Hypertension affects millions of people worldwide and has been reported in patients with Alzheimer's disease (AD) some decades before the onset of the disease. High blood pressure has also been related to pathological manifestations of AD (Skoog and Gustafson, 2006). The hippocampus is a highly vulnerable and plastic structure that gets damaged by stimuli, e.g. hypoxia. In order to establish whether hypertension could damage the hippocampus and play a role in its atrophy we undertook a study to examine the relationship between hypertension and hippocampal atrophy in patients with AD.

Background: Falls are a major cause of morbidity and mortality among elderly people, and people with dementia run an increased risk of falling. The aim of this study is to identify risk factors for falls in people with dementia.

Method: The study was performed over a six-month period in northern Sweden using a sample of 160 residents living in 20 group dwellings for people with dementia.

Results: Sixty-four residents (40%) sustained at least one fall during the period. The total number of falls during the study period was 191, and the fall incidence was 2.6 per person year (169 falls/130 residents). Using logistic regression analysis, the independent risk factors strongly associated with falling were: requiring help with hygiene, displaying verbally disruptive/attention-seeking behavior, able to rise from a chair, walking with assistive devices, and participating in outdoor walks. These factors explained 36.1% of the variance in falls with a concordance of 79.6%. Thirty-five percent of the falls occurred between 9 pm and 6 am, with a peak between 5 pm and 6 pm. Symptoms preceding the falls were anxiety (31.1%) and confusion (13.3%).

Conclusion: Among residents with dementia it is important to identify those who run an increased risk of falling and need more careful supervision, especially in the evening and during the night. In addition, the causes of anxiety and confusion have to be prevented and treated.

Background: Elderly suicide rates are associated with the elderly population size, the proportion of elderly in the general population and the elderly dependency ratio.

Methods: A cross-national study examining the “a priori” hypothesis that the relationship between elderly suicide rates and average annual population growth rates would be curvilinear (U-shaped curve) fitting the quadratic equation y = a + bx + cx2 (where y is the elderly suicide rate, x is the population growth rate and a, b and c are constants) was conducted using data from the World Health Organization and the United Nations.

Results: There was a significant curvilinear (U-shaped curve) relationship between elderly suicide rates and average annual population growth rates fitting the above quadratic equation.

Conclusions: A theoretical model with three sequential stages incorporating population growth, the elderly population size, the proportion of elderly in the general population, life expectancy and birth rates was proposed to explain the findings. Caution should be exercised in the application of this model because of the cross-sectional and ecological study design whereby the findings are subject to ecological fallacy and require rigourous testing in within-country longitudinal studies over time.

Background: Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia.

Methods: The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. χ2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables.

Results: The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge.

Conclusion: Suboptimal medication use is a potential source of decreased function in older patients with dementia.

Aggressive and violent behavior is a problem throughout healthcare services (Behar et al., 2008). The incidence of such acts is known to be over two and half times greater in mental health settings than in general hospital environments (National Audit Office, 2003). All types of aggression may have negative physical and psychological consequences for the victim, and therefore none ought not to be overlooked. However, one particularly serious feature is physical assault, which may result in a physical injury to the victim, although reported levels are relatively low (Stubbs et al., 2009). Physical assault may also affect the psychological, emotional and spiritual well-being of health staff and a minority may go on to develop post-traumatic stress type symptoms (Needham et al., 2005). Indeed, these symptoms may last longer than the original physical injury itself (Needham et al., 2005).

Background: The elderly are at high risk of developing tuberculosis. The prevalence and incidence of depression and anxiety are higher in those with tuberculosis than in the general population. A positive correlation between national suicide rates and rates of mortality due to tuberculosis has been reported.

Methods: The relationships between elderly suicide rates and (i) the prevalence of tuberculosis, (ii) the proportion of detected cases of tuberculosis, and (iii) the proportion of cured cases of tuberculosis were examined in a cross-national study using data from the World Health Organization and the United Nations.

Results: There were no significant correlations between elderly suicide rates and the prevalence of tuberculosis and the proportion of detected cases of tuberculosis. There were weak but significant negative correlations between the proportion of cured cases of tuberculosis and suicide rates for both sexes in both elderly age-bands.

Conclusion: Caution should be exercised in interpreting the findings and the direction of the causal relationship from this cross-sectional ecological study because of ecological fallacy. However, if the findings are true then potentially the study has important implications for prevention of elderly suicides, particularly in countries with a high prevalence of tuberculosis.

Background: Little is known about sleep quality and alcohol use problems in the elderly minority population. This study aimed to identify a one-month prevalence of poor sleep quality and alcohol use problems among elderly Taiwanese aboriginal women and to examine the association between them.

Methods: A cross-sectional survey with stratified random sampling was conducted in eight aboriginal communities in Taiwan. The 1261 elderly aboriginal women (response rate 84%) completed all assessments. Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), while the CAGE questionnaire was used to evaluate alcohol use problems.

Results: Of the study participants, 20.54% and 25.59% had poor sleep quality and alcohol use problems, respectively. Controlling for confounding factors, alcohol use problems were a risk factor for poor sleep quality (AOR = 1.44, p = 0.0433). Alcohol use problems were associated with three components of PSQI: sleep disturbances, subjective sleep quality, and daytime dysfunction.

Conclusions: The elderly Taiwanese aboriginal women with problematic alcohol drinking experienced poorer sleep quality. Development of a program to reduce alcohol use problems might improve sleep quality among elderly Taiwanese aboriginal women.

Background: Little is known about the sociodemographic correlates and health effects associated with lifetime alcohol misuse in community dwelling elderly people in Brazil.

Method: Data were obtained from a representative sample of 6961 residents aged 60+ in the state of Rio Grande do Sul, Brazil. The structured interview included a five-item lifetime alcohol use questionnaire addressing abuse and dependence, and questions regarding sociodemographic characteristics, lifestyle and social support, and health conditions.

Results: In the interview, 10.6% respondents (25.3% men, 2.9% women) endorsed at least one lifetime alcohol misuse question. Controlled analyses comparing a gradient of alcohol misuse (none, one or more than one item endorsed), found that men, people aged 60–69 (compared to older persons) and tobacco users were more likely to endorse alcohol misuse items. Persons reporting lower income and who were of non-white race/ethnicity did not differ from their comparison groups with respect to endorsing one item, but they were more likely to endorse two or more items. Endorsing more than one item was associated with impaired activities of daily living, the presence of respiratory problems and psychiatric disorders, but was protective against vascular conditions.

Conclusions: Major lifetime alcohol misuse (defined as endorsing more than one of five items reflecting alcohol abuse or dependