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

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

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

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

Background: This is the first study to investigate the associations between chronic health conditions of older people and their impact on co-resident psychological morbidity using population-based samples in low and middle income countries (LAMICs).

Methods: Single-phase cross-sectional catchment area surveys were undertaken in urban sites in Cuba, Dominican Republic and Venezuela, and in rural and urban catchment areas in Mexico, Peru, India and China. All residents aged 65 years and over were interviewed with a co-resident key informant. Exposures were structured clinical diagnoses (10/66 and DSM-IV dementia and ICD-10 depression), self-reported diagnosis (stroke) and physical impairments. Mediating variables were dependence and disability (WHODAS 2.0), and the outcome was co-resident psychological morbidity assessed using SRQ-20.

Results: Poisson regression analysis was used to estimate the prevalence ratios (PRs) for the associations between health conditions and psychological morbidity in each site, and meta-analysis was used to pool the estimates. 11,988 pairs comprising a participant and a co-resident informant were included in the analysis. After meta-analysis, independent effects were noted for depression (PR2.11; 95% CI 1.82–2.45), dementia (PR 1.98; 95% CI 1.72–2.28), stroke (PR 1.42; 95% CI 1.17–1.71) and physical impairments (PR 1.17; 95% CI 1.13–1.21). The effects were partly mediated through disability and dependence. The mean population attributable fraction of total chronic conditions was 30.1%.

Conclusion: The prevalence of co-resident psychological morbidity is higher among co-residents of older people with chronic conditions. This effect was prominent for, but not confined to, depression and dementia. Attention needs to be directed to chronic conditions.

Background: Agraphia in Korean patients may be different from agraphia in other patients who use alphabetical writing systems due to the “visuoconstructional script” characteristics of the Korean writing system, Hangul. Patients with early onset Alzheimer's disease (EOAD) have a severe degree of hypometabolism in the parietal area, which is known to be involved in processing visuospatial function. Thus, we explored the diverse error patterns manifested in writing single syllables in Korean patients with EOAD.

Methods: A study sample of 35 patients with EOAD and 18 healthy controls (HC) performed a Hangul writing task. We analyzed the erroneous responses of the subjects according to visuoconstructional and linguistic characteristics. In addition, we evaluated the relationship between Hangul writing and the neuropsychological variables as well as the severity of dementia.

Results: When comparing the total number of erroneous responses between EOAD and HC groups, the performances of EOAD patients were significantly worse than those of HC. EOAD patients demonstrated visuoconstructional errors even in the early stages of the disease. Severity of dementia and multiple cognitive domains such as attention, language, immediate memory, and frontal executive functions significantly correlated with the performance of Hangul writing.

Conclusion: Our findings suggest that patients with EOAD exhibit not only linguistic errors but also visuoconstructional manifestations of agraphia, which are associated with cognitive impairments in the multiple domains.

The authors omitted the following statement from the Acknowledgments section: “The views expressed in this paper are those of the authors and not necessarily those of the Department of Veterans Affairs”.

Background: The capacity of friends and family member informants to make judgments about the presence of a mood disorder history in an older primary care patient has theoretical, clinical, and public health significance. This study examined the accuracy of informant-reported mood disorder diagnoses in a sample of primary care patients aged 65 years or older. We hypothesized that the accuracy (sensitivity and specificity) of informant reports would vary with the patient's personality.

Methods: Hypotheses were tested in 191 dyads consisting of patients and their friends or relatives (informants) recruited from primary care settings. Gold-standard mood disorder diagnoses were established at consensus conferences based on a review of medical charts and data collected in a structured interview with the patient. Patients completed an assessment battery that included the NEO-Five Factor Inventory.

Results: Sensitivity and specificity of informant-derived mood disorder diagnoses were related to patient personality. Sensitivity of informant-derived lifetime mood disorder diagnoses was compromised by higher Extraversion and higher Agreeableness. Specificity of informant-derived lifetime mood disorder diagnoses was compromised by lower Agreeableness and higher Conscientiousness.

Conclusion: Patient personality has implications for the accuracy of mood disorder histories provided by friends and family members. Given that false negatives can have grave consequences, we recommend that practitioners be particularly vigilant when interpreting collateral information about their extraverted, agreeable patients.

Background: An association between sense of coherence (SOC) and suicidal behavior has been suggested. The aim of this study was to identify factors associated with low SOC in elderly suicide attempters.

