Background: The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery.

Methods: Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias.

Results: 26 publications reported an incidence of postoperative delirium of 4–53.3% in hip fracture samples and 3.6–28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6–28.8] vs. 12.1% [95% CI = 9.6–14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7–34.7] vs. 8.8% [95% CI = 4.1–13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%.

Conclusions: Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.

Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.

Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.

Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

The focus of dementia intervention research has broadened from a focus purely on the person with dementia to include the caregiver as well. Psychological, physical, social and health care utilization costs are well documented and effective caregiver interventions reported. Caregivers are crucial to many aspects of the path of dementia traveled by affected persons. They influence outcome and they are a secondary target in drug trials. Measurement of caregiver outcomes should be targeted to likely outcome, and key mediating variables should be measured too. A list of potential instruments and recommendations is provided.

Concerns increasingly have been raised about the influence of pharmaceutical companies on doctors and their practice of medicine. The pharmaceutical industry has grown in profitability and influence over the past twenty years and is now second only to armaments in the U.S. economy (Public Citizen, 2002). Guidance is available from most Royal Colleges on the appropriateness of using finances/gifts and other benefits from pharmaceutical companies. A declaration of conflict of interest is required for most journals, and evidence shows that there are signs of a small but increasing proportion of articles declaring competing interests in some journals (Hussein and Smith, 2001). Concerns are probably greater in psychiatry, as psychiatric research is particularly susceptible to the influence of vested interests because of the subjective nature of diagnosis and outcome, the variable course of most psychiatric disorders, and the importance of placebo effects, including the context of participating in a research project (Moncrieff et al., 2005).

Regrettably, psychological treatments are often overlooked in the management of severe late-life depression while ECT is favored, even though it is more likely to be harmful and its evidence base is slim. This is of little surprise given that psychiatrists are often guilty of overlooking potentially beneficial psychosocial interventions preferring more familiar biological treatments. This position is unacceptable: depressed older adults deserve access to a whole range or interventions in order to maximize benefits and choice.

Background: Evidence suggests an association between congestive heart failure (CHF) and cognitive function, particularly in heart transplant patients and patients hospitalized for CHF. We examined the association between CHF and cognitive performance in stable outpatients recruited from primary care.

Methods: This is a cross-sectional secondary data analysis of the Steel Valley Seniors Survey, an epidemiological study of elderly primary care outpatients. Participants aged ≥ 65 years were recruited in primary care clinics. The study cohort (n = 354) is a subgroup, composed of subjects with Mini-mental State Examination score < 25, and a random sample of the remaining, who underwent a baseline assessment in the home. The assessment included demographics, comorbid illnesses, depressive symptoms, functional status, a neurological examination and a neuropsychological battery. CHF is defined by self-report and/or chart review, and stable CHF as not being hospitalized in the year prior to the assessment. The associations between CHF and specific cognitive tests were examined by bivariate analysis and logistic regression, controlling for demographic variables.

Results: Subjects with CHF performed worse on tests of visual memory [10.1 (S.D. 5.4) vs. 12.7 (S.D. 5.2), p = 0.007], Trailmaking B [0.1 (0.1) vs. 0.2 (0.1), p = 0.002], category fluency [11.1 (4.4) vs. 13.4 (4.5), p = 0.008], and clock drawing [5.6 (1.9) vs. 6.7 (1.4), p < 0.001] compared to subjects without CHF, after adjustment for relevant demographic variables.

Conclusion: CHF is associated with lower cognitive functioning in a population of patients with stable heart failure in primary care settings.

Background: There has been increasing interest in the measurement of quality of life in cross-sectional investigations and in the assessment of intervention outcomes in elderly adults. Several instruments used in this measurement have not yet been adequately tested.

Objective: To describe the psychometric properties of the World Health Organization's Quality of Life Instrument–Short Version (WHOQOL-BREF) in a sample of Brazilian elderly.

