Over the past twenty years, qualitative research has gained recognition as a useful approach to scientific inquiry on issues related to health and health care, including those of particular interest to psychogeriatrics. This is evidenced not only by the inclusion of health-related qualitative reports in exclusively qualitative publications but also by their acceptance in venues that have traditionally favored quantitative methods of investigation (Sandelowski, 2004). The increased number of these reports has also led in recent years to systematic reviews of qualitative studies and qualitative metasyntheses, metaethnography or meta-analyses (Nygard, 2004;Smith et al., 2005; Steeman et al., 2006).

Psychogeriatrics and psychogeriatric research have been particularly slow to take hold in developing countries. In part this is because the elderly constitute relatively small proportions of those countries' populations, and are thus of low priority for specialized services. A recent report in Science (Miller, 2006) addresses mental health needs in developing countries worldwide but does not include old-age mental disorders other than dementia. Similarly, an article from Brazil (Garcez-Leme et al., 2005), in another international journal, provides an overview of that country's resources and needs in geriatrics, but neglects to mention mental disorders or mental health professionals. Yet, these countries are aging faster than the industrialized world and have fewer resources with which to care for their mentally ill elderly. High-quality, locally acquired information will be essential for planning appropriate mental health services.

This issue of International Psychogeriatrics is 96 pages thicker than usual, because it carries not only the International Psychogeriatric Association (IPA) Consensus Statement on Defining and Measuring Treatment Benefits in Dementia, but also a series of papers that were presented at the two-day conference devoted to the development of the consensus statement, which took place in the precincts of Canterbury Cathedral on 31 October and 1 November 2006. During the conference, the delegates (whose names are listed in an appendix to the consensus statement) heard presentations on what outcomes matter to people with dementia and their caregivers, how these can be measured and what they mean, cognitive change as an outcome, biological outcome measures, quality of life, neuropsychiatric symptoms (also known as behavioral and psychological symptoms of dementia (BPSD)), global measures of change, the relevance of different outcome measures to various cultures, activities of daily living, economic outcomes and the regulator perspective. These presentations have been refined into papers and are now published within these pages. In addition to 12 formal presentations on these topics, nine discussants led the conference in exploring the issues raised by the talks, and there was active and often heated debate on almost all the issues discussed. During the afternoon of 1 November agreement was achieved on several key points, which formed the basis for a draft consensus statement prepared the next day. This statement has been refined by a process of circulation among participants, whose suggestions have been incorporated into the document that is now published in this issue.

The Scientific Committee and Congress Organising Committee of the IPA 2007 Osaka Silver Congress would like to extend their deep thanks and appreciation to everyone who has contributed to the Scientific Program to help produce a rich and diverse program, reflecting IPA's mission, as well as ensuring one of very high scientific quality. We would also like to thank all members of the Scientific Committee for their dedication and hard work in helping to form the program and assess all the abstracts prior to acceptance.

The International Psychogeriatric Association (IPA) was founded 25 years ago as a multidisciplinary organization with the ambitious vision of improving the mental health of the elderly around the world. For a variety of reasons, some leaders were skeptical about the value of an international organization and it was the vision and energy of Dr. Sanford Finkel, together with a relatively small group of colleagues, who brought IPA to life and nurtured it through its infancy. Dr. Finkel, known to all as Sandy, has chronicled some of the history of IPA elsewhere and I won't repeat it here other than to emphasize the profound effect that IPA's first executive director, the dedicated and beloved Fern Finkel, had on IPA until her retirement in 2006. The importance of IPA as a leading professional organization is now well established, but beyond its many achievements in molding and guiding the profession, IPA is also a professional home for our members, a place of intellectual comfort where colleagues speak a common language and share common goals. Within IPA we can relax, share universal concerns for the ambivalently viewed population of elders that the world worries about but often avoids or ignores at the same time. We can share our challenges and they are many, our hopes, our successes and our uncertainties.

Technological developments in medicine have conspired to increase costs, not only because they often require more expensive procedures, but also because they increase the size of the patient population who, at least potentially, could benefit from treatment. Health care has been considered a right of citizenship to which every person must have guaranteed equal and unlimited access. However, because of relentless pressure on public health care budgets, health care is now being treated in much the same way as food or housing or pensions – the government simply establishes a guaranteed base level of protection. Economics is about getting better value from the deployment of scarce resources when a choice has to be made. An important purpose of economic evaluation is that it should serve as a tool for decision-making regarding the allocation of scarce resources (Drummond et al., 1997). Cost effectiveness means cutting costs, but not at the expense of less effective outcomes (Mooney and Drummond, 1982). There appear to be lots of mental health issues with health economic implications.