Methods: Eighty non-demented hospital-treated suicide attempters aged 70 years and older (38 men, 42 women, mean age 79.4 years) took part in an interview with a research psychologist and completed the 29-item SOC questionnaire. The interview included questions regarding social situation and health-related factors. The Comprehensive Psychopathological Rating Scale (CPRS) provided symptom ratings that were used in a diagnostic algorithm for DSM-IV major depression. The Cumulative Illness Rating Scale for Geriatrics (CIRS-G) was used to identify individuals with serious physical illness.

Results: There was a strong relationship between major depression and SOC. While we could show no relationship between severe physical illness and SOC, associations were demonstrated with social variables including too little time spent with children, too little time spent with grandchildren and having moved within the past five years. These associations remained significant in regression models adjusted for sex, age and major depression.

Conclusions: A number of social variables were independently related to SOC in elderly suicide attempters. Prospective studies are needed in order to determine whether SOC-strengthening interventions can reduce the risk of suicidal behavior in seniors.

Background: Job satisfaction and quality of life among home care workers who serve simultaneously as informal carers for their own family members have seldom been explored. This study examined how this dual role influences job satisfaction and quality of life by comparing these dual carers with home care workers who do not provide informal care. The study also explored whether the factors related to job satisfaction and quality of life between these two groups were different.

Method: Standardized self-administered questionnaires (Job Satisfaction Survey, the World Health Organization Quality of Life (WHOQOL) scales and various social demographic questions) were administered to the two groups of home care workers in Taiwan from March to April 2009. A total of 1,641 home care workers working in 119 non-government organizations sponsored by 23 local authorities completed and returned the questionnaires.

Results: The two groups did not differ in individual characteristics, work characteristics or job satisfaction. Analysis results indicate that the lowest mean scores for all home care workers were the domains of promotion and pay within their job satisfaction and the domain of environment within their quality of life.

Conclusions: Multiple regression analysis revealed a significant effect of unpaid caregiving in terms of quality of life but not in terms of job satisfaction. Moreover, job satisfaction and quality of life among home care workers were significantly determined by both their work conditions (e.g. travelling time, salary and length of work experience) and personal variables (e.g. age, family income and family support).

Background: The orbitofrontal cortex has been implicated as a key component in depression by several imaging studies. This study aims to examine morphometrically glial cell and neuronal density and neuronal volume in the orbitofrontal cortex of late-life major depression patients.

Methods: Post mortem tissue from 13 patients with major depression and 11 matched controls was obtained and analyzed using the optical disector and nucleator methods.

Results: No changes were found in glial cell, pyramidal or non-pyramidal neuron density, or in non-pyramidal and pyramidal neuron volume in the orbitofrontal cortex.

Conclusions: Based on previous findings, this study suggests variability in morphological changes within the orbitofrontal cortex, as well as the prefrontal cortex as a whole.

Background: The “vascular depression” hypothesis has sought to explain differences in etiology between early and late life depression, and has been reinforced by recent imaging and morphometric studies. Gamma-aminobutyric acid (GABA) is thought to play a major role in the neurobiology of depression. However, it is unclear whether there is an effect on GABA neuronal subpopulations in an elderly depressed cohort. This study therefore examined immunohistochemically two calcium-binding proteins, calretinin and parvalbumin, which have been demonstrated to bind to two distinct GABAergic interneuron subpopulations, within the dorsolateral prefrontal cortex (DLPFC) of elderly depressed patients, against age-matched controls.

Methods: Post-mortem tissue was obtained from nine controls and 11 depressed patients for the parvalbumin study and seven controls and 14 depressed patients in the calretinin study, and the mean percentage per area of immunohistochemical staining of the two antibodies was measured in individual layers and across the whole of the DLPFC.

Results: The study found a reduction in parvalbumin immunostaining in layer 6 (p = 0.05) of the DLFPC in elderly depressed patients. However, no significant changes were found in parvalbumin or calretinin immunostaining in the any other layer of the DLPFC in elderly depressed patients.

Conclusion: The study does not suggest any change in GABA interneuron subpopulations, though significant reductions in layer 6 may represent subtle disturbance in GABA parvalbumin-expressing interneuron and glumatatergic pyramidal projection neuron regulation in late-life depression.

Introduction: Although in most developed countries the use of restraints is regulated and restricted by law, the concept of restraint in nursing home care remains ambiguous. This study aims to explore how care professionals and family members of nursing home residents with dementia in the Netherlands experience and define the concept of restraint.

Methods: Individual interviews were held with relatives (n = 7) and key persons (n = 9) in seven nursing homes. We also conducted eight focus group discussions with nursing home staff. In addition, a structured questionnaire was administered to the nurses of participating nursing homes.

