Objectives: To examine delirium, chronic medical problems and sociodemographic factors as predictors of activities of daily living (ADL), basic ADL (BADL) and instrumental ADL (IADL).

Methods: A prospective cohort study of four groups of elderly patients examined in the emergency department (ED): those with delirium, dementia, neither, and both. All were aged 66 years or older and living at home. Delirium was assessed with the Confusion Assessment Method and dementia with the Informant Questionnaire on Cognitive Decline in the Elderly. Demographic variables and chronic medical problems were ascertained with questionnaires. Outcome was ADL at 6, 12 and 18 months, measured with the ADL subscale of the Older Americans Resources and Services instrument.

Results: Univariate analyses suggested significantly poorer ADL, particularly IADL, at 18 months in the delirium versus the non-delirium group, in the absence of dementia only. Statistically significant independent predictors of poorer ADL at 18 months in the non-dementia groups were poorer initial ADL, stroke, Parkinson's disease, hypertension and female sex. Independent predictors of poorer BADL at 18 months in the non-dementia groups were poorer initial BADL, Parkinson's disease, stroke, cancer, colds/sinusitis/laryngitis, female sex and hypertension. Independent predictors of poorer IADL at 18 months in the non-dementia groups were poorer initial IADL, stroke, never-married status, colds/sinusitis/laryngitis, arthritis and hypertension, with Parkinson's disease showing a non-significant but numerically large regression coefficient.

Conclusion: Rather than finding delirium to be a predictor of poorer functional outcome among survivors, we found an interaction between delirium and dementia and several plausible confounders, primarily chronic medical problems, although we cannot rule out the effect of misclassification or survivor bias.

Background: Cross-sectional studies have shown that late-onset depression is associated with larger deep white matter lesions (WMLs) and subcortical gray matter lesions (GMLs). In a longitudinal analysis, we examined changes in deep WMLs and subcortical GMLs in older depressed and nondepressed subjects over a 4-year period.

Methods: Brain magnetic resonance imaging (MRI) scans were obtained on 164 depressed and 126 healthy subjects aged 60 years or older at baseline, and 2 and 4 years after recruitment. WMLs and GMLs were measured using a semiautomated technique. We used repeated-measures analysis of covariance to determine cross-sectional lesion volume differences, whether lesion volume changes differed between patients and controls, and the effect of lesion volume changes on outcome in late-life depression.

Results: Mean volumes of lesions for the depressive group were 6.51, 8.18 and 7.75 cm2 for WMLs and 0.23, 0.30 and 0.34 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Mean volumes of lesions for the control group were 4.83, 6.22 and 6.45 cm2 for WMLs and 0.17, 0.25 and 0.23 cm2 for GMLs at baseline, 2-year and 4-year follow-up, respectively. Cross-sectional between-group mean lesion volumes were significantly different for each measure. However, the pattern of WML and GML volume changes over time was not significantly different between groups. Treatment outcome was associated with changes in total and white matter lesion volume over time.

Conclusions: Lesion volume progression is associated with aging and the pathological condition of late-life depression. The mechanisms that produce these progressive lesion changes remain unclear. Treatments aimed at arresting lesion progression may play a role in the management of late-life depression.

Introduction: Brief cognitive tests such as the Mini-mental State Examination (MMSE) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) have been used to detect cognitive impairment and dementia in studies of stroke patients. However, there are few data on their validity for such use. We have evaluated their validity in detecting cognitive impairment not dementia (CIND) and dementia in a community-based sample of first-ever stroke patients.

Methods: The standardized MMSE (S-MMSE) and the 16-item IQCODE were administered to 79 patients 1 year after a first-ever stroke. CIND and dementia were diagnosed independently using a comprehensive cognitive battery. The performances of the two tests were evaluated using receiver operating characteristic (ROC) analyses. Combined performance was evaluated when their scores were used in parallel (the “or rule”), in series (the “and rule”) or as a weighted sum (the “weighted sum rule”).

