Background: A third of family carers of people with dementia describe acting abusively in research studies, but far fewer cases of abuse are currently detected in clinical situations. This discrepancy may be explained by inadequate detection by health professionals, or disagreement regarding what constitutes elder abuse. This study was undertaken to determine the sensitivity and specificity of the revised Modified Conflict Tactics Scale (MCTS) for detecting clinically significant abuse.

Methods: We interviewed 220 family carers of people consecutively referred to psychiatric services with dementia in Essex and London (U.K.), using the MCTS to measure abuse. We defined abuse cases using (1) the MCTS conventional scoring system; (2) the Pillemer criteria; and (3) clinical judgment of an expert panel.

Results: Our panel judged that 15 (6.8%) of carers reported potentially clinical concerning abusive behavior; but 47 (21%) were cases according to the Pillemer criteria and 74 (34%) using the MCTS conventional scoring system. We developed a weighted MCTS scoring system, with high sensitivity and specificity for detecting clinically concerning abuse.

Conclusions: The MCTS could be used routinely in clinical practice with carers of people with dementia to detect clinically concerning cases of abuse, many of which are currently being missed.

Background: The relationship between depressive symptoms and health service use among older people is not well understood. In this study we examined the two-way relationships between depressive symptoms and hospitalization and/or physician visits by older adults.

Methods: In a one-year follow-up study of 973 community-dwelling older adults in the Singapore Longitudinal Aging Studies (SLAS), depressive symptoms (15-item Geriatric Depression Scale score ≥5) were assessed at baseline and one year later. Information on self-reported physician visits and hospitalization were collected bimonthly over one year.

Results: When demographic characteristics, medical comorbidities, functional status and other covariates were controlled for, baseline depressive symptoms were associated with increased episodes of subsequent physician visits during the one-year follow-up (RR,1.34; 95% CI, 1.05–1.70), but not with subsequent hospitalization(s) during the same period. Conversely, participants with five or more physician visits (versus less than 5) over one year were more likely to be depressed at one year (OR, 10.2; 95% CI, 3.36–31.1); hospitalization during this period was also significantly associated with depressive symptoms at one year (OR = 6.43, 95% CI, 2.48–16.6).

Conclusion: Depressive symptoms and health service use have reciprocal relationships. Health service use for non-mental illnesses may be optimized by efforts at post-hospitalization interventions to recognize and treat depression in older persons.

Background: It is well known that the global population is aging and that those over the age of 80 are the fastest growing part of this expansion. Also known is that prevalence of hypertension and cognitive decline both increase with increasing age.

Method: The Hypertension in the Very Elderly Trial (HYVET) was a double blind placebo-controlled trial of antihypertensive treatment (indapamide SR 1.5 mg ± perindopril 2–4 mg) and recruited only those hypertensives who were aged 80 or over and were without a diagnosis of dementia at baseline. Systolic blood pressure had to be in the range 160–199 mmHg and diastolic pressure <110 mmHg. Cognitive function was assessed at baseline using the Mini-mental State Examination prior to randomization into the trial. Also collected at baseline was information relating to sociodemographic, clinical, cardiovascular and biochemical factors which may impact upon cognitive function. This paper reports on the baseline cognitive function data from the HYVET trial and its relationship to these factors.

Results: The mean age of the 3763 HYVET participants who had full cognitive function data at baseline was 83.6 years; 60 percent were female. The median MMSE score at baseline was 26 and, in multivariate analyses, higher at younger age, with male gender, higher educational level, having higher creatinine, higher total cholesterol and lower high-density lipoprotein cholesterol.

Conclusions: This is the first such study to examine a large number of very elderly hypertensives and it shows some similar patterns to those seen in younger elderly groups.

Background: Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders.

Methods: Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established.

Results: Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants.

Conclusions: Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Background: The high prevalence of subjective memory impairment (SMI) in the elderly living in developed countries may be partly dependent on greater demand placed on them by new technologies. As part of a comprehensive study on cognitive impairment in a population living in the Amazon rainforest, we evaluated the prevalence of SMI and investigated the features associated with it.

Methods: We evaluated 163 subjects (82 females) with a mean age of 62.3 years (50–94 years), 110 of whom were illiterate, using the answer to a single question “Do you have memory problems?” to classify them into groups with or without SMI. The assessment involved application of the Mini-mental State Examination (MMSE), delayed recall from the Brief Cognitive Battery designed for the evaluation of low educated and illiterate individuals, the Patient Questionnaire (PQ) of the Primary Care Evaluation of Mental Disorders (PRIME-MD), and the Happiness Analogical Scale.

