It was well beyond my expectations when I heard from Professor Ames that our meta-analysis paper (Han et al., 2000) was among the top-cited papers in International Psychogeriatrics. As an expression of my gratitude to the editor for the invitation and to the audience of this paper, I would like to offer this informal discussion on the background of the paper and extend a few ideas that were not conveyed fully at the time, due either to insufficient knowledge or unavailability of relevant data or methodologies.

Nursing a person with dementia in a ward setting can be stressful and a challenge for staff and patients alike. Healthcare assistants are identified as requiring a specific training program. They form part of the front-line workforce and yet have the least access to training but often most contact with patients. The program in this study focused on person-centered care and used six self-study workbooks. Experienced registered nurses are trained to be facilitators of 12 group discussions in the ward setting. The training program viewed the facilitator as playing a key role in empowering the healthcare assistant but also in promoting reflective practice. The outcomes to date have been positive and showed a development in confidence and competence of the healthcare assistants involved.

Background: The Australian Imaging, Biomarkers and Lifestyle (AIBL) flagship study of aging aimed to recruit 1000 individuals aged over 60 to assist with prospective research into Alzheimer's disease (AD). This paper describes the recruitment of the cohort and gives information about the study methodology, baseline demography, diagnoses, medical comorbidities, medication use, and cognitive function of the participants.

Methods: Volunteers underwent a screening interview, had comprehensive cognitive testing, gave 80 ml of blood, and completed health and lifestyle questionnaires. One quarter of the sample also underwent amyloid PET brain imaging with Pittsburgh compound B (PiB PET) and MRI brain imaging, and a subgroup of 10% had ActiGraph activity monitoring and body composition scanning.

Results: A total of 1166 volunteers were recruited, 54 of whom were excluded from further study due to comorbid disorders which could affect cognition or because of withdrawal of consent. Participants with AD (211) had neuropsychological profiles which were consistent with AD, and were more impaired than participants with mild cognitive impairment (133) or healthy controls (768), who performed within expected norms for age on neuropsychological testing. PiB PET scans were performed on 287 participants, 100 had DEXA scans and 91 participated in ActiGraph monitoring.

Conclusion: The participants comprising the AIBL cohort represent a group of highly motivated and well-characterized individuals who represent a unique resource for the study of AD. They will be reassessed at 18-month intervals in order to determine the predictive utility of various biomarkers, cognitive parameters and lifestyle factors as indicators of AD, and as predictors of future cognitive decline.

Background: There are limited cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD). The aim of the present study was to increase understanding of the effects of culture on BPSD by comparing the rates of BPSD in nursing home residents across three residential facility types: (1) mainstream nursing homes in Sydney, (2) ethno-specific Chinese nursing homes in Sydney, and (3) a long-term high care facility in Shanghai known as a dementia hospital.

Methods: 149 residents and their caregivers voluntarily participated in this study. The rates and levels of BPSD were assessed by interviewing staff with the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Clinical interviews using the Mini-mental State Examination (MMSE) and Global Deterioration Scale (GDS) were conducted with residents to assess dementia severity.

Results: The mean NPI-NH total score for the sample was 28.5 (SD = 17.2) with no significant differences across the three facility types. Comparison of NPI-NH subscales showed residents from the ethno-specific Chinese facilities had lower rates of hallucinations than Shanghai residents (p = 0.003), but no differences from those in mainstream facilities. Shanghai residents had lower frequencies of disinhibition and irritability than ethno-specific Chinese residents (p = 0.003, p = 0.004 respectively), but no differences with mainstream residents.

Conclusion: The prevalence of BPSD does not differ among nursing home populations of different cultural backgrounds. Longitudinal community studies among different cultural groups would better elucidate the effects of culture on BPSD at different stages of dementia.

Background: The clinical presentations in dementia with Lewy bodies (DLB) and frontotemporal dementia (FTD) overlap considerably with that of Alzheimer's disease (AD) despite different pathological processes. Autopsy studies have also shown that multiple brain pathology occurs frequently, even in cases with a single clinical diagnosis. We aimed to determine the frequency of clinical diagnosis of FTD and DLB and the underlying pathology in a well-characterized cohort of patients with a clinical diagnosis of probable or possible AD.

Methods: We conducted a retrospective analysis of 170 AD patients (probable AD = 83; possible AD = 87) originally enrolled in a case-control study, 27 with postmortem examination, to establish the number of cases meeting probable diagnosis for FTD and DLB, using a checklist of features compiled from their consensus criteria.

Results: 23/83 probable AD cases and 32/87 possible AD cases met probable criteria for another dementia, more commonly DLB than FTD. AD pathology was present in 8/15 probable AD and 8/12 possible AD cases coming to autopsy. DLB pathology was seen in four cases and FTD pathology in eight cases. In the AD cases reaching clinical diagnosis for a second dementia syndrome and coming to autopsy, a minority showed non-AD pathology only.

