Delirium is a cognitive disorder characterized by acute onset, fluctuating course and disturbances in consciousness, orientation, memory, thought, perception and behavior (American Psychiatric Association, 2000). It occurs in hyperactive, hypoactive or mixed forms in up to 42% of older hospital inpatients (Siddiqi et al., 2006), many with pre-existing dementia (Fick et al., 2002).

The emergence of the novel swine-origin influenza A (H1N1) virus in humans has aroused great concern among medical professionals about the possible evolution of a full-blown influenza pandemic, one on the scale of the “Spanish” influenza pandemic of 1918–19 (Belshe, 2009). It has been speculated that the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill more than 100 million people worldwide, including a large number of economically active young people (Taubenberger and Morens, 2006). Health administrations worldwide have stepped up reporting and surveillance of the deaths and illnesses associated with H1N1, and most countries have national strategies to fight the outbreak, though skeptics doubt how such plans could be operationalized, especially in developing countries (Coker, 2009). As of 6 July 2009, the cumulative total of H1N1 cases exceeds 90,000 in over 100 countries, with over 400 deaths directly related to the infection (World Health Organization, 2009a). Optimists might believe this pandemic is not going to match the scale of the historical 1918 pandemic given the relatively low fatality rate observed thus far. However, the World Health Organization has cautioned that we have just entered Phase 6 of the pandemic – i.e. we are in the early days of the 2009 flu pandemic (Chan, 2009). The course of the pandemic is thus unpredictable at this stage but it is evident that international multilateral plans and agreements have enabled much greater coordination of communication and action than ever before. The guidance behind these multilateral international actions, rooted in the World Health Organization's International Health Regulations (IHR) 2005, only came into being five years ago in response to the threat of emerging infectious diseases and particularly by the events related to the emergence of Severe Acute Respiratory Syndrome (SARS) (Katz, 2009). The morbidity and mortality directly resulting from this novel influenza A H1N1 outbreak are in the center of the world media's spotlight, but the potential impact of the pandemic on global mental health has not yet received the attention it deserves.

This issue is the first of six which will comprise the journal's 21st volume. In my culture (and some others) it is conventional to celebrate 21st anniversaries, which for a long period were associated with the attainment of an entitlement to enjoy such privileges as the right to vote, to marry without parental consent and to enter into contracts. For International Psychogeriatrics our 21st anniversary represents something of a milestone for what began as a small association journal founded with two annual issues in 1989. To celebrate this achievement we have commissioned a number of commemorative pieces which will appear throughout 2009 and the journal has been completely redesigned in order to emulate the majority of academic journals which now appear in this larger A4 format instead of the quarto size used for our first 20 years. The cover has been changed to give us what I am told is a more attractive and contemporary look and the front of each issue will now feature one or more photographs representing aspects of the diverse discipline of psychogeriatrics. If you have an image which would enhance a future cover, please advise me by email ([email protected]) and we will try to use it.

Dementia is on the rise and, as a result, the aged care workforce has an increasing need for up-to-date information on how to care for people living with dementia. While dementia research continues to mushroom, any research findings that have practical implications also need to be passed on to those at the coalface of dementia care as quickly as possible. This Supplement brings together a number of papers that have addressed various perspectives on dementia education, training and knowledge transfer in the U.S.A., U.K. and Australia.

The World Health Organization (2002) describes population aging as “one of humanity's greatest triumphs” as well as “one of our greatest challenges.” Growth in the number of older people as a proportion of the total population (described as the graying of the world's population) is a global phenomenon. With increasing age the causes of death and disease change: in early life communicable diseases, nutritional deficiencies and maternal/perinatal conditions are most important, but after midlife, chronic conditions assume increasing importance. Amongst the chronic conditions of later life, mental disorders feature prominently, the two most common being dementia and depression (Faculty of Old Age Psychiatry, 2006).

In primitive societies, old age was frequently valued. (Simmons, 1945). Older persons often provided knowledge, experience and institutional memory that was of adaptive – even survival – value to their societies. Although nomadic groups in various parts of the world abandoned the old and disabled when safety and security were at stake, overall older people were venerated. However, as the number and percentage of older persons, especially the frail and demented, increased, the perception grew that they were burdens to their families and society. This perception became widespread as societies shifted from agrarian economies, where older men had traditionally owned the land, to industrialized economies, where work was no longer centered in the home and older persons lost their authority.