Results: A very high prevalence of SMI (70%) was observed, exceeding rates reported by similar studies conducted in developed countries. SMI was more frequent in women, whereas age and education did not impact on prevalence. Subjects with SMI had significantly more somatic and psychiatric symptoms on the PQ, as well as lower means on the MMSE, but not on the delayed recall test. Multiple logistic regressions showed that the most important factor associated with the presence of SMI was a high score on the PQ (OR: 3.84, p = 0.011).

Conclusion: Psychological and somatic symptoms may be the principal cause of SMI in this population.

Background: Foreign home care services provided to frail older adults by individuals from the developing world are a global phenomenon. This study evaluated the challenges associated with live-in foreign home care from the perspective of older care recipients and their family members.

Methods: Qualitative interviews were conducted with 23 family members and seven older care recipients. Interviews were analyzed thematically.

Results: Three main themes were identified: (i) the intense fears associated with witnessing the decline of the older care recipient and the subsequent employment of a foreign home care worker; (ii) actual negative experiences within this caregiving setting; and (iii) the ways in which family members and older care recipients coped with these challenging experiences.

Conclusions: The key to this caregiving arrangement is the establishment of trust. Yet, many care recipients experienced violations of trust that resulted in abuse and neglect, which served to further intensify fears and concerns about this caregiving arrangement. The same coping methods used to maintain this arrangement, despite fears and concerns, are the ones responsible for maintaining the older care recipient in an abusive situation.

Background: Depression in the elderly is a common and disabling condition. The aim of the study was to evaluate the sensitivity and specificity of a two-question screen to identify depression and common mental disorders in the elderly.

Method: Residents of a ward in the town of Vellore were identified by a door-to-door survey from which 204 subjects aged over 60 years were selected for the study by systematic random sampling. They were screened using the two-question screen. The Revised Clinical Interview Schedule (CIS-R) was employed to confirm the diagnosis.

Results: The prevalence of depression and common mental disorder, using the CIS-R standard, was found to be 31.5%. The two-question screen has a sensitivity of 93.8% and specificity of 48.2%.

Conclusions: The high sensitivity of the two-question screen makes it a useful screening method which can be employed by health workers in the field.

Objective: This study investigates attitudes to the prescription of mood stabilizer drugs for older patients by old age psychiatrists.

Methods: From a sample of 508 members of the Old Age Faculty of the Royal College of Psychiatrists practicing in England and Wales, 188 (37%) took part in a postal questionnaire survey. A proforma questionnaire investigating opinions about potential indications for, and current concerns about, mood stabilizer drugs was sent to all participants.

Results: Nearly all respondents initiated prescriptions for mood stabilizer drugs and a large majority agreed that they are therapeutically appropriate for prophylaxis of affective disorder (95%), treatment resistant depression (95%), acute mania (91%) and for behavioral symptoms in dementia (75%). Concerns about safety (77%), drug interactions (68%) and lack of scientific evidence (53%) were common.

Conclusions: Old age psychiatrists are frequent prescribers of mood stabilizer drugs for a variety of indications but have understandable concerns arising from a relative lack of scientific evidence of efficacy and effectiveness in older patients.

Background: There is a paucity of past research concerning longitudinal changes in loneliness in old age and in the factors that correlate with loneliness in older persons. This study examines (a) whether loneliness increases with age, (b) characteristics of the lonely older population, and (c) predictors of becoming lonely in old age.

Methods: Data are from the Cross-Sectional and Longitudinal Aging Study, a national longitudinal study on the health, mental, and social status of people aged 75 and older living in Israel. Loneliness was measured as the frequency at which participants had felt lonely during the last month (range: 0–3). The analysis included two waves of data, with an average gap of 3.5 years between them, with 1147 participants at wave 1 and 588 participants at wave 2.

Results: Data showed an increase in the mean level of loneliness over time, rising from 0.62 to 0.80, p<0.001. The strongest correlate of being lonely at wave 1 was unmarried status. Different variables predicted loneliness in the married and the unmarried. Among the married, lonelier persons tended to have experienced more traumatic events, had more doctor's visits, and manifested less cognitive vitality. In contrast, among the unmarried, loneliness was higher in those with financial difficulties, poor health, and less social network support. The longitudinal transition to becoming lonely was more likely in women, those with insufficient financial resources, and people with poorer health.

Conclusions: Results highlight the following implications for the development of preventive programs: (a) helping older persons maintain and develop social networks for preventing increased loneliness, (b) taking demographic factors, health factors, and previous trauma into account when designing interventions, and (c) targeting unmarried women for interventions.

Background: Populations worldwide are aging and the overall prevalence of dementia at death is now 30%. Since the contemporary social impact of a disease is indicated by the frequency of its newspaper coverage and since obituary notices illuminate conceptions of death, we hypothesized that obituary notices placed by families would reflect societal attitudes to aging and dementia.

Methods: We undertook critical discourse analysis of obituaries in representative national and local newspapers in Canada and the U.K.

Results: In the 799 obituaries studied, chronological age, suggested donations in memory of the deceased, and donations to dementia charities were each included in significantly more obituaries in Canadian newspapers than in U.K. ones. Military service was explicit for significantly more men aged ≥ 80 years in Canada compared to the U.K. (41% versus 4%; p < 0.05). Of the donations to medical charities, nearly half (n = 117) were to cancer charities and one-fifth (54) to heart and stroke foundations. In the U.K., obituaries for those aged ≥ 70 years were more likely to recommend donations to children's charities (n = 12) or the Royal National Lifeboat Institution (8) than dementia charities (7).

Conclusions: Donations to dementia charities were significantly more common in obituaries in Canada than in the U.K. In both countries, donations to medical charities did not reflect disease prevalence or impact to the individual. Societal attitudes in the U.K. may be impacted by the fragmentation of aging research and antipathy to geriatric medicine in the national medical press.

Objective: Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities.

Methods: A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed.

Results: Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis.

Conclusion: A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Background: The elderly population size in the U.K. and its constituent countries is increasing. Traditionally, suicide rates increase with aging.

Methods: Time trends in elderly suicide rates and age-associated trends in suicide rates in the U.K. and its three constituent countries (England and Wales, Scotland and Northern Ireland) were examined and comparisons were made of elderly suicide rates in these three countries using data from the World Health Organization.

Results: Elderly suicide rates in both sexes declined over the 24-year period 1979 to 2002 in the whole of the U.K., England and Wales, and Scotland, but only in females in the age-band 65–74 years in Northern Ireland. Female suicide rates increased with age while male suicide rates peaked in the age-band 25–34 years in England and Wales. In Northern Ireland and Scotland male suicide rates decreased with age and peaked in the age-band 25–34 years, and female suicide rates peaked in the age-bands 25–34, 35–44 and 45–54 years. Elderly suicide rates were lowest in Northern Ireland.

Conclusion: The similarities and differences in elderly suicide rates, time trends for elderly suicide rates and age-associated trends in suicide rates between the three constituent countries of the U.K. offer an opportunity to examine the differential characteristics between these countries which may potentially explain these observations.

Background: Depression in old age is an important public health problem causing considerable morbidity and disability worldwide. There is a dearth of community studies from India investigating geriatric depression and its associated risk factors. This study aimed to establish the nature, prevalence and factors associated with geriatric depression in a rural south Indian community.

Methods: We recruited 1000 participants aged over 65 years from Kaniyambadi block, Vellore, India. We assessed their socio-demographic profile, psychiatric morbidity, cognitive functioning, anthropometrics and disability status using the following structured assessment tools: Geriatric Mental State, Community Screening Instrument for Dementia, Modified CERAD 10 word list learning task, History and Aetiology Schedule Dementia Diagnosis and Subtype, WHO Disability Assessment Scale II, and Neuropsychiatric Inventory. We adopted a case control framework to study the factors associated with geriatric depression.

Results: Prevalence of geriatric depression (ICD-10) within the previous one month was 12.7% (95% CI 10.64–14.76%). Low income (OR 1.78; 95% CI 1.08–2.91), experiencing hunger (OR 2.58; 95% CI 1.56–4.26), history of cardiac illnesses (OR 4.75; 95% CI 1.96–11.52), transient ischemic attack (OR 2.43; 95% CI 1.17–5.05), past head injury (OR 2.70; 95% CI 1.36–5.36) and diabetes (OR 2.33; 95% CI 1.15–4.72) increased the risk for geriatric depression after adjusting for other determinants using conditional logistic regression. Having more confidants (OR 0.13; 95% CI 0.06–0.26) was the significant protective factor. Age, female gender, cognitive impairment and disability status were not significantly associated with geriatric depression. DSM-IV diagnosis of major depression was significantly correlated with experiencing hunger, diabetes, transient ischemic attack, past head injury, more disability and less nourishment; having more friends was protective.

Conclusions: Geriatric depression is prevalent in rural south India. Poverty and physical ill health are risk factors for depression among elderly while good social support is protective.

In parallel with the aging of Japanese society, the number of older Japanese with dementia has been steadily increasing. In response to this trend, the Japanese government has established long-term care insurance and an adult guardianship system. At the same time, national and local governments, medical associations, the Alzheimer's Association and pharmaceutical companies have tried to promulgate knowledge regarding dementia. It is therefore important to assess whether these social movements are having an impact on the perception of dementia among the general population in Japan.

Background: Depression is a common psychological problem among older people. Health-related quality of life (HRQoL) is now recognized by healthcare providers as an important treatment goal for people with depression. This study aimed to identify predictors of change in HRQoL among older people with depression.

Methods: In a longitudinal study, data were collected when participants were newly diagnosed with a depressive disorder at a regional outpatient department in Hong Kong and 12 months later. Seventy-seven Chinese participants aged 65 years or older completed the study. Measures included the Physical Health Condition Checklist (PHCC), Geriatric Depression Scale (GDS), Modified Barthel Index (MBI), Instrumental Activities of Daily Living (IADL) scale, Social Support Questionnaire (SSQ), and World Health Organization Quality of Life Scale-Brief Version (WHOQOL).

Results: Significant improvements between the first and second assessments were noted in the total WHOQOL scores, GDS scores, and the number of the social support. The results of linear regression models showed that the increases in the IADL scores and decreases in the PHCC and GDS scores were significantly associated with higher final WHOQOL scores.

Discussion: Treatment for depression was effective in improving the participants’ overall condition and their perceived HRQoL. The results suggest that interventions to alleviate older people's level of depression, manage their physical ill health and enhance their instrumental activities of daily living ability could help improve their perceived HRQoL.

Background: Osteoporosis causes much morbidity and mortality among elderly people. Older inpatients with severe mental illness may be at particular risk of osteoporosis because of factors including immobility, vitamin D deficiency and psychotropic medication.

Method: We screened predominantly older inpatients with severe mental illness for osteoporosis using a peripheral DEXA scanner. Associations were examined between patient variables and osteoporosis as detected by DEXA scan, Z-scores and history of fragility fractures. Patients were followed up to see how many subsequently received drug treatment for osteoporosis. Patient acceptability of the scanning technique was also assessed.

Results: It was possible to scan 72/89 (81%) of patients. Mean T-score was −2.79 (SD 1.50) and mean Z-score −0.76 (SD 1.34). Forty-two (58%) patients had osteoporosis and 23 (32%) osteopenia. Twelve (17%) patients with a history of fragility fractures had osteoporosis on DEXA scan. A scan suggestive of osteoporosis and a history of fragility fractures were both associated with age of 75 years and over and thoracic kyphosis. Low Z-scores were associated with longer hospital stay and osteoporosis-predisposing drugs. Patient acceptability of scanning was high. At follow-up, only 7/16 (44%) patients were suitable for central scanning and 9/40 (23%) for bisphosphonates.

Conclusion: Older institutional patients with severe mental illness are likely to be at high risk of developing osteoporosis. Peripheral DEXA scanning is acceptable to these patients and identifies those at high risk of fractures. Some behaviorally disturbed patients are not suitable for central scans or for some osteoporosis drug treatments.

Background: Depression is common in old age and is often associated with stigma. However, to date, little is known about self-stigma (internalization of stigmatic beliefs) in depressed older people despite its importance and consequences. The aim of this study was to examine self-stigma and its correlates in depressed older people.

Methods: Phone interviews were conducted with 54 persons diagnosed with major depression (78% female, average age = 74) from a psychogeriatric clinic in the central area of Israel. Self-stigma was assessed using an adapted version of the Internalized Stigma of Mental Health (ISMI) scale. Symptoms of depression were assessed using the short form of the Geriatric Depression Scale (GDS). Self-esteem was measured using Rosenberg's Self Esteem Scale. Information regarding sociodemographic and psychiatric health characteristics was also collected.

Results: Self-stigma was relatively moderate with 10% to 20% of the participants reporting self-stigma. Those who reported higher levels of self-stigma were younger than those who did not report it. Income and education were lower in persons who reported high levels of stigmatization. Persons who reported stigmatization scored higher on the GDS and reported lower self-esteem than those without stigmatization.

Conclusions: This study represents an effort to examine the correlates of self-stigma in depressed older people. Since self-stigma exists among older adults, further studies are required to extend this body of knowledge.

Background: Delirium, an acute altered level of cognition, is a frequent complication of medical illness in the elderly. Antipsychotic medications (APs) are often used to treat agitation and psychosis in delirium. The goal of this study is to compare mortality in delirious elderly medical inpatients treated with APs with those who did not receive APs.

Method: 326 elderly hospitalized patients were identified with delirium at an acute care community hospital. A nested case-control analysis was conducted on this cohort. Cases consisted of all patients who died in hospital within eight weeks of admission. Each case was matched for age and severity of illness to patients (controls) alive on the same day post-admission. Conditional logistic regression was used to assess the impact of exposure to AP on mortality. Covariates used for adjustment were the Charlson comorbidity score and the acute physiology score. Odds ratio (OR) and 95% confidence intervals were calculated from the regression coefficients.

Results: 111 patients received an AP. A total of 62 patients died, 16 of whom were exposed to an AP. The OR of association between AP use and death was 1.53 (95% C.I, 0.83–2.80) in univariate and 1.61 (95% C.I, 0.88–2.96) in multivariate analysis.

Conclusion: In elderly medical inpatients with delirium, administration of APs was not associated with a statistically significant increased risk of mortality. Larger studies are needed to clarify the safety of AP medication in elderly patients with delirium.