Conclusions: Presence of core clinical features of non-AD dementia syndromes is common in AD. Concordance between clinical and pathological diagnoses of dementia remains variable. We propose that repeat clinical examinations and structural neuroimaging will improve diagnostic accuracy. In addition, clinical diagnostic criteria for the main dementia syndromes require refinement.

Background: Development of a scale to rate the degree and various aspects of uncleanliness will facilitate description and research in cases of severe domestic squalor.

Methods: Discussion with representatives of relevant agencies led to selection of various aspects of domestic uncleanliness and clutter to be assessed when describing cases of squalor. Rooms and areas with varying functions (toilet, kitchen, bedroom, etc.) were all to be rated, along with other indicators of squalor (e.g. odor, vermin). Trial use and further discussion resulted in reduction to ten items, each rated on a four-point scale, with succinct descriptions of anchor-points. Two experienced psychogeriatricians then used this new Environmental Cleanliness and Clutter Scale (ECCS) to rate independently 55 dwellings which had been reported by Aged Care staff as cluttered or unclean, and also rated overall degree of squalor. Reliability and indications of validity were analyzed.

Results: The inter-rater reliability for the ten items was considered satisfactory (κ 0.48, varying from 0.31 to 0.58). Cronbach's α for the new scale was 0.94, demonstrating high internal consistency. Each author's ratings of degree of squalor (none to severe) matched well with the other's ratings on the scale; a score of >12 usually indicated moderate or severe squalor.

Conclusion: The ECCS proved reliable and useful in rating cases where elderly people were living in severe domestic squalor.

Background: Despite the high prevalence and morbidity of minor and subsyndromal depression in primary care elderly people, there are few data to identify those at highest risk of poor outcomes. The goal of this observational cohort study was to characterize the one-year outcomes of minor and subsyndromal depression, examining the predictive strength of a range of putative risks including clinical, functional and psychosocial variables.

Methods: Patients aged ≥ 65 years were recruited from primary care medicine and family medicine practices. Of 750 enrollees, 484 (64.5%) completed baseline and one-year follow-up assessments of depression diagnosis (major depression vs. minor and subsyndromal depression vs. non-depressed) by the Structured Clinical Interview for DSM-IV, depressive symptom severity (Hamilton Rating Scale for Depression), and validated measures of other predictors.

Results: Patients with baseline minor and subsyndromal depression were more depressed than the non-depressed group at follow-up: They had a 7.0-fold (95% CI 4.5–10.8) risk of developing major depression, and a one-year adjusted Hamilton Depression Score of 11.0 (95% CI 10.2–11.8) compared with 7.8 (95% CI 7.1–8.5) for the non-depressed group; these outcomes were less severe than those of the major depression group. Independent predictors of depression outcomes included race, psychiatric and physical functioning, and social support.

Conclusions: Minor and subsyndromal depression are likely to persist, and pose an elevated risk of worsening over one year. Clinicians and preventive interventions researchers should focus on modifiable risks, such as psychiatric functioning or social support, in elders suffering clinically significant depressive symptoms.

Background: Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A.

Methods: The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview – Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition.

Results: When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19%. Prevalence was similar for men (10.19%) and women (11.44%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression.

Conclusions: The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.

Background: There is growing evidence that a palliative approach to care provision for people with dementia in residential aged care facilities improves their quality of life and provides support for family members. Despite the development of Guidelines for a Palliative Approach in Residential Aged Care (hereafter the Guidelines), there is limited evidence that these have been adopted. To date, little research has been undertaken to explore processes which could assist aged care staff to develop their practice consistent with the intent of the Guidelines.

Methods: This project utilized an action research method, through which staff members from a residential dementia special care unit (SCU) undertook an investigation into their practice to explore how they could develop strategies to support a palliative approach to care provision. A key focus was related to addressing the information needs of family members of residents on the SCU.

Results: Aged care staff involved in this project had little understanding of available evidence that could assist them to better support family members, including the existence of the Guidelines. Through their engagement in successive action research cycles, these staff accessed evidence-based resources and developed strategies to address the information needs of family members.

Conclusions: When provided with an opportunity to reflect on and critique their practice, aged care staff were better positioned to engage with evidence concerning a palliative approach and to execute change in their practice to improve care provision for family members.

I would like to thank the editor of International Psychogeriatrics for the opportunity to comment on this article (Unützer et al., 2000). The work leading to this paper was undertaken early in my career and has become the foundation for a decade of research focused on improving the care of older adults with depression.

Background: Enabling the families and carers of people with dementia to access information, support and opportunities for education and training is critical to ensuring that both the carer and person with dementia maintain their quality of life. The Dementia Caring Pilot Project trialed an innovative approach to providing this support through offering tailored activities aimed at enhancing and developing a range of skills, both dementia-specific and life oriented.