In 1974 one of us attended a lecture on aging by the Nobel prize winning immunologist, Sir Macfarlane Burnet. Burnet indicated that oxidative stress was central to the aging process, and that interventions to ameliorate this process should prolong the human lifespan and diminish the incidence of age-related diseases, one of the most important of which is, of course, Alzheimer's disease (AD). A decade after this lecture was given, Burnet died of rectal carcinoma – a typical age-related disease. Thirty three years on, has the field advanced at all?

Since the first human application of electroconvulsive therapy (ECT) by Cerletti and Bini in 1938 (Endler, 1988), its history has been replete with examples of both successes and failures. The failures have been related not only to adverse effects but also to the use of ECT at various times without appropriate clinical indications. Acknowledging that ECT has been misused and abused in the past, professional organizations have made strenuous efforts to develop guidelines for its proper use (American Psychiatric Association, 2001). However, persisting stereotypes have fostered fear and distrust in patients and their families, as well as in the general public and popular media (Brewis, 2001), sometimes resulting in reduced access to ECT.

Background: Caregiving for people with dementia has consistently been linked with psychological problems, usually in terms of caregiver burden, general psychological distress and depressive symptomatology, while morbidity due to anxiety has been relatively neglected in this group.

Methods: We conducted a systematic review of the literature, searching electronic databases, reference lists, relevant systematic reviews and contacting experts in the field. We used Centre for Evidence Based Medicine (CEBM) criteria for inclusion and rating the validity of all studies that reported (1) the prevalence, predictors and covariates of anxiety disorders or anxiety caseness, and (2) covariates and predictors of the level of anxiety symptoms.

Results: Thirty-three studies met our inclusion criteria. Clinically, significant anxiety affects about a quarter of caregivers for people with dementia and was more common than in matched controls. Such caregivers have higher anxiety levels than controls, and that confrontative and escape avoidance coping, caregiver burden and poorer caregiver physical health are factors associated with higher anxiety levels from cross-sectional studies.

Conclusions: Coping style may be more associated with anxiety than depression while other covariates (burden and poor physical health) are similar to those for caregiver depression. We found no conclusive evidence about factors associated with anxiety disorders or predicting anxiety from longitudinal studies. Neither care recipient cognition nor ADL impairment; nor caregiver age nor duration of caring are associated with caregiver anxiety levels. Good quality cohort studies are needed to determine whether these factors also predict anxiety disorders.

Background: We reviewed studies of in-service interventions for caregivers of persons with dementia in nursing homes published between 1990 and 2004. The aim was to obtain an overview of the evaluated interventions and to characterize their methodological quality.

Methods: A thorough literature search was conducted, including searching electronic databases for selected intervention studies and previous reviews. Selected studies were summarized and compared along certain categories, and methodological quality was assessed.

Results: A total of 21 studies were identified, mostly published in the United States. Most were of poor methodological quality. Although nearly all reported positive effects, their results must be interpreted cautiously due to methodological weaknesses. Extensive interventions with ongoing support successfully demonstrated sustained implementation of new knowledge. Owing to methodological weaknesses and a lack of follow-up evaluations, little or no evidence existed for the efficacy or, particularly, the transfer of knowledge in simpler interventions when reinforcing and enabling factors were not present.

Conclusion: On an international and, particularly, on a national level a lack of evaluated in-service training programs for caregivers in homes for people with dementia is apparent. Methodological weakness is common. This study highlights the need for well-defined methodologically improved studies, providing conclusive evidence of the effects of intervention types to help improve the quality of dementia care.

Current symptomatic treatments for dementia have only modest efficacy. Assessing meaningful benefits in this variably progressive syndrome is complex and difficult. This consensus statement was generated by an international group representing caregivers, organizations and professionals with expertise in dementia.

We recommend the statement of clear, pre-defined diagnostic and severity criteria and outcome measures, which include functional and executive capacity, in treatment trials. Outcomes can include effects on people with dementia (PWD) with regard to cognition, behavioral and psychological symptoms, quality of life, global assessments, and activities of daily living, and must be tailored to the education and culture of the participants. Outcomes can also appropriately encompass effects on caregivers. New instruments may be needed, as validation of many existing measures has been in relatively homogenous populations. Treatment goals can be to prevent dementia emerging, or in those with established dementia to slow deterioration, and to postpone, stabilize or improve symptoms. Comparisons between treatment groups should be on the basis of clinically relevant measures with both risk and benefit reported for all participants regardless of whether or not they continue to receive treatment throughout the trial. Characterization of any groups that respond well to treatment has been unsuccessful to date, but may be facilitated in the future by measurement of putative biomarkers. Despite considerable recent progress and several ‘candidate’ biomarkers, none is yet satisfactory for determining diagnosis, severity, progression or prediction of response.

