Background: Published information on psychiatric intensive care provision and requirements of older adults is limited. This audit aims to describe and compare demographic data, clinical characteristics and outcomes of patients admitted to a Scottish regional psychiatric intensive care unit (PICU) for older adults during two 18-month periods five years apart.

Method: Data on all patients admitted to the PICU for older adults during the two sample periods, commencing 2001 and 2006 respectively, were collected prospectively by the clinical care team, and included information on previous psychiatric contact and detentions under mental health legislation, diagnoses, cognitive ratings, reasons for transfer to the PICU, treatments and outcomes. Continuous variables were subject to statistical analyses.

Results: Twenty-one and 20 male patients were admitted during the 2001 and 2006 cohorts respectively, with equivalent mean ages of 72.9 years. The majority of patients were married, diagnosed with dementia, with similar levels of previous psychiatric admissions and detentions under mental health legislation. The commonest reason for transfer to the PICU was physical aggression. The 2006 cohort exhibited shorter inpatient stays prior to transfer to, and shorter durations of stay in, the PICU.

Conclusions: The PICU for older adults provides a function similar to the PICU for general adults. The cohorts were similar on most recorded variables, with noted differences possibly reflecting increased awareness and acceptance of the service, reduced tolerance by staff of aggressive behaviors by patients, and enhanced community services in the region. These perceptions warrant further study and clarification.

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.

Background: The role of technology to facilitate independent living for people with dementia is not fully realized, with initial attempts (e.g. tracking devices) being considered unacceptable from a practical and ethical perspective. The aim of this study is to create acceptable and effective prototype technologies to facilitate independence for people with dementia through a user-centered design process involving them and their carers.

Method: The study comprised a three-stage participatory design process: scoping stage (five focus groups, 10 people with dementia and 11 carers); participatory design stage (five workshops, 22 participants) and prototype development stage (four meetings with two people with dementia and one carer). Focus groups and workshops were digitally recorded, fully transcribed and subjected to constant comparative analysis.

Results: People with mild to moderate dementia enjoy a variety of activities both on their own and with their families; however, concerns included getting lost, a loss of confidence with curtailment of usual activities, and carer anxiety. Existing technologies (mobile phones) were used intermittently. Participants felt strongly that future devices should be disguised and be integrated easily into their daily routines. Suggested areas for functional improvement included two-way communications, flexibility of function as the illness progresses, and something to “guide” them home when out walking or driving. Attention should also be focused on minimizing the size, weight and visibility of devices to reduce stigmatization.

Conclusion: Prototypes for two devices (armband and electronic notepad) were developed. The study showed that involving people with dementia in the process of participatory design is feasible and could lead to devices which are more acceptable and relevant to their needs.

There is a gap between the knowledge obtained in dementia research and the practical use of it. This review examines the concept of knowledge translation (KT) and the process of translating research into practice in the field of dementia. KT in dementia practice involves key players including researchers, educators, clinicians, policy-makers, the general public and consumers who act within a multidimensional network, disseminating findings widely to effect changes in community awareness, clinical practice and health policy. Challenges include the volume of dementia research; difficulties in determining who is responsible for KT; the problems of premature KT; the lack of resources to perform KT; the paucity of research about effective KT strategies; and the characteristics of the dementia care workforce. Key features of effective KT include a simple compelling message; use of interpersonal contact and roles; a practical framework with an emphasis on “know-how”; and the provision of resources and support. More effective dementia KT will require a commitment by key players to engage in the process, a better understanding of effective KT strategies, adequate resources, and judicious selection of appropriate evidence-based information.

Background: Previous research has found an association between post-stroke depressive symptoms and premorbid personality. This study sought to investigate further the relationship between premorbid personality and a number of common post-stroke behavioral and psychological symptoms in a three-month follow-up study.

Methods: This prospective study was conducted between May 2003 and January 2005 in a Perth metropolitan teaching hospital. The pre-stroke personality of stroke survivors was assessed by interviewing a close family member (informant) within four weeks of the index stroke using the NEO Personality Inventory-Revised. Three months after the stroke, patients were followed up and assessed with the Cambridge Cognitive examination and Hospital Anxiety and Depression Scale, and their informants completed the Neuropsychiatric Inventory-carer distress version (NPI) and instrumental activities of daily living scale.