Results: In the questionnaire, over 80% of the respondents indicated considering “fixation” (e.g. use of belts) as a restraint and 50 to 70% of the respondents regarded other physical interventions, such as geriatric chairs and bedrails, as restraints. The interviews and focus group discussions show that the residents' perception of the intervention, the staff's intention behind the intervention and concerns of privacy are the criteria used by the respondents in defining an intervention as a restraint.

Conclusions: When trying to diminish restraint use, it is important to be aware of the “local logic” of care practice and to take into account the fact that, for staff and relatives, an intervention is only regarded as a restraint when it is bothering a resident or when an intervention is used for the sole purpose of restricting freedom and/or when interventions invade the privacy of a resident.

Background: Sleep problems are common in the general population. A strong association between stress due to inadequate social relationships or loneliness and sleep problems has been found. This paper aims to investigate stress in close social relationships in relation to disrupted sleep patterns in middle-aged and older adults. In addition, in exploring the underlying processes involved in poor social interactions, loneliness is assumed to be a mediator in the stress-sleep quality relation.

Methods: Data from a community sample of 7074 Norwegian middle-aged and older adults in the Hordaland Health Study (HUSK) were used to examine the mediating role of loneliness.

Results: A significant association between interpersonal stress and both nocturnal sleep problems and daytime sleepiness was found in both age groups. This relation was mediated by loneliness (indirect path) as well as effected by a direct path (RMSEA = 0.051; CFI = 0.93). The size of the indirect effect varied with age. Nocturnal sleep problems were fully mediated by loneliness in the older group, while 74% of the total effect was mediated through loneliness in the middle-aged group. For daytime sleepiness, a partial mediation of 36% and 40% was observed for the two groups respectively.

Conclusions: The mediation effects found in this study indicate that the wider social aspects of an individual's life should be taken into account when planning interventions for improving sleep quality in the elderly.

Background: The study of mental disorders in the elderly presents substantial challenges due to population heterogeneity, coexistence of different mental disorders, and diagnostic uncertainty. While reliable tools have been developed to collect relevant data, new approaches to study design and analysis are needed. We focus on a new analytic approach.

Methods: Our framework is based on latent class analysis and hidden Markov chains. From repeated measurements of a multivariate disease index, we extract the notion of underlying state of a patient at a time point. The course of the disorder is then a sequence of transitions among states. States and transitions are not observable; however, the probability of being in a state at a time point, and the transition probabilities from one state to another over time can be estimated.

Results: Data from 444 patients with and without diagnosis of delirium and dementia were available from a previous study. The Delirium Index was measured at diagnosis, and at 2 and 6 months from diagnosis. Four latent classes were identified: fairly healthy, moderately ill, clearly sick, and very sick. Dementia and delirium could not be separated on the basis of these data alone. Indeed, as the probability of delirium increased, so did the probability of decline of mental functions. Eight most probable courses were identified, including good and poor stable courses, and courses exhibiting various patterns of improvement.

Conclusion: Latent class analysis and hidden Markov chains offer a promising tool for studying mental disorders in the elderly. Its use may show its full potential as new data become available.

Background: The objectives of this study were to characterize the psychiatric comorbidity of a group of older subacute inpatients and then determine whether their psychiatric comorbidity affected measures of rehabilitation outcomes.

Methods: Eighty-eight older subacute inpatients were recruited for this prospective study. Psychiatric comorbidity was defined according to a participants' performance on four inventory scales: the Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), Brief Psychiatric Rating Scale and Health of the Nation Outcome Scale 65+. Rehabilitation outcome referred to the participants' length of stay and their performance at discharge on the EuroQol-5D health-related quality of life questionnaire and Barthel index.

Results: 68% of the participants scored in the clinical range on at least one of the four scales assessing psychiatric comorbidity at admission, with 51% in the clinical range for GDS and 32% for the GAI. The decrease in scores by the time of discharge was significant for all four scales. Linear regression analyses pointed to a trend for depressive symptoms at admission to be an influential but nonsignificant predictor of rehabilitation outcome. An interesting association was found between the length of the previous acute admission and the GDS score on admission to the subacute unit.

Conclusion: A high prevalence of psychological symptoms was identified upon admission, with a significant decrease by the time of discharge. These factors did not significantly predict the selected measures of rehabilitation outcome. Opportunities for future longitudinal research on the prevalence and impact of psychiatric comorbidities on patient outcomes are considered.

Background: Apathy is a common and important behavioral syndrome in various neuropsychiatric diseases, such as mild cognitive impairment (MCI) and Alzheimer's disease (AD). So far, only few studies have compared the neuropsychological correlates of apathy in patients with MCI and dementia. The aim of the current study was to examine the association between apathy and neuropsychological functioning in patients with MCI and AD.