For too long, too many in science and society alike viewed aging as offering little that was of value. There was a collective illusion of knowledge that aging was characterized by inevitable, unalterable decrements in functioning that led to a dismal destiny in later life. This was a widespread perspective on aging, especially in the scientific community. To the extent that scientists considered aging as a wasteland of scientific opportunity, they had little interest in studying it. By not studying aging, little new was discovered about it, thereby preserving negative assumptions about what later life held for all of us. Both Freud and Piaget, for example, viewed development of the mind as essentially a first quarter of the life-cycle phenomenon – psychologically for Freud, intellectually for Piaget (Freud, 1978; Piaget, 1972).

Professor David Ames, the editor-in-chief of International Psychogeriatrics, has kindly asked some of us who edited the journal at one time or another to write a personal piece. I was asked because I edited the journal longer than anyone else – from 1996 to 2003. I decided in 2003 that I would give up my editorship and my National Health Service (U.K.) consultant's post. It also coincided with my 65th birthday, which was declared by von Bismarck, the nineteenth-century Chancellor of Germany, to be the age of retirement when a pension would be received. The decision was not meant by me to be taken too seriously but it was convenient. My record will not last of course, since David Ames will have completed two terms, which will finish in 2011. The job is like that of the U.S. President, namely, two terms only!

There is now widespread concern about the inadequate care and support provided to people with dementia from diagnosis to death. It is acknowledged that while there is a range of effective ways to care for and support people with dementia and their families from diagnosis to death, these have yet to become integral to practice. In England, for example, the National Dementia Strategy seeks to transform the quality of dementia care. One of the key components to transforming the quality of care is to ensure we have an informed and effective workforce. We argue here that in order to transform the quality of care we need to distinguish between the aims of training and education. Whilst there is a place for skills-based workplace training, Higher Education in dementia studies has a key role to play in the provision of specialist knowledge and skills in dementia care emphasizing as it does the development of critical thinking, reflection and action. In this paper we describe dementia studies at Bradford University available at both undergraduate and postgraduate levels. We outline their aims and learning outcomes, curricula, approach to teaching, learning and assessment. We describe the nature of students who study with us, noting their fit with the Higher Education Funding Council in England's agenda for widening participation in higher education. Higher Education in dementia studies has a unique role to play in equipping practitioners and professionals with the information, skills and attitudes to realize the potential for quality of life for people with dementia and their families.

Eleven authors, 29 patients and an open-label design would not generally be regarded as strong predictors of a publication's citation success, so this one (Grace et al., 2001) probably needs some explaining. I was advised early in my prospective publishing career always to look for “a gap in the market” and in 2001 this short paper probably filled a significant gap in clinical knowledge. It was almost a decade since the first reports had appeared about dementia with Lewy bodies (DLB) being a relatively common cause of dementia in older people, and by 2001 the first iteration of the consensus criteria for DLB diagnosis was starting to be widely used. Clinicians were therefore becoming more confident about recognizing DLB in their clinics, realized that cholinesterase inhibitors (ChEIs) were often useful in symptom control, and wanted to know more about their effects in the longer term. This short paper gave them some useful evidence to support their practice. The lead author, Janet Grace, who was working as my clinical lecturer, had for a couple of years been following up a group of DLB patients whom she had originally entered in an earlier placebo controlled study (McKeith et al., 2000) and was interested in charting their progress with the ready help of U.K. colleagues in Essex, Manchester, Southampton and Nottingham. Although the 21 patients who remained on treatment did show some evidence of disease progression after two years, neither their Mini-mental State Examination (MMSE) scores nor their Neuropsychiatric Inventory (NPI) scores were significantly worse than at baseline. And reassuringly their parkinsonism had not worsened, which was a common concern at that time.