Results: Depressive symptoms were the most commonly reported post-stroke symptom (45.1%). Spearman's correlations showed that high neuroticism was positively correlated with NPI total scores (ρ = 0.37, p = 0.007), NPI total distress scores (ρ = 0.47, p = 0.001), and specifically with agitation and irritability NPI composite scores. Agreeableness was inversely correlated with agitation (ρ = −0.40, p = 0.004) and irritability (ρ = −0.37, p = 0.007) composite scores.

Conclusions: Premorbid personality traits of high neuroticism and low agreeableness are associated with the presence of post-stroke agitation, irritability, and carer distress. This knowledge may contribute to the development of strategies designed to identify patients and families who require more intense supervision and support during post-stroke rehabilitation.

Background: The genetic region coding for low-density lipoprotein receptor-related protein1 (LRP1) is considered an intriguing susceptibility locus for Alzheimer's disease (AD). Amnestic mild cognitive impairment (aMCI) is characterized by episodic memory impairment and represents the prodromal stage of AD. Our aim in this study is to investigate the relationship between LRP1 genetic variation and aMCI, and the influence of LRP1 on cognitive performance.

Methods: We performed a case-control association study analyzing five polymorphisms in LRP1 gene by TaqMan Assays-on-Demand SNP Genotyping. All samples were derived from Chinese subjects (109 cases, 104 healthy controls) and assessed using multi-dimension neuropsychological instruments.

Results: We identified haplotypes within the region containing the LRP1 gene. Of these, haplotype TAA (T: rs1800194; A: rs11837145; A: rs10876967) was significantly associated with aMCI, being over-represented in aMCI versus healthy controls. Haplotype TAA was associated with poor performance on episodic memory in all subjects.

Conclusions: This study confirms the association between genetic variants in LRP1 and aMCI. Moreover, we have identified a relationship between LRP1 genetic variation and specific aspects of neurocognitive function. Our convergent results suggest that LRP1 plays an important role in cognitive function and possibly in the pathogenesis of aMCI.

Background: The study aims to provide insight into the type of music being offered in Dutch nursing homes to patients with both dementia and verbal and vocal agitation. It also investigates the degree to which the music offered corresponds to the musical preferences of the nursing home residents.

Method: Using random sampling, 20 nursing homes were selected to participate in this study. Within these homes, semi-structured interviews were conducted with nursing home physicians (n = 17) and other nursing home care providers (n = 20). Each interview focused on up to three psychogeriatric residents with verbal and vocal agitation. In total, 51 residents were discussed in the interviews.

Results: For each resident, the frequency of music, the type of music being offered, and the degree of correspondence between the music being offered and the resident's preferences varied. In almost all cases, music was being offered in the communal living room during the mid-morning coffee and the afternoon tea, while music was only infrequently offered to residents during meals. However, this music was not tailored to the preferences of the residents. During patient-centered care activities in the early morning and before sleep, when offered, the music was generally tailored to the preferences of the resident(s).

Conclusion: Music is frequently played in nursing homes to patients with dementia who have verbal and vocal agitation. When offered to a group of residents, the music tends not to be tailored to the preferences of the residents. However, when offered individually, musical preferences are generally taken into account.

Background: Most studies examining psychotropic medication use on cognition in older persons with dementia include measures of global cognitive function. The present study examined the relationship between different types of psychotropic medication and specific cognitive functions in older people with dementia.

Methods: Two hundred and six institutionalized older adults with dementia (180 women, mean age 85 years) were administered neuropsychological tests. Psychotropic medication use was extracted from their medical status and categorized as: sedatives, antidepressants and antipsychotics.

Results: Analysis of covariance revealed that psychotropic consumers, and particularly those who used antipsychotics, performed worse on neuropsychological tests of executive/attentional functioning than non-consumers. There were no differences between consumers of other classes of psychotropic drugs and non-consumers. The number of psychotropic drugs used was inversely related to executive/attentional functioning.

Conclusions: These findings show that in institutionalized older adults with dementia, specific impairment of cognitive function, i.e. executive/attentional impairments, are associated with antipsychotic medication use. Future longitudinal studies are recommended.

Background: Agitation is common in people with dementia, is distressing to patients and stressful to their carers. Drugs used to treat the condition have the potential to cause particularly severe side effects in older people with dementia and have been associated with an increased death rate. Alternatives to drug treatment for agitation should be sought. The study aimed to assess the effects of bright light therapy on agitation and sleep in people with dementia.