Methods: Two-hundred-and-sixty AD patients and 178 MCI patients visiting the Memory Clinic of the Maastricht University Medical Centre participated in the study. Linear regression analysis, corrected for age, gender, level of education and depression, was performed to reveal cross-sectional associations between apathy and scores on neuropsychological tests of memory, attention, psychomotor speed and executive functioning.

Results: In patients with MCI, apathy was characterized by decreased verbal fluency and psychomotor tracking. In AD, patients with apathy differed from non-apathetic patients only on a verbal fluency task.

Conclusion: Apathy is related to executive dysfunction in the early phases of cognitive decline. In particular, in the prodromal phase of AD, apathy seems to be characterized by poor initiating. In the more advanced stages of cognitive deterioration, associations between apathy and specific neuropsychological correlates may be obscured by the more severe neuropathology. Awareness of apathy in the early phase of cognitive impairment may help in early diagnosis of AD.

Background: The use of standardized scales is critical for monitoring the interventions within and between different populations, but the current Spanish tools are dispersed in several scales. A simple tool for simultaneously and exhaustively evaluating patient's symptoms and caregiver's distress in Spanish-speaking groups is needed.

Methods: RMBPC was translated into Spanish by cross-cultural adaptation. Comprehensibility and easiness of SpRMBPC were evaluated with 92 patient-caregiver dyads. Reliability, stability and scale structure were evaluated by Cronbach's α, test-retest and factor analysis respectively. Concurrent and discriminant validity were assessed by correlation with validated tools for measuring stage of dementia; memory, disruptive behaviors and depression symptoms of the patients; and anxiety, depression and burden of the caregivers (CDR, MMSE, NPIq, NPIdisruption, NPI depression, HADS-A; HADS-D and Zarit Burden Interview respectively).

Results: Almost all caregivers completed the questionnaire (97% completeness; 7.5% missing data). Both the frequency of Patient's Symptoms and Caregiver Reaction scores and subscores displayed high stability and reliability. All of these scores correlated positively with their respective validated tools as predicted, except with MMSE. The patients' subscores for Disruptive Behaviors and Memory Impairment displayed their highest correlation with the disruptive symptoms and level of dementia validated tools.

Conclusions: SpRMBPC is a validated tool for assessing the dementia stage and the psychiatric morbidity of patients and caregivers. The Frequency Disruption and Memory subscales assess specifically patient's disruptive symptoms and dementia stages. These tools can be applied to analyze the burden of the patient's disease and the caregiver's distress in Spanish-speaking populations.

Background: Although community psychiatric services commonly encounter cases where intervention is needed due to persons’ unclean or cluttered living conditions, evidence concerning the referral rate and prevalence of severe domestic squalor is sparse.

Methods: Between 2000 and 2009, ratings of cleanliness and clutter have been made in all cases of people living in squalor who have been referred to an old age psychiatry service in Central Sydney. Where possible, one-year follow-up was arranged.

Results: 173 persons aged 65 years or more were referred to the service during the ten years and assessed as living in squalor (120 moderate or severe, two thirds of whom showed a moderate or severe degree of hoarding/clutter). Of 157 followed up after one year, 47% were still at home, 32% were in long-term care homes, 12% had moved elsewhere, and 9% had died. The annual new referral rate was close to 1 per 1000 elderly people in the catchment area, and of moderate or severe squalor was 0.66 per 1000. Limiting follow-up to those in moderate or severe squalor, 41% were still at home one year later. Current findings suggest that the minimum prevalence in the community of older people living in moderate or severe squalor in Sydney is 1 per 1000.

Conclusions: The costs of intervening in cases of severe domestic squalor are considerable. Increased attention and funding are warranted, as the incidence and prevalence are higher than had previously been estimated.

Background: The study evaluated the effects of an annual medication assessment conducted as part of a Comprehensive Geriatric Assessment (CGA) on the prevalence of psychotropic drug use in community-dwelling elderly people.

Methods: Randomly selected persons (n = 1000) aged ≥75 years living in the city of Kuopio, Finland were randomized to intervention and control groups. The intervention group underwent an annual (2004–2006) medication assessment as part of a CGA by physicians. Data on drug use were gathered by interviews at baseline (2004) and in three following years (2005–2007). Generalized estimating equations (GEE) were applied to explore whether the prevalence of psychotropic drug use differed between the community-dwelling participants of the intervention (n = 361) and control groups (n = 339) over time.