Results: Both tests were extremely poor at detecting CIND individually and in combination. For dementia, at traditional cut-points, the S-MMSE (≤23) was insensitive (0.50, 95% CI 0.16–0.84) and the IQCODE (≥3.30) nonspecific (0.63, 95% CI 0.51–0.75). An acceptable balance between sensitivity and specificity was achieved for dementia using the “or rule” combination, but with only modest positive predictive value.

Conclusions: The S-MMSE and the IQCODE were individually poor at detecting CIND and dementia after a nonaphasic first-ever stroke. The combination was useful in detecting dementia but it does not replace the need for detailed neuropsychological tests.

Objective: To compare the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein Mini-mental State Examination (MMSE) for diagnosis of dementia in a multicultural cohort of elderly persons.

Methods: A total of 129 community-dwelling persons were selected at random from a database of referrals to an aged-care team. Subjects were stratified according to language background and cognitive diagnosis, and matched for age and gender. The RUDAS and the MMSE were administered to each subject in random order. Within several days, a geriatrician assessed each subject for dementia (DSM-IV criteria) and disease severity (Clinical Dementia Rating Scale). All assessments were carried out independent and blind. The geriatrician also administered the Modified Barthel Index and the Lawton Instrumental Activities of Daily Living Scale, and screened all participants for non-cognitive disorders that might affect instrument scores.

Results: The area under the receiver operating characteristic curve (AUC) for the RUDAS [0.92, 95% confidence interval (95%CI) 0.85–0.96] was similar to the AUC for the MMSE (0.91, 95%CI 0.84–0.95). At the published cut-points (RUDAS < 23/30, MMSE < 25/30), the positive and negative likelihood ratios for the RUDAS were 19.4 and 0.2, and for the MMSE 2.1 and 0.14, respectively. The MMSE, but not the RUDAS, scores were influenced by preferred language (p = 0.015), total years of education (p = 0.016) and gender (p = 0.044).

Conclusions: The RUDAS is at least as accurate as the MMSE, and does not appear to be influenced by language, education or gender. The high positive likelihood ratio for the RUDAS makes it particularly useful for ruling-in disease.

Background: Most instruments designed to detect dementia can lack appropriate sensitivity in the early stages of Alzheimer's disease (AD), and are subject to educational bias. The Short Cognitive Performance Test (Syndrom-Kurztest, SKT) is considered a suitable instrument to measure cognitive decline as it assesses memory, attention, and related cognitive functions, taking into account the speed of information processing.

Objectives: The aim of this study was to examine the psychometric characteristics of the SKT as a dementia screening instrument in a Brazilian population sample, as compared to the Mini-mental State Examination (MMSE) and the Clock-Drawing Test (CDT). The effect of educational level on performance in the three screening tests was also verified.

Methods: Fifty-one elderly subjects were assessed. Consensus diagnoses were established by an expert multidisciplinary team, considering clinical, neuropsychological and neuroimaging data. Subjects were further classified into those with (1) mild and moderate AD, (2) non-Alzheimer's dementia, (3) mild cognitive impairment, and (4) controls, according to National Institute for Communicative Disorders and Stroke – Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria.

Results: Statistical analyses revealed high internal consistency for the SKT (Cronbach's α = 0.80) and significant correlations between the total score and the SKT subscores separately (p < 0.01). Comparison of the three tests revealed strong correlations between the SKT and the MMSE (r = −0.66, p < 0.0001) and between the SKT and the CDT (r = −0.57, p < 0.0001). The SKT, MMSE and CDT scores were correlated with education.

Conclusions: The Brazilian version of the SKT maintains its original psychometric properties and displays significant correlation with previously validated screening tools for dementia. Like other dementia screening tests, the SKT is subject to educational bias.

Background: The role of individual differences, including pre-morbid personality, in the development of post-stroke depression, has received relatively little attention. We undertook a cross-sectional study to investigate the relationship between pre-morbid personality and other individual differences, and depression following acute stroke.

Method: We studied 61 consecutive patients admitted to a dedicated stroke inpatient unit. DSM-IV depressive diagnoses were ascertained using the Composite International Diagnostic Interview and depressive symptoms were ascertained on the Hamilton Depression Rating Scale and the Center for Epidemiologic Studies Depression Scale. Informant-rated personality scores were obtained on the full 240-item Neuroticism, Extraversion and Openness Personality Inventory – Revised. Adaptive function was measured on the Modified Barthel Index and the Instrumental Activities of Daily Living scale. Cognitive function was assessed on the Mini-mental State Examination.