Methods: A single center randomized controlled trial of bright light therapy versus standard light was carried out. The study was completed prior to the mandatory registration of randomized controls on the clinical trials registry database and, owing to delays in writing up, retrospective registration was not completed.

Results: There was limited evidence of reduction in agitation in people on active treatment, sleep was improved and a suggestion of greater efficacy in the winter months.

Conclusions: Bright light therapy is a potential alternative to drug treatment in people with dementia who are agitated.

Background: The differential outcomes procedure (DOP) has proved useful to improve discrimination learning in both animals and humans. Here we adapted DOP to assess its utility to overcome the memory loss commonly associated with normal aging.

Methods: In a delayed matching-to-sample task, subjects were exposed to a man's face, and after a delay, they were required to decide if the previously seen face was within a set of six men's faces. For half the subjects, each sample face was paired with its own outcome (differential outcomes condition); outcomes were randomly arranged for the remaining half of subjects (non-differential condition). Either short (5 second) or long (30 second) delays were interposed between the sample and the comparison stimuli.

Results: Results showed that relative to younger adults, older adults' performance decreased with the longer delay. However, the use of differential outcomes was able to reverse the detrimental effect of the increased delay in the elderly group, raising their performance to the level shown by younger adults.

Conclusions: These findings demonstrate, for the first time, that DOP can help elderly people overcome their memory limitations, and they draw attention to the potential of this procedure as a therapeutic technique.

Background: Suicidal behavior among the elderly is a research field in which qualitative and quantitative methods can and should supplement each other. The objective of this qualitative study is to investigate whether the descriptions of elderly people who committed suicide, given by those who knew them, can provide common features that create recognizable patterns, and if so whether these patterns can help to shed light on the suicidal process.

Method: This is a psychological autopsy study based on qualitative interviews with 63 informants concerning 23 suicides committed by persons aged over 65 in Norway. The informants were relatives, their family doctors, and home-based care nurses. In general, the analysis of the interviews follows the systematic text condensation method.

Results: The descriptions have three main topics: life histories, personality traits and relationships. “Life histories” includes the sub-topics ability to survive and action-oriented achievers. They describe people who came through difficult circumstances when growing up and who were action-oriented in life in general and in crises. “Personality traits” includes the sub-topics obstinacy and controlling others. The informants saw the elderly people as strong-willed, obstinate and possessing a considerable ability to control themselves and those around them. “Relationships” includes the sub-topics I didn't know him and He showed no ability to meet us halfway, and describes the informants’ experience of emotionally closed persons who kept a distance in their relationships.

Conclusions: On the basis of the descriptions of the elderly people given in this study, we argue that these individuals will find difficulty in accepting and adapting to age-related loss of function since their self-esteem is so strongly associated with being productive and in control. Loss of control reveals their vulnerability – and this they cannot tolerate.

Background: Verbal fluency (VF) tasks are simple and efficient clinical tools to detect executive dysfunction and lexico-semantic impairment. VF tasks are widely used in patients with suspected dementia, but their accuracy for detection of mild cognitive impairment (MCI) is still under investigation. Schooling in particular may influence the subject's performance. The aim of this study was to compare the accuracy of two semantic categories (animals and fruits) in discriminating controls, MCI patients and Alzheimer's disease (AD) patients.

Methods: 178 subjects, comprising 70 controls (CG), 70 MCI patients and 38 AD patients, were tested on two semantic VF tasks. The sample was divided into two schooling groups: those with 4–8 years of education, and those with 9 or more years.

Results: Both VF tasks – animal fluency (VFa) and fruits fluency (VFf) – adequately discriminated CG from AD in the total sample (AUC = 0.88 ± 0.03, p < 0.0001) and in both education groups, and high educated MCI from AD (VFa: AUC = 0.82 ± 0.05, p < 0.0001; VFf: AUC = 0.85 ± 0.05, p < 0.0001). Both tasks were moderately accurate in discriminating CG from MCI (VFa: AUC = 0.68 ± 0.04, p < 0.0001; VFf: AUC = 0.73 ± 0.04, p < 0.0001) regardless of the schooling level, and MCI from AD in the total sample (VFa: AUC = 0.74 ± 0.05, p < 0.0001; VFf: AUC = 0.76 ± 0.05, p < 0.0001). Neither of the two tasks differentiated low educated MCI from AD. In the total sample, fruits fluency best discriminated CG from MCI and MCI from AD; a combination of the two improved the discrimination between CG and AD.