Results: At baseline, nearly 40% of the participants used psychotropic drugs in each group. In the intervention group, the study physicians implemented 126 psychotropic drug-related changes, 39% of which were persistent after one year. The prevalence of use of psychotropic drugs, antipsychotics and anxiolytic/hypnotics did not differ between the groups over time. The prevalence of antidepressant use remained constant in the intervention group, but increased in the control group (p-value for interaction = 0.039). The prevalence of concomitant use of psychotropic drugs decreased non-significantly in the intervention group, but increased in the control group (p-value for interaction = 0.009).

Conclusions: Conducting an annual medication assessment outside the usual primary health care system does not appear to reduce the prevalence of psychotropic drug use in community-dwelling elderly people. However, it may prevent concomitant use of psychotropic drugs.

Background: Antipsychotics are frequently used to treat psychosis, aggression and agitation in patients with Alzheimer's disease (AD), but safety warnings abound. Escitalopram was investigated since citalopram has demonstrated some effectiveness in AD. We compared escitalopram and risperidone for psychotic symptoms and agitation associated with AD.

Methods: Inpatients with AD, who had been hospitalized because of behavioral symptoms, were recruited to a six-week randomized, double-blind, controlled trial. Participants (n = 40) were randomized to once daily risperidone 1 mg or escitalopram 10 mg.

Results: The NPI total score improved in both groups. Onset was earlier in the risperidone-treated group, but improvement did not significantly differ between groups by study end. Completion rates differed for escitalopram (75%) and risperidone (55%), mainly due to adverse events. There were no adverse events in the escitalopram group, while in the risperidone group two patients suffered severe extrapyramidal symptoms and four patients suffered acute physical illness necessitating transfer to general hospital.

Conclusion: Escitalopram and risperidone did not differ in efficacy in reducing psychotic symptoms and agitation in patients with AD. Completion rates were higher for escitalopram-treated patients. Replication in larger trials with ambulatory patients is needed.

Background: There is a high prevalence of subjective memory complaints (SMCs) amongst older adults, many of whom experience significant distress. It remains unclear why some older adults with SMCs experience more distress than others. The Common Sense Model of Illness Perceptions has been used to explain patients’ differential response to illness based on the beliefs they hold about their illness and subsequent selection of coping strategies. The present study aimed to examine the role of perceptions and coping styles in predicting anxiety and depression in older adults with SMCs.

Methods: 98 participants with SMCs completed the Illness Perception Questionnaire for Memory Problems (IPQ-M), Ways of Coping Questionnaire (WCQ), Geriatric Depression Scale (GDS) and Beck Anxiety Inventory (BAI). Multiple regression analysis was used to determine the contribution of illness perceptions and coping to the explanation of variance in depression and anxiety.

Results: Perceptions of SMCs were found to predict both depression and anxiety while coping strategies did not. Perceptions of serious consequences of SMCs and causal attributions predicted greater depression, while attribution of memory problems to lack of blood to the brain was the only predictor of increased anxiety.

Conclusions: Illness perceptions predicted depression and anxiety in older adults with SMCs. Contrary to the Common-Sense Model coping style was not found to be an important determinant of psychological distress. The findings provide a basis for developing interventions to reduce psychological distress in older adults with subjective memory complaints. Targeting causal attributions and perceived consequences of SMCs may help to improve well-being.

Background: The phenomenology of delirium is understudied, including how the symptom profile varies across populations. The aim of this study was to explore phenomenology occurring in patients with delirium referred to an old age psychiatry consultation-liaison setting and compare with delirium occurring in palliative care patients.

Methods: Consecutive cases of DSM-IV delirium were assessed with the Delirium Rating scale Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD).

Results: Eighty patients (mean age 79.3±7.7 years; mean DRS-R98 total score 21.7±4.9 and total CTD score 10.2±6.3) were included. Forty patients (50%) with comorbid dementia were older, had a longer duration of symptoms at referral, and more severe delirium due to greater cognitive impairments. Inattention (100%) was the most prominent cognitive disturbance, while sleep-wake cycle disturbance (98%), altered motor activity (97%), and thought process abnormality (96%) were the most frequent DRS-R98 non-cognitive features. Inattention was associated with severity of other cognitive disturbances on both the DRS-R98 and CTD, but not with DRS-R98 non-cognitive items. The phenomenological profile was similar to palliative care but with more severe delirium due to greater cognitive and non-cognitive disturbance.

Conclusion: Delirium is a complex neuropsychiatric syndrome with generalized cognitive impairment and disproportionate inattention. Sleep-wake cycle and motor-activity disturbances are also common. Comorbid dementia results in a similar phenomenological pattern but with greater cognitive impairment and later referral.