Results: An increased risk of post-stroke depression was conferred by both pre-morbid neuroticism [odds ratio (OR) 3.69; 95% confidence interval (95% CI) 1.25–10.92] and a past history of mental disorder (OR 10.26; 95% CI 3.02–34.86). There was no significant relationship demonstrated between lesion location and post-stroke depression.

Conclusions: Informant-rated pre-morbid neuroticism and a past history of mental disorder were important predictors of depression following stroke. Stroke side was not significantly related to risk of depressive symptoms following stroke.

Background: Few studies have investigated the association of psychiatric morbidity with acute hospitalization risk in elderly people.

Method: We examined this association using population-based data for 1092 older adults aged ≥60 years in Singapore, including subjects who reported at least one acute hospitalization from any medical condition(s) in the 12 months prior to interview (N = 136). Psychiatric morbid/comorbid disorders were diagnosed using the Geriatric Mental State examination.

Results: In a multivariate analysis, comorbid psychiatric disorders were inde-pendently associated with hospitalization [adjusted odds ratio 2.76, 95% confidence interval 1.20–6.33], after controlling for age, ethnicity, employment status, number of medical comorbidities, number of activities of daily living limitations, hearing and visual impairment, SF-12 Physical and Mental Component Summary scores, social, productive, fitness and health activities, and regular visits to health-care providers. Neither dementia diagnosis nor cognitive impairment measured by the Mini-mental State Examination was associated with increased hospitalization risk.

Conclusion: Psychiatric morbidity in old age was significantly associated with increased hospitalization risk. This finding underlines the importance of treating psychiatric illness to reduce the risk of acute hospitalization in elderly patients.

Background: The Dutch version of the Coping With Depression (CWD) course for older adults has been implemented in the prevention arm of the community-based mental health care system in the Netherlands. The study group included older adults with subclinical depression as well as those with a major depressive disorder; all were enrolled into the course by mental health care professionals. The effectiveness (immediate and long-term) of the course for this heterogeneous population was studied in an effectiveness trial.

Method: Participants were self-referred, responding to media announcements. A total of 119 participants aged 55–85 years (69% female), with subclinical depression and major depression, were randomized to either the CWD course (N = 61) or the waiting list (N = 58).

Results: Nine participants dropped out of the course. According to a diagnostic interview based on the DSM-IV, 39% had a major depressive disorder (MDD), 69% had had a previous MDD, and 45% had an anxiety disorder. Older adults in the intervention group showed a significant decrease in depression symptoms. Gains were maintained over 14 months. In the intervention condition 83% had a pre-treatment score ≥ 16 on the Center for Epidemiologic Studies Depression Scale (CES-D); at post-treatment 62% still scored ≥ 16.

Conclusions: The course was beneficial for participants with mild or severe depression, and treatment acceptability was high. It should be fitted into a stepped-care protocol that varies intervention intensity according to clinical needs, using the post-treatment level of functioning as an indication for the next step.

Objective: This cross-sectional study examined the prevalence and characteristics of depression in subjects with mild cognitive impairment (MCI). The data presented here are from the first wave of the longitudinal Personality and Total Health Through Life 60+ (PATH 60+) Project.

Method: A total of 2551 community-dwelling individuals in the age range 60–64 years were recruited randomly through the electoral roll. They were screened using a short cognitive battery and those who screened positive underwent detailed medical and neuropsychological assessments. There were 29 subjects who fulfilled the Mayo Clinic criteria for MCI and these were compared to 520 controls. Subjects were evaluated for depression symptoms and DSM-IV major and minor depression syndromes.

Results: Subjects with MCI had more minor depression and higher scores on a symptom scale. However, a multivariate examination of specific symptoms showed that the differences were confined to only two motivation-related symptoms (“felt slowed up” and “little interest or pleasure”).

Conclusion: Motivation-related depressive symptoms are more relevant in subjects with MCI than mood-related symptoms.