Conclusions: Both categories were similar in discriminating CG from AD; the combination of both categories improved the accuracy for this distinction. Both tasks were less accurate in discriminating CG from MCI, and MCI from AD.

Background: This study examines the effectiveness of a nursing home staff training program designed to improve the interaction between residents with dementia and their caregivers.

Methods: A three-arm cluster-randomized and controlled population of 96 caregivers and 210 residents was used. Caregivers of the intervention group (IG) received a three-month training program in dementia care. Data were gathered at baseline, immediately after the training and at a six-month follow-up-assessment. Short- and long-term effects of the training program were assessed in comparison with another intervention referred to as the relaxation group (RG) and a wait-list control group (CG).

Results: Results indicated significant positive effects of the training program on caregivers' knowledge immediately after the training and on the use of physical restraints at the six-month follow-up. Caregivers' overall competence increased significantly both in the IG and in the RG. No intervention effects were found on caregivers' level of burnout, their health complaints or on the use of sedative drugs. Relaxation training was more successful in the reduction of caregivers' health complaints.

Conclusions: Results of the study indicate both the effectiveness and the limitations of a general training program in dementia care. The complexity of the nursing home setting potentially needs more complex interventions. Ongoing and continued support of the caregivers, as well as changes in organization and environment, are more likely to be helpful in the long-term improvement in the quality of care. Future research should focus on studies of specific interventions, such as the interesting effects of relaxation training on the caregivers' state of health.

Background: While the relationship of apolipoprotein E (APOE) to behavioral symptoms of dementia (BSD) has been studied in community-dwelling persons with AD, it has received limited attention within the nursing home (NH) population. The aim of this study was to examine the association between APOE genotype and BSD in NH residents using direct observation.

Methods: Thirty-six participants, aged 71–102 years, were compared using a non-randomized two-group design with continuous measures. APOE genotype was obtained by buccal swab. BSD, including restlessness, escape restraint, tapping and banging, searching and wandering, pacing and walking, and vocalization, were measured using the Modified Agitated Behavior Rating Scale. Participants were observed every 20 minutes for 12 hours per day for five days. Each participant's mean behavior scores were compared according to the presence or absence of the APOE ϵ4 allele.

Results: Resident characteristics included a mean MMSE of 10.44 indicating moderate to severe dementia and a mean of 3.44 medical co-morbidities. Fifty-six percent of the participants had one ϵ4 allele. A significant difference was found between APOE ϵ4+/4− and mean behavioral scores (F1,31 = 4.40, p = 0.04). Restlessness was significantly inversely correlated with MMSE (r = −0.367, p = 0.03), but not APOE genotype. There was no significant correlation between proxy reporting and direct observation (r = 0.257, p = 0.13).

Conclusion: Findings indicate that the presence of the APOE ϵ4+ genotype increases the risk for BSD in NH residents with dementia. Direct observation proved a more accurate estimate of BSD than proxy report.

Background: Dementia and visual impairment are among the most common medical conditions in later life. Almost nothing is known about the experiences and needs of older adults with both conditions.

Method: In this qualitative study using in-depth individual interviews, multiple perspectives were sought through a case-study approach. Fifty-two interviews were conducted: 17 with older adults with visual impairment and dementia, 17 with family caregivers, and 18 with care professionals.

Results: Impaired memory and a lack of visual cues created profound disorientation and distress, which could be manifested in disruptive behavior. Visual hallucinations compounded older adults' disorientation, and caregivers were uncertain about how to manage them. Visual impairments reduced the ability of older adults to perform certain activities safely, while dementia impaired their ability to assess the risks accurately. Concerns about safety prompted family members to limit their relatives' activities even in early stages of dementia. Low-vision services perceived themselves to be ill equipped to manage dementia-related needs, while visual needs were accorded a low priority by dementia services. A lack of joint working by the two services led to an overcautious approach.