Higher rates of cerebrovascular adverse events (CVEs) and mortality for dementia patients taking active drugs were reported during industry-sponsored clinical trials of atypical antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Since then, the use of antipsychotics for BPSD has not been recommended on the basis of advisory warnings issued by regulatory authorities in several countries. Nevertheless, there are currently no demonstrated pharmacologic alternatives. Although early published and unpublished data indicated a risk, few subsequent publications have supported the initial finding. In order to update earlier comments published in International Psychogeriatrics (Shah and Suh, 2005), this editorial briefly introduces subsequent reports, summarizes the discrepant findings of experimental and non-experimental studies, highlights the effect of “Simpson's paradox”, which causes us to throw doubt on conclusions based on meta-analyses or pooled-analyses, explains this discrepancy in the light of current knowledge, and concludes with practical recommendations regarding the use of atypical antipsychotics in dementia.

Psychogeriatrics is a specialty defined by its many contrasts and complexities. Over-reliance on biological models sometimes artificially narrows the breadth and content of psychogeriatric research, educational programs, service delivery and management models to the detriment of patient care. This guest editorial proposes a conceptual model that defines the scope of the field and provides a structure that overlays standard approaches to diagnosis and formulation. Five key defining elements of psychogeriatrics – the five “Cs” – are explored: complexity, chronicity, comorbidity, continuity and context.

It is puzzling that major public health systems in the developed world do not engage in the routine clinical outcomes measurement (RCOM) of their interventions. For example, the budget of the U.K. National Health Service (NHS) for 2008/9 was £81 billion, with 15 million inpatient episodes, yet a Martian's question “How much better are these patients for all this expense?” cannot be answered for any but a tiny proportion of them, and then only by local enthusiasts. It is true that death rates of patients are now routinely and publicly reported, but as Florence Nightingale – whose reputation was made and then almost destroyed by mortality statistics (Iezzoni,1996) – herself remarked:

Background: Dementia is becoming a major public health problem in Latin America (LA), yet epidemiological information on dementia remains scarce in this region. This study analyzes data from epidemiological studies on the prevalence of dementia in LA and compares the prevalence of dementia and its causes across countries in LA and attempts to clarify differences from those of developed regions of the world.

Methods: A database search for population studies on rates of dementia in LA was performed. Abstracts were also included in the search. Authors of the publications were invited to participate in this collaborative study by sharing missing or more recent data analysis with the group.

Results: Eight studies from six countries were included. The global prevalence of dementia in the elderly (≥65 years) was 7.1% (95% CI: 6.8–7.4), mirroring the rates of developed countries. However, prevalence in relatively young subjects (65–69 years) was higher in LA studies The rate of illiteracy among the elderly was 9.3% and the prevalence of dementia in illiterates was two times higher than in literates. Alzheimer's disease was the most common cause of dementia.

Conclusions: Compared with studies from developed countries, the global prevalence of dementia in LA proved similar, although a higher prevalence of dementia in relatively young subjects was evidenced, which may be related to the association between low educational level and lower cognitive reserve, causing earlier emergence of clinical signs of dementia in the LA elderly population.

Background: Challenges to wills on the basis of lack of testamentary capacity and/or undue influence are likely to increase over the next generation. Since contemporaneous assessment of testamentary capacity can be a powerful influence on the outcome of such challenges, there will be an associated increase in requests for expert assessment of testamentary capacity. There is a need to provide such potential experts with the knowledge and guidelines necessary to conduct assessments that will be helpful to the judicial system.

Methods: A subcommittee of the International Psychogeriatric Association (IPA) task force on “Testamentary Capacity and Undue Influence” was formed to establish guidelines for contemporaneous assessment of testamentary capacity.

Results: The task-specific criteria for testamentary capacity as outlined by Lord Chief Justice Cockburn in the well-known Banks v. Goodfellow case are described. Additional issues are identified for probing and documentation. This is designed to determine whether the testator can formulate a coherent, rational testamentary plan that connects his/her beliefs, values and relationships with the proposed disposition of assets. Rules of engagement by the expert assessor are defined as well as an approach to the clinical examination for testamentary capacity resulting in a clear and relevant report.

Conclusion: Guidelines for experts who are asked to provide a contemporaneous opinion on testamentary capacity should help to inform disputes resulting from challenges to wills. A consistent clinical approach will help the courts to make their determinations.

Background: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to “undue influence” when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence.

Method: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence.

Results: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common “red flags” which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary.

Conclusion: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.