Objective: The size of the elderly population is growing rapidly in Turkey. We aimed to characterize geriatric psychiatry consultations to obtain the characteristic pattern of these patients for further interventions.

Method: A retrospective chart review was undertaken for each patient.

Results: One hundred and sixty-six patients with a mean age (± S.D.) of 75.5 ± 6.6 years were included in this study. Most referrals came from the Department of Internal Medicine (42.2%), with sleep problems (42.1%), depression (29.5%) and anxiety (28.3%) being the most common reasons for referral. Hypertension was the most frequent medical diagnosis (53.6%). The mean number ± S.D.) of medications used by each patient was 4.4 ± 2.0. The leading psychiatric diagnosis at the end of the assessment was adjustment disorder (31.3%).

Conclusion: Turkish geriatric psychiatry consultation patients display similar characteristics to elderly patients from other western countries. The main difference comes from diagnosis of adjustment disorder, which may be related to hospital conditions and strong family ties in developing countries.

Background: Patient-reported outcomes assessment enhances the understanding of disease impact in a range of disorders. At mild levels of cognitive impairment the patient perspective on functioning, behavior and symptoms can be particularly valuable for syndrome characterization when clinical and neuropsychological findings are limited. We have evaluated the psychometric performance of the 55-item Patient-Reported Outcomes in Cognitive Impairment (PROCOG)©, a new patient-reported measure, to measure mild to moderate cognitive impairment symptoms and their impact from the perspective of patients with dementia of the Alzheimer's type (DAT) and mild cognitive impairment (MCI).

Methods: The sample of 75 DAT patients, 78 MCI patients and 33 cognitively intact control subjects (> 64 years) was recruited through medical centers in the U.SA. Validity was assessed through correlation to the Quality of Life – Alzheimer's Disease (QOL-AD) and Centers for Epidemiologic Studies – Depression Scale (CES-D) and neuropsychological assessments (WAIS subscales and MMSE).

Results: PROCOG scores for MCI patients were generally intermediate between DAT and control subjects. Internal consistency and test-retest reliability were acceptable. Correlations with the CES-D and QOL-AD were in the moderate to high range; correlations with the neuropsychological measures were low to moderate.

Conclusions: The PROCOG demonstrated good to excellent psychometric properties among a sample of older adults with MCI and DAT as well as cognitively intact older adult control subjects and provides a method for collecting unique information on the patient experience of cognitive impairment. Subscales permit focused evaluation of domains relevant to the patient's experience of cognitive impairment.

Background: Behavioral and psychological symptoms of dementia (BPSD) commonly occur among cognitively impaired people in geriatric care. BPSD are often managed with antipsychotic drugs, despite the associated serious health risks. The aim of the present study was to discover factors associated with the use of antipsychotics.

Methods: A cross-sectional study in all geriatric care units in the county of Västerbotten, Sweden, which included 2017 residents aged 65 years and over with cognitive impairment (mean age was 83.5 years). Data were collected from prescription records and observations made by care staff of BPSD among residents during the preceding week. A multivariate regression model was con-structed to find factors independently associated with antipsychotic drug use.

Results: Eleven factors were independently associated with the use of antipsychotics. Aggressive, verbally disruptive and wandering behavior, hallucinatory and depressive symptoms, male sex, living in a group dwelling for people with dementia, imposed mental workload, the ability to rise from a chair, activities of daily living (ADL) dependency and lower age all correlated significantly.

Conclusions: Antipsychotic drug treatment of old people with cognitive impairment in geriatric care is common, and determined not only by the patient's symptoms but also by factors related more closely to the caregiver and the caring situation. These findings raise important questions about the indications for drug treatment in relation to the patient's quality of life.

Background: Depression is common in elderly people but physicians may not screen for it because of the length of time required by current screening instruments. We have developed a short screening instrument for depression for use in elderly people with normal cognition, mild cognitive impairment or early dementia.

Methods: Participants were aged 55 years or more, had scored 20 or more on the standardized Mini-mental State Examination (SMMSE) and had been referred to a specialist geriatric outpatient memory clinic. Scores on the 30-item Geriatric Depression Scale (GDS) were analyzed. A composite GDS score, consisting of the top five individual question scores that correlated to depression (GDS ≥ 14), were analyzed using a receiver operating curve analysis.

