD is diagnosed. A new diagnostic category, mild cognitive impairment (MCI), has been evolving to identify patients who demonstrate objective memory impairment but have essentially intact function or only limited functional impairment and do not meet diagnostic criteria for dementia. The amnestic subtype of this condition is associated with a high risk of AD – 16% of amnestic MCI patients convert to AD each year compared with 1% to 3% of normal elders. A recent three-year study found that patients with amnestic MCI who were treated with donepezil had a significantly reduced likelihood of progression to dementia in the first 12 months of treatment. The effect of donepezil in delaying onset of dementia was supported by significant differences favoring donepezil in the Mini-mental State Examination, the Clinical Dementia Rating-Sum of the Boxes, the Global Deterioration Scale, and the modified Alzheimer Disease Assessment Scale-cognitive subscale (ADAS-Cog) over the first 18 months of treatment. A previous study evaluated the effects of donepezil on memory and cognition in patients with MCI. Although donepezil had no significant effect on memory as measured by the New York University Paragraph Recall Test, it significantly improved scores on the modified ADAS-Cog. Donepezil therefore shows promise in this patient population and warrants further investigation using extended study durations and refined outcome measures.

Background: Animal-assisted therapy (AAT) is gaining popularity as part of therapy programs in residential aged care facilities. Humans and pet dogs respond to quiet interaction with a lowering of blood pressure and an increase in neuroche-micals associated with relaxation and bonding. These effects may be of benefit in ameliorating behavioral and psychological symptoms of dementia (BPSD).

Methods: Medline, PsychInfo and CINAHL databases (1960–2005) were searched for papers on AAT or pets and dementia. Publications of controlled trials that measured the effect of AAT for dementia were reviewed.

Results: Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia. One study has shown that aquaria in dining rooms of dementia care units stimulate residents to eat more of their meals and to gain weight but is limited by the small number of facilities studied. There is preliminary evidence that robotic pets may provide pleasure and interest to people with dementia.

Conclusions: Current literature suggests that AAT may ameliorate BPSD, but the duration of the beneficial effect has not been explored. The relative benefits of “resident” versus “visiting” pet dogs are unclear and are confounded by the positive effect of pet interaction on staff or caregivers. Further research on the potential benefits of AAT is recommended.

Background: Both the lesion location hypothesis and the vascular depression hypothesis have been proposed to explain the high incidence of depression in stroke patients. However, research studying both hypotheses in a single cohort is, at present, scarce.

Objective: To test the independent effects of lesion location (left hemisphere, anterior region) and of co-occurring generalized vascular damage on the development of depression in the first year after ischemic stroke, while other risk factors for depression are controlled for.

Methods: One hundred and ninety consecutive patients with a first-ever, supratentorial infarct were followed up for one year. CT was performed in the acute phase of stroke, while in 75 patients an additional MRI scan was also available. Depression was assessed at 1, 3, 6, 9, and 12 months after stroke using self-rating scales as screening tools and the SCID-I to diagnose depression according to DSM-IV criteria.

Results: Separate analyses of the lesion location hypothesis and the vascular depression hypothesis failed to reveal significant support for either of these biological models of post-stroke depression. Similar negative results appeared from one overall, multivariate analysis including variables of both focal and generalized vascular brain damage, as well as other non-cerebral risk factors. In addition, level of handicap and neuroticism were independent predictors of depression in this cohort, as has been reported previously.

Conclusion: This study supports neither the lesion location nor the vascular depression hypothesis of post-stroke depression. A biopsychosocial model including both premorbid (prior to stroke) vulnerability factors, such as neuroticism and (family) history of depression, as well as post-stroke stressors, such as level of handicap, may be more appropriate and deserves further study.

The article by Onishi, J. et al. (2006). Behavioral, psychological and phsyical symptoms in group homes for older adults with dementia. International Psychogeriatrics, 18, [sUE ADD actual published page numbers here I do not know what they are because I am at home and do not have running order for March] contains an error at the foot of its first page. The article was received at the editorial office on 30 Sep 2004 (not 30 Sep 2005) and was returned for revision on 18 Nov 2004 (not 18 Nov 2005).

Within the spectrum of cognitive disorders Mild Cognitive Impairment (MCI) is a relatively new concept which has become increasingly popular both in clinical practice and in clinical research. Still, the concept of MCI has several shortcomings which limit its utility in clinical practice and research.

Background: To investigate the characteristics of patients in whom artificial nutrition and hydration (ANH) is forgone, duration of survival after the decision and factors that are associated with duration of survival.

Methods: Observational study based on written questionnaires in 32 Dutch nursing homes. Of 178 nursing home patients with dementia, their treating nursing home physician (NHP) filled in a questionnaire directly after the decision was made to forgo ANH. The maximum follow-up was 6 weeks. Cox proportional hazards analysis was used to determine predictors of survival.

Results: Decisions to forgo ANH in Dutch nursing homes were made most often in patients with severe dementia who also had an acute illness. More than half the patients (59%) died within 1 week after the decision. Patients with dyspnea and/or apathy were more likely to die during follow-up than patients without these symptoms. Patients who were considered more severely ill by the NHP were more likely to die than those who were considered less severely ill. The presence of restlessness indicated a higher chance of survival.

Conclusions: The clinical judgment of the NHP of the severity of illness appeared to be a strong predictor of patient survival. NHPs should not rely solely on their clinical judgment concerning survival, but they should also consider the presence or absence of dyspnea, apathy and restlessness.

Acetylcholinesterase inhibitors have demonstrated safety and efficacy in patients with mild to moderate Alzheimer's disease (AD). Although studies of biomarkers in AD suggest a neurobiological rationale for continuing cholinomimetic therapy in patients with severe AD, there have been few studies on the effects of these drugs in such patients. While the interpretation of earlier studies on therapy for severe AD has been complicated by the inclusion of patients with moderate AD, a recent study in Swedish nursing home residents demonstrates the clinical utility of donepezil in a population of exclusively severe patients – i.e. those with Mini-Mental State Examination scores of 1 to 10 inclusive. Significant differences favoring donepezil treatment were observed at the end of this six-month, double-blind placebo-controlled study on the two primary outcome measures: the Severe Impairment Battery (SIB) and Modified Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory for Severe AD (ADCS-ADL-severe). Donepezil-treated patients showed a mean improvement on the SIB after six months compared with baseline, and less decline on the ADCS-ADL-severe than would be expected for untreated patients. These results extend and confirm earlier data suggesting that donepezil is effective in patients with moderate and severe AD.

Background: Music therapy is a potential non-pharmacological treatment for the behavioral and psychological symptoms of dementia, but although some studies have found it to be helpful, most are small and uncontrolled.

Methods: This case–control study was carried out by qualified music therapists in two nursing homes and two psychogeriatric wards. The participants were 38 patients with moderate or severe Alzheimer's disease (AD) assigned randomly to a music therapy group and a control group.

Results: The study showed a significant reduction in activity disturbances in the music therapy group during a 6-week period measured with the Behavior Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). There was also a significant reduction in the sum of scores of activity disturbances, aggressiveness and anxiety. Other symptoms rated by subscales of the BEHAVE-AD did not decrease significantly. Four weeks later the effects had mostly disappeared.

Conclusions: Music therapy is a safe and effective method for treating agitation and anxiety in moderately severe and severe AD. This is in line with the results of some non-controlled studies on music therapy in dementia.