Method: Alzheimer's Australia worked closely with Commonwealth Carer Respite Centres (CCRCs) across Australia to identify potential participants, and then deliver skills enhancement activities that were suited to their individual needs.

Results: Nationally, 47 CCRCs participated in the Project and 324 skills enhancement activities were provided to over 1000 participants.

Conclusions: The Project was successful in giving the families and carers of people with dementia the opportunity to express the need for the capabilities they wished to enhance, and to have the opportunity of a flexible service response.

Background: In the past day-care facilities for people with dementia were developed with little input from the users. As these facilities play an increasingly important role in the lives of the growing number of community-living persons with dementia and their caregivers, it now seems obvious to incorporate users' perspectives when establishing or optimizing day care. This study addresses the needs and wishes of informal caregivers when providing skilled psychogeriatric day-care in the Netherlands.

Method: This is a qualitative, exploratory study, based on interviews with family caregivers and professional focus groups as the primary data source.

Results: Using data from the interviews, the needs and wishes of carers were classed into three general domains: (1) approach to care – relating to shared and tailored care and confidence in professionals as well as the facility as important themes; (2) professional expertise – relating to the carers' need for education and information regarding dementia, available resources, as well as cooperation between professionals; and (3) the day program – concerning the content and structure of the day care.

Conclusions: The interviews with the caregivers suggest that the relationship with day-care personnel is an important aspect of psychogeriatric day-care. Caregivers have high expectations regarding the expertise of professionals, but seem to be unaware of available resources and services. Professionals should play a more active role in providing education, advice and support. Above all, the attendees must have a positive experience of the day-care facilities and its activities.

Background: Neuropsychiatric symptoms in dementia patients are common and are often treated with psychotropic drugs. The aim of this study was to determine the prevalence and correlates of psychotropic drug use in Dutch nursing home patients with dementia.

Methods: Psychotropic drug use of 1322 patients on 59 dementia special care units (SCUs) in 25 nursing homes was registered. Drugs were categorized according to the Anatomical Therapeutical Chemical classification (ATC). The influence of age, gender, dementia stage measured by the Global Deterioration Scale (GDS), and type of neuropsychiatric symptoms on psychotropic drug use was analyzed using binomial logistic regression analysis.

Results: 63% of the patients used at least one psychotropic drug. Psychotropics in general and antipsychotics in particular were most frequently prescribed in GDS stage 6, and in patients aged between 65 and 75 years. Psychotropics in general were positively associated with depression, night-time behavior and agitation. Antipsychotic drug use was positively associated with psychosis, agitation and night-time behavior and was negatively associated with apathy. Anxiolytics were associated with age, psychosis, agitation and night-time behavior. Antidepressants were most frequently prescribed in GDS stage 6 and associated with female gender, agitation and depression. Sedatives were only associated with night-time behavior.

Conclusion: Nursing home patients with dementia have a high prevalence of psychotropic drug use. In particular, the association with neuropsychiatric symptoms raises questions of efficacy of these drugs and the risk of chronic use.

Background: Neuropsychological tests, including tests of language ability, are frequently used to differentiate normal from pathological cognitive aging. However, language can be particularly difficult to assess in a standardized manner in cross-cultural studies and in patients from different educational and cultural backgrounds. This study examined the effects of age, gender, education and race on performance of two language tests: the animal fluency task (AFT) and the Indiana University Token Test (IUTT). We report population-based normative data on these tests from two combined ethnically divergent, cognitively normal, representative population samples of older adults.

Methods: Participants aged ≥65 years from the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) and from the Indianapolis Study of Health and Aging (ISHA) were selected based on (1) a Clinical Dementia Rating (CDR) score of 0; (2) non-missing baseline language test data; and (3) race self-reported as African-American or white. The combined sample (n = 1885) was 28.1% African-American. Multivariate ordinal logistic regression was used to model the effects of demographic characteristics on test scores.

Results: On both language tests, better performance was significantly associated with higher education, younger age, and white race. On the IUTT, better performance was also associated with female gender. We found no significant interactions between age and sex, and between race and education.

Conclusions: Age and education are more potent variables than are race and gender influencing performance on these language tests. Demographically stratified normative tables for these measures can be used to guide test interpretation and aid clinical diagnosis of impaired cognition.

Background: There is limited information describing memory clinics at a national level in Australia. The aim of this study was to gather information about the resourcing, practices and clinical diagnoses of Australian memory clinics.

Methods: A postal survey was sent to all Australian memory clinics identified by key specialists working in dementia assessment services.