Results: There were 810 patients with SMMSE scores of 20 or greater, of whom 202 (24.9%) scored 14 or more on the GDS, indicating depression. GDS question 16, “Do you often feel downhearted and blue?,” had the highest correlation with the overall scores of 14 or more on the 30-point instrument (r = 0.64, p < 0.001). The next four questions with the highest correlates were Q10, “Do you often feel helpless?” (r = 0.56, p < 0.001), Q3, “Do you feel that your life is empty?” (r = 0.54, p < 0.001), Q9, “Do you feel happy most of the time?” (r = 0.52, p < 0.001), and Q1, “Are you basically satisfied with your life?” (r = 0.50, p < 0.001). The negative predictive value of “Do you often feel downhearted and blue?” answered negatively for depression was 96%. These five questions were used as a short screening instrument. The positive predictive value of four or five positive responses was 97%. These data were not significantly different whether the patient's SMMSE score was 20–25 or 26–30.

Conclusions: The AB Clinician Depression Screen (ABCDS), comprising five questions, can rapidly identify patients with depression or eliminate that diagnosis. In this population, these five questions may be used instead of the longer 30-question GDS scale.

Background: The aim of this study was to identify key aspects of the impact of cognitive impairment on patients with mild cognitive impairment (MCI) and mild probable Alzheimer disease (AD) and their informants, and identify overlap and differences between the groups.

Methods: Structured focus group discussions were conducted with MCI patients, AD patients, MCI informants, and AD informants. Participants were recruited from memory clinics in the U.K. and the U.S.A. A total of 20 AD and 20 MCI patients and 16 AD and 11 MCI informants participated. Sessions were content reviewed to identify key impacts of cognitive impairment; results were compared across diagnostic groups and for patients and informants.

Results: Seven key themes emerged: uncertainty of diagnosis, skill loss, change in social and family roles, embarrassment and shame, emotionality, insight, and burden. Patients were able to discuss the impact of cognitive impairment on their lives and reported frustration with recognized memory problems, diminished self-confidence, fear of embarrassment, concerns about changing family roles due to cognitive impairment, and anxiety. Informants reported more symptoms and more impairment than did patients and indicated increased dependence on others among patients.

Conclusion: MCI and mild AD exert substantial burden on patients' lives and the lives of those close to them.

We report the case of an elderly woman with Alzheimer's disease, risk factors for vascular dementia, and atrium-ventricular blockade, who presented with severe agitation and psychosis. She was treated with aripiprazole and assessed with the Neuropsychiatric Inventory (NPI) over the course of 14 weeks. NPI scores showed a marked decrease in psychosis and agitation at week 4, and complete recovery at week 14, except for depression.

Background: It is currently not known whether elderly men and women present with different subtypes of depression and mania/bipolar disorder. The aim of this study was to compare the prevalence of subtypes of a single depressive episode and mania/bipolar disorder according to the ICD-10 for elderly men and women in a nationwide sample of all out- and inpatients in psychiatric settings.

Methods: All patients older than 65 years who received a diagnosis of a single depressive episode and mania/bipolar disorder in the period from 1994 to 2002 at the end of their first outpatient treatment or at their first discharge from psychiatric hospitalization in Denmark were identified in a nationwide register.

Results: A total of 9837 patients aged more than 65 years received a diagnosis of a single depressive episode (69.9% were women) and 443 a diagnosis of mania/bipolar disorder (61.6% were women) at the end of their first contact with psychiatric health care. Slightly more women than men received a diagnosis of mild (70.8%) or moderate depression (67.4%) compared to severe depression (65.9%). Men more often presented with a single depressive episode with comorbid substance abuse or comorbid somatic illness. No gender differences were found in the prevalence of depression with or without melancholic or psychotic symptoms. Men more often presented with mania/bipolar disorder with comorbid substance abuse.

Conclusions: The distributions of the subtypes of a single depressive episode or mania/bipolar disorder are remarkably similar for male and female patients aged over 65 years with first contact with the psychiatric health-care system.