To provide meaningful data, economic analyses should use up-to-date, country-specific data. Health economic measures should be incorporated as secondary outcomes in all Phase 3 trials since health systems are concerned with cost-effectiveness as well as clinical outcome. Health utility measures are not, however, validated satisfactorily in dementia, thus calling into question previous health economic analyses. While current drugs appear to reduce the amount of family caregiver time required by PWD, these costs fall in the main on older individuals who often exert little political leverage, rather than on society at large. Traditionally, elderly people have been marginalized in the political process. The growth in the older population across the world, and their potential for increasing political empowerment may lead to a radical re-evaluation of the economics of treatment in dementia.

Does the pharmaceutical industry exert excessive influence on prescribing, research and publication in the field of psychogeriatrics? This is a topic about which I receive a significant number of emails and one which often gets discussed when those active in research in our discipline get together (at both sponsored and unsponsored events!).

The pharmaceutical industry has made significant contributions to the field of geriatric psychiatry. Drug treatment has improved the quality of life for many vulnerable patients suffering from burdensome psychogeriatric syndromes. We do not dispute here the contributions of the pharmaceutical industry to patient care. Rather, we describe how the industry, driven by the need to produce profits, has implemented conscious strategies to promote the prescribing and thus the sales of drugs, without regard to patients' best interests. The industry has influenced the conduct and publication of research, and the promotion of drugs to physicians and patients, for purely marketing purposes.

Background: The object of this study was to develop an Iranian version of the General Health Questionnaire-28 (GHQ-28) for use with elderly subjects.

Methods: The GHQ-28 Farsi version was evaluated for face validity among 204 elderly subjects aged 59 years or older, chosen randomly from residents of Tehran. The Composite International Diagnostic Interview (CIDI) was used to establish a gold standard diagnosis of mental disorders.

Results: The GHQ-28 was an internally consistent measure. Cronbach's α, split-half coefficients and test-retest reliability were 0.9, 0.89 and 0.58 respectively. Four factors were extracted using factor analysis: “depression,” “psychosocial activity,” “anxiety,” and “somatic.” Using receiver operating curve (ROC) analysis, the optimum cutoff score for the GHQ-28 in this group was 19/20 (sensitivity 0.83, specificity 0.76). Using a loading of 0.6 or greater, a short form of the instrument (GHQ-15) (α = 0.9) was derived and correlated well with the longer form of the scale (r = 0.97). Using ROC analysis, the optimum cutoff score was 10/11 (sensitivity 0.83, specificity 0.69).

Conclusions: The short and long forms of the GHQ-28 are suitable screening instruments for elderly Iranian residents, particularly those living in urban areas.

Two surveys of caregivers of people with dementia were conducted in the U.K. and Poland. Among 64 U.K. carers, cognition, early diagnosis and general practitioner support were of particular concern to those caring for people with early dementia, while former carers were more concerned with pain, comfort and palliative issues. There was very strong support for better workforce training. In Poland, restoration of health and more time off from caring were the most desired outcomes.

Older patients hospitalized with major depression in the U.S.A. are more likely to be treated with electroconvulsive therapy (ECT) than younger patients (Olfson et al., 1998; Thompson et al., 1994). Concerns have been expressed that ECT may be “overused” in these older patients, who may be especially sensitive to its physical and cognitive adverse effects. We selectively review the evidence on this issue, addressing several questions that are important for clinicians who treat older depressed patients. While ECT is used in other geriatric syndromes (e.g., depression in Parkinson's disease, bipolar depression, etc.), we focus exclusively on non-bipolar major depression because there is almost no published evidence relevant to these other conditions.

Background: This paper describes an innovative education program for the management of mental health problems in long-term care (LTC) homes and the evaluation of its longer-term sustainability. Since 1998, the [ldquor]Putting the P.I.E.C.E.S. Together[rdquor] learning initiative has been providing education sessions and related learning strategies aimed at developing the knowledge and skills of health professionals who care for older persons with complex physical and mental health needs and associated behaviors, in Ontario, Canada. A major focus of this province-wide initiative was the development of in-house Psychogeriatric Resource Persons (PRPs).

Methods: Evaluation of this initiative included the completion of pre- and post-education questionnaires (over three data collection time periods) assessing learner confidence (N = 1,024 and 792, for pre- and post-education, respectively) and session evaluation questionnaires gathering feedback on the session (N = 2,029 across all sessions). A survey of LTC homes in Ontario (N = 439, 79% of the homes in the province) was conducted to assess longer-term sustainability.

Results: Ratings of the sessions indicated that they were relevant to learners' clinical practice. There were significant increases in ratings of ability to recognize and understand challenging behaviors and mental health problems, and in ability to use a variety of assessment tools. Few homes (15%) do not have a PRP; over 50% of the staff who completed the first session in 1999 continue to serve as a PRP and to apply learned skills.

Conclusions: A learning initiative with supportive and reinforcing strategies can develop in-house PRPs to enhance the care of the elderly in LTC. Incorporation of PRP functions into job descriptions and management support contributed to the success of this initiative. This study highlights the importance of work environments that support and reinforce the use of learned skills to the success of continuing education and quality improvement initiatives in LTC.