Conclusions: The research identified considerable unmet needs and opportunities to improve care. The provision of clear verbal communication and optimized visual inputs is likely to reduce disorientation, distress and agitated behavior, while one-to-one contact is needed to overcome feelings of isolation. Family caregivers require additional respite services and advice on managing hallucinations. Increased sharing of information and skills between mental health and low-vision professionals would help maximize older adults' independence.

Background: This study examines the psychometric properties of the Dysfunctional Thoughts about Caregiving Questionnaire (DTCQ).

Methods: DTCQ was administered to 227 dementia family caregivers.

Results: Principal components analyses resulted in a two-factor solution: Perception of Sole Responsibility and Perfectionism. The DTCQ has a strong internal consistency and an adequate temporal stability. The DTCQ score differentiated between depressed and non-depressed caregivers, although only in the female group. Construct validity was also supported by significant relationships between DTCQ scores and global dysfunctional attitudes, social support, seeking social support and number of hours per day engaged in caring. The dysfunctional thoughts about caregiving specify rigid and inappropriate contingencies to guide and assess behavior while acting as cognitive barriers that make healthy care difficult.

Conclusion: The results of this study showed that such dysfunctional thoughts have a significant relationship to variables identified as mediators in caregiving stress models. The DTCQ has potential uses for both research and clinical purposes.

Background: The Camberwell Assessment of Need for the Elderly (CANE) is widely used for multidimensional evaluation of older people with mental health problems. The aim of this study was to evaluate reliability and validity of a Portuguese version of CANE.

Method: A cross-sectional multicenter study was designed using a convenience sample of elderly mental health services' users. CANE was compared with EASYCare, GHQ12, MMSE, Barthel Index and GDS15 to assess criterion and construct validity. Inter-rater and test-retest reliability were also assessed.

Results: 79 patients (76% female), with mean age of 74 (± 6.6) years were included. Most patients lived at home with a family caregiver, generally female. Only 32% had no carer. Dementia was the commonest psychiatric diagnosis (61%) and somatic comorbidity was very prevalent (85%). Kappa values (κ) for inter-rater item reliability ranged from 0.72 to 1.00 (mean values: 0.96 patient, 0.93 carer, 0.90 staff). The intraclass correlation coefficient (ICC) for total scores ranged from 0.95 to 0.98.

For test-retest item reliability, the mean κ value was: 0.80 patient, 0.77 carer, 0.81 staff. ICC for total scores ranged from 0.82 to 0.92. Given the absence of a gold standard, criterion validity was assessed by comparing CANE with EASYCare (rs0.460; p ≤ 0.01), GDS (rs0.615; p ≤ 0.01), GHQ (rs0.581; p ≤ 0.01) and Barthel Index (rs-0.435; p ≤ 0.01). Overall, inter-item and item-total correlations for CANE and item comparison with other measures indicated reasonable construct validity.

Conclusion: The psychometric proprieties of CANE seem to be consistently good, in accordance with other studies. Robust results on ecological, face, content, criterion and construct validity, as well as good reliability, were achieved. This version is a promising tool for research and practical use in Portuguese old age settings.

Background: In the absence of an easily applicable performance test for making valid measurements of fundamental activities of daily living (ADL) in dementia patients, this study reports the development of an ADL performance test which constitutes both a reliable and a valid measurement of the relevant autonomous areas of everyday activities for dementia patients.

Methods: The Erlangen Test of Activities of Daily Living (E-ADL-Test) consists of five items: pouring a drink, cutting a piece of bread, opening a small cupboard, washing hands and tying a bow. Each test item underwent standardized evaluation on a scale of 0 to 6. To determine retest reliability each assessment was repeated at two-weekly intervals. The Global Deterioration Scale, Mini-mental State Examination (MMSE) and Nurses' Observations Scale for Geriatric Patients (NOSGER) were used to assess construct validity. Spearman's rank correlation coefficient was applied. Forty-six patients (42 women and 4 men) with clinically diagnosed dementia, who were resident in nursing homes, took part in the validation study. Their average age was 86.

Results: The E-ADL-Test revealed good inter-individual differentiation ability, particularly in cases of moderate to severe dementia. Cronbach's α was 0.77, retest reliability 0.73. The correlation coefficients were −0.47 with GDS, 0.60 with NOSGER and 0.72 with MMSE.

Conclusions: The E-ADL-Test is a suitable performance test for measuring activities of daily living as it is easy to use, reliable, valid and well accepted.