Method: A total of 424 elderly adults selected through convenience sampling completed the instruments WHOQOL-BREF, the Beck Depression Inventory (BDI), the Beck Hopelessness Scale (BHS) and a sociodemographic data form. Discriminant validity, concurrent validity, criterion validity and internal consistency were analyzed.

Results: The sample comprised predominantly women (64.2%), community-dwelling subjects (84.4%) and subjects who consider themselves healthy (67.5%). All domains in the instrument showed the ability to discriminate levels of depressive symptoms and hopelessness, as well as different perceptions of health status. The correlation coefficients among the domains and the BDI and BHS scores were statistically significant. The reliability coefficients present scores ranging from 0.614 to 0.925.

Conclusion: The WHOQOL-BREF instrument shows suitable psychometric performance in a sample of Brazilian older adults, becoming a useful alternative in the measurement of quality of life in this population.

Objectives: To examine the effect of risperidone on specific behavioral and psychological symptoms of dementia (BPSD) among patients with psychosis of Alzheimer's disease (AD).

Methods: Post hoc exploratory analysis of data on 479 nursing-home patients with psychosis of AD from three 12-week, double-blind, placebo-controlled clinical trials. Criteria for psychosis of AD were a diagnosis of AD or mixed dementia and a rating of ≥ 2 on any delusion or hallucination item of the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale when entering the trial. Mean changes from baseline to endpoint were examined for items on the Cohen-Mansfield Agitation Inventory (CMAI) and BEHAVE- AD.

Results: On the CMAI, risperidone was significantly more effective than placebo in treating cursing or verbal aggression (p = 0.004), hitting (p < 0.001), performing repetitious mannerisms (p < 0.001), pacing, aimless wandering (p = 0.017), hoarding things (p = 0.02), hiding things (p = 0.02) and repetitive sentences or questions (p = 0.025). On the BEHAVE-AD, risperidone was significantly more effective than placebo in treating physical threats and/or violence (p = 0.001), agitation (other) (p = 0.001) and verbal outbursts (p = 0.026). Although analysis on individual hallucination and delusional items did not demonstrate specific responses, analyses of a composite of delusional items revealed significant drug-placebo differences.

Conclusions: These data indicate that risperidone is effective in treating a variety of symptoms associated with psychosis of AD.

Electroconvulsive therapy (ECT) is one of the oldest interventions in psychiatry. Like many aging celebrity rock-stars of the 1960s, ECT has outlived critics who predicted its early demise and in fact continues to create a bigger bang than it did at inception (http://www.rollingstones.com/abiggerbang/). ECT owes its longevity largely to a series of well-conducted trials since the 1970s that secured its endorsement by special committees and task forces of national associations (American Psychiatric Association, 2001; Royal College of Psychiatrists, 1995), and guideline developers (Bauer et al., 2002; Fochtmann and Gelenberg, 2005; Kennedy et al., 2001; NICE, 2003).

Outcome assessment for clinical dementia trials could be enhanced by using the Mini-mental State Examination (MMSE) and the Hopkins Verbal Learning Test (HVLT), in addition to imaging and genetic screening. The statistical power of trials could be increased if heterogeneity of the sample were reduced by the administration of a risk factor inventory which could be used for subject selection or selection of drug responders.

Background: The adverse effects of behavioral and psychological symptoms of dementia (BPSD) are well described but treatment remains problematical, including overuse of psychotropic medication. This study aims to compare the outcome of two approaches to BPSD, one focusing on causality and using predominantly psychosocial interventions, the other relying predominantly on psychotropic medication.

Methods: Thirty-three residential care clients manifesting BPSD who had been referred to a community psychogeriatric service (intervention group) were assessed and treated, with the focus placed on the causes of the behavior and why it was perceived as a problem by nursing staff. Cases were managed primarily by psychosocial means with psychopharmacology as an adjunct. A control group was made up of 22 referrals to an adjacent service, which used primarily psychopharmacology with psychosocial methods as an occasional adjunct.