Background: The aim of this study was to examine the impact of residential respite care on disruptive behavior displayed by older people, particularly those with dementia.

Methods: A quasi-experimental, repeated-measures, single-group design was used. The participants were a consecutive series of 100 older people with a mean age of 81.8 years (range 66–96 years) who had been booked for a respite admission to one of several residential aged care facilities in a provincial Australian city. A diagnosis of dementia was reported for 29% of the sample. Disruptive behaviors were rated before and after the period of respite by home caregivers (N = 100) and during the period of respite by nurses (N = 25) using the Dementia Behavior Disturbance Scale (DBDS).

Results: Age, male gender and the presence of dementia were all significantly related to the frequency of reported disruptive behaviors. Residential respite care was associated with a significant reduction in the frequency of reported disruptive behaviors in older people (Wald χ2 = 28.28, p < 0.0001). However, this improvement in behavior did not persist into the post-respite period. The deteriorating behavioral trajectory that was evident prior to respite care continued following the period of respite care.

Conclusions: Residential respite care was associated with a temporary diminution in the frequency of reported disruptive behaviors in older people. This finding should be reassuring both for family carers considering placing a relative in residential respite care and for health workers considering whether to recommend such a course of action.

Background: Post-stroke depression (PSD) frequently complicates stroke and is associated with an impaired functional outcome, more severe cognitive deficits, a reduced quality of life, and a higher mortality. The aim of this study was to assess whether general risk factors for major depressive disorder (MDD) in the community are also risk factors for PSD, and to identify additional, stroke-related risk factors.

Methods: In a hospital setting, 190 consecutively admitted patients were assessed for MDD 1 month after stroke, and at follow-up after 3, 6, 9 and 12 months. A Cox model was created with four established risk factors for MDD in the community (female sex, prior personal history of depression, positive family history of depression, and somatic comorbidity other than stroke). Five potential disease-related risk factors (disability, cognitive deterioration, inter- and intrahemispheric lesion location, and generalized vascular damage on computed tomography (CT) scan) were then added individually to this model, to see whether these would improve the significance of the overall model.

Results: The Cox model of four general risk factors for depression in the community was shown to be a valid model to predict depression in stroke patients. Of the disease-specific factors, only incorporation of “disability” in this model improved its significance.

Conclusion: Established risk factors for depression in the community are also predictors of depression in the first year after stroke. Disability is a non-specific disease-related variable that is associated with PSD. The contribution of stroke-specific factors may be less than is generally assumed.

Background: Two-phase diagnostic surveys are popular in psychiatric epidemiology. The Geriatric Depression Scale (GDS) and the General Health Questionnaire (GHQ) are commonly used to screen in older and younger populations, respectively.

Method: In Phase I, in this Brazilian population-based study, we screened 392 participants aged ≥ 75 years. In Phase II, half of those scoring ≥ 11 in the GDS and ≥ 4 in the GHQ and 20% of others were selected for detailed evaluation with ICD-10 diagnoses assessed by the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (n = 126).

Results: Internal consistencies were good for all scales. At the optimal cut-off points GDS-30 (14/15) yielded 73% sensitivity and 65% specificity, while classical GHQ (4/5), Likert (15/16) and c-GHQ (5/6) yielded 66–75% sensitivity and 57–62% specificity. Receiver operating characteristic (ROC) curve analysis against SCAN indicated only moderate screening potential [area under the ROC curve (AUROC): GDS = 0.76; classical GHQ = 0.74; Likert = 0.76; c-GHQ = 0.73], with no statistically significant differences. All measures were biased by disability and self-reported health.

Conclusions: In this study, neither screen was sufficiently predictive of SCAN ICD-10 diagnosis to recommend their use in two-phase surveys. Despite its theoretical advantages, the GDS-30 performed no better than the GHQ-12, and was biased in similar ways.

The onset of obsessive–compulsive disorder (OCD) for the first time in old age is uncommon and has been mostly related to cerebral abnormalities. We report a case of late-onset OCD in a 77-year-old woman following stressful life events but with a normal cerebral structure. The contribution of life events and vulnerability factors on the genesis and the presentation of her illness are discussed in relation to the literature on OCD.