Results: Of 23 surveys sent out, 14 were returned. Most clinics are located in Victoria where they receive Victorian state funding. The average clinic has 1.67 effective full time clinical staff including 0.42 medical staff, 0.24 allied health staff, 0.53 clinical nursing staff and 0.48 psychologists. Clinics are open on average twice a week and each half-day clinic has two new and three review patients, seeing new patients twice initially then once more over 12 months. Patients wait 10 weeks for initial assessment with 59% referred by general practitioners. The Mini-mental State Examination and clock drawing are utilized universally. The most common diagnoses are Alzheimer's disease (37.8%) and mild cognitive impairment (19.8%) but 6.9% of patients have no cognitive impairment.

Conclusions: This survey has provided useful benchmarking data on Australian memory clinics which can also be used by other countries for comparative analyses.

Background: Critical study of attempted suicides may allow greater understanding of completed suicides because of the considerable overlap between attempted and completed suicides in the elderly.

Methods: Age-associated rates (60–74 years versus 75+ years), trends over time and methods of attempted suicide in the elderly in England were examined using recently collected national data for a nine-year period.

Results: The rate of attempted suicides in the 60–74 years age-band increased over the nine-year study period. Rates of intentional self-poisoning by and exposure to non-opiod analgesics, antipyretics and antirheumatics, intentional self-poisoning by and exposure to narcotics and psychodysleptics and intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system increased over the nine-year study period in both elderly age-bands. The rates and the frequency of intentional self-poisoning by and exposure to non-opiod analgesics, antipyretics and antirheumatics and intentional self-harm by sharp objects were higher in the 75+ years age-band compared to the 60–74 years age-band. The rates and frequency of intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system, intentional self-poisoning by and exposure to alcohol and intentional self-harm by smoke, fire and flames were higher in the 60–74 year age-band compared to the 75+ years age-band.

Conclusions: There is a need to develop strategies to reduce access to targetted methods of attempted suicide in elderly that are most prevalent and increasing over time.

Background: Elderly suicides rates are associated with socio-economic status and life expectancy. Although suicide rates in younger people are associated with both higher and lower levels of educational attainment, little is known about this association in the elderly.

Method: The relationship between Human Development Index (HDI) – a composite index measuring average achievements on three basic dimensions of human development (life expectancy, educational attainment and socio-economic status) – and elderly suicide rates was examined in a cross-national study utilizing secondary data from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (inverted U-shaped curve) relationship between elderly suicide rates in males and the HDI, fitting the quadratic equation y = a + bx − cx2. A similar curvilinear relationship was observed in females, but the significance level only approached 0.05.

Conclusions: A model with four sequential stages was proposed to explain the findings: (i) low elderly suicide rate – low human development society; (ii) high elderly suicide rate – low human development society; (iii) high elderly suicide rate – high human development society; and (iv) low elderly suicide rate – high human development society.

Background: Short-term residential care (SRC) has proved to be effective in reducing the burden on family caregivers of dementia patients. Nevertheless, little is known about the factors which influence its usage or the expectations of family caregivers regarding quality. In this paper we address the following questions: (i) which variables of the care situation, the caregivers and their attitudes act as predictors for the utilization of SRC facilities? (ii) What are the views of caregivers about the quality of SRC?

Methods: The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in four regions of Germany. With a 20% response it was possible to analyze the quantitative and qualitative data from 404 and 254 family caregivers respectively. Predictors for utilization were evaluated using binary logistic regression analysis. The answers to questions of quality were evaluated using qualitative content analysis.

Results: Significant predictors for the utilization of SRC are the assessment of the helpfulness of SRC and the caregiver's knowledge of the accessibility of SRC facilities. Family caregivers who had already used SRC most frequently expressed the wish for “good care” in SRC facilities, followed by a program of suitable activities for dementia patients.

Conclusions: In order to increase the rate of utilization, family caregivers must be convinced of the relevant advantages of using SRC facilities. The staff should be trained in caring for dementia patients and appropriate activities should be available.

Background: Psychotic symptoms in Alzheimer disease (AD + P) identify a heritable phenotype associated with greater cognitive impairment. Knowing when the cognitive course of AD + P subjects diverges from that of subjects without psychosis would enhance understanding of how genetic variation results in AD + P and its associated cognitive burden. This study seeks to determine whether the degree of cognitive impairment and cognitive decline in early AD predicts subsequent AD + P onset.

Methods: 361 subjects with possible or probable AD or mild cognitive impairment (MCI) without psychosis were evaluated every 6 months until psychosis onset.

Results: Severity of cognitive dysfunction was a strong predictor of AD + P up to two years prior to psychosis onset. Cognition did not decline more rapidly prior to onset of AD + P.

Conclusions: Individuals who will develop AD + P already demonstrate excess cognitive impairment during the mild stages of disease. Genetic variation and brain pathophysiology may lead to a cognitive risk phenotype which is present prior to dementia onset.