Results: Measures of behavior and staff response showed significant improvement in both groups at two- and five-months' follow-up. Antipsychotic use in the intervention group decreased over time while in the control group it increased. Service measures showed both groups required approximately the same number of clinical visits but the intervention group experienced fewer medication changes, fewer drug side effects, and all but one case could be treated in situ. Five control group participants spent extended periods as inpatients in a psychogeriatric unit. Minor sampling differences did not affect the results, and neither they nor the nature of the behavior explained the difference in clinical approach.

Conclusion: The causality-focused approach appears to be as effective as the more common predominantly pharmacological approach, and appears to involve lower human and financial costs.

Background: Diagnosis of mild cognitive impairment (MCI) and its subtypes requires a detailed diagnostic assessment and so may be missed at routine primary-care appointments, since the ordinary dementia screening tests lack sensitivity owing to ceiling effects, especially in highly educated subjects.

Methods: The study was undertaken using a cross-sectional assessment of 112 elderly subjects (mean age 67.96 ± 5.77 years, and mean education level of 12.8 ± 5.7 years) with a semi-structured interview and a neuropsychological battery.

Results: MCI patients did not differ from controls on total MMSE scores (p = 0.212). Nevertheless, MCI patients showed worse performance than controls on the verbal memory task (p = 0.012), and “drawing a pentagon” (p = 0.03). Amnestic MCI patients performed worse only on the “three-word recall” task (p = 0.013); non-amnestic MCI patients performed worse on the “three-stage command” task (p = 0.001); and multiple-domain MCI patients performed worse on the “drawing a pentagon” task (p = 0.001) and had a trend toward performing poorly on the ‘three word recall’ task (p = 0.06).

Conclusion: The analysis of MMSE subtest scores, in addition to MMSE total scores, may increase the sensitivity of the MMSE test in screening for MCI and its subtypes.

In 1919 the Dodge brothers successfully sued Henry Ford for his intended largesse, i.e. decreasing dividend payments by using his company to pursue broader social goals “to employ still more men, to spread the benefits of this industrial system to the greatest possible number, to help them build up their lives and their homes,” one of the mechanisms of which included increasing their wages. The Michigan Supreme Court stated that a corporation exists to benefit its stockholders, and may not use profits for “other purposes” (Hood, 1998). This landmark case demonstrated that the prime purpose of any corporation is to maximize its profits for shareholders. Therefore, it is probably naïve of doctors, researchers and the general public to expect the pharmaceutical industry to be driven by other principles, regardless of how noble they might seem. As a result, the driving force that supports the interests of the pharmaceutical industry may not be always aligned with the interests of doctors, patients and the communities to which they belong. How are we to judge that this conflict has evolved in such a way as to produce “excessive” influence of the pharmaceutical industry over other interested parties?

Background: The aim of the study was to determine the correlation and agreement between the Mini-mental State Examination (MMSE) and Clock Drawing Test (CDT), administered and scored using Shulman's method (2000), in elderly Brazilian adults with very low levels of formal education.

Methods: CDT and MMSE tests, performed by a sample of 1118 elderly subjects from a population-based cohort, were evaluated. Spearman's correlation coefficient was calculated for the total sample and according to gender, age and schooling level. Agreement was assessed using receiver operating characteristic (ROC) analysis.

Results: CDTs with high scores had high corresponding MMSE scores whereas CDTs with low scores had a wide range of corresponding MMSE scores. Correlation was moderate (ρ = 0.64) and no difference was found according to gender, age or schooling level. For CDT cut-off 3/4, the best MMSE cut-off was 27/28 and agreement between tests was 75.1%.

Conclusions: Correlation between tests was moderate. Subjects who performed well on the CDT could be expected to obtain high MMSE scores. Although one test does not substitute for the other, the CDT may be more practical in developing countries where resources are limited and low education is common in the elderly, as well as in situations where time for assessment or screening is limited. Moreover, the CDT may be sensitive to cognitive domains not assessed by the MMSE.

Because the biological pathological process is observed decades years before the clinical onset of Alzheimer's disease (AD), there is a theoretical ad-vantage in using biological markers for the early diagnosis of AD. Neuro-psychological test batteries, brain imaging and biological markers are expected to be used for screening and differential diagnosis of dementia and also for evaluation of the efficacy of early intervention.

No single biological marker can serve all the purposes of screening, differential diagnosis and measurement of severity. Biological markers that reflect molecular stress, such as oxidative, ribotoxic, and nitroso stress, need to be developed, particularly for measuring the clinical outcomes of interventions. As well as providing a better understanding of the molecular pathogenesis of AD, there is a possibility of finding a surrogate marker of AD, which might fulfill the requirement of sufficient sensitivity and specificity for AD diagnosis, as well as indicating the disease-modifying activity of interventions. In this study we examine whether the mechanism of secretase activity will offer a new surrogate marker of AD.

The articles in this debate address two separate but overlapping questions regarding the management of severe depression in older adults: (1) Is electroconvulsive therapy (ECT) an efficacious and safe treatment, and (2) What is the role of psychotherapy? That the first question is asked at all may come as a surprise to the many practitioners of geriatric psychiatry who consider ECT to be an indispensable part of their therapeutic tool kit. Yet, Wilkinson argues that the evidence supporting the efficacy of ECT in the elderly is “sparse” and derived from studies that are “of poor quality.” He provocatively states that psychotherapy “is at least as important as ECT” in the management of severe late-life depression, and advocates the more widespread use of psychotherapy to treat severe depression in older adults, including individuals admitted to psychiatric inpatient units. There are two issues here. First, what is severe depression? Second, what constitutes sufficient evidence to support the use of ECT or psychotherapy in severe depression in late life?

Background: Dementia in the elderly is associated with a greater risk of being subjected to abuse. More than half of those in Japan who abuse elderly relatives with dementia do not realize that their behavior corresponds to abuse.

Objective: This study sought to examine the effect of the presence of dementia in the elderly on attitudes toward abuse.

Methods: The subjects of this study were 135 people aged between 18 and 86 who were not taking care of elderly relatives at the time of the survey. The subjects were asked to rate how abusive they thought each of 12 behaviors listed in a questionnaire was in regard to three categories of elderly: (1) elderly with dementia who require care (DC); (2) elderly without dementia who require care (NC); and (3) elderly without dementia who do not require care (NN).

Results: The results of ANOVAs showed that the attitude of the subjects was associated with experience of caregiving, category of elderly, and type of abuse. The results of Bonferroni's tests indicated that the behaviors, especially those behaviors that included physical, psychological, and economic abuse, toward the DC category were not considered to be as abusive as those toward either the NC category or NN category.

Conclusions: This study suggests that people might rate abusive behavior as being less abusive when the person being cared for has dementia.

Background: There is general consensus regarding the benefit of acetylcholinesterase inhibitors (e.g. donepezil) in Alzheimer's disease (AD). However, the combined effect of acetylcholinesterase and cognitive stimulation therapy (CST) is still controversial.

Objective: This study examines their combined effect on the progression of cognitive decline in AD by comparing the cognitive performance of 17 AD patients treated with CST and donepezil (combined treatment group) and 13 AD patients treated with donepezil alone (control group).

Methods: Patients in the combined treatment group received 5 mg of donepezil per day and about 20 one-hour CST sessions for one year, whereas the control group received only 5 mg of donepezil per day. The first eight sessions were carried out once a week, and subsequent sessions were generally once every two weeks. The patients were evaluated for changes in cognitive ability by administering the Mini-mental State Examination (MMSE) before the start of CST (baseline) and about one year later (follow-up).

Results: A repeated-measure analysis of variance revealed a significant group × time interaction. The MMSE score decreased significantly in the control group, but did not change significantly in the combined treatment group. Three patients in the control group declined by four points on the MMSE, compared to none in the combined treatment group. Effect size (ES) in the control group was relatively large and negative, while the ES in the combined treatment group was close to zero.

Conclusions: The results suggest the possibility that donepezil plus CST slowed the rate of cognitive decline more than the administration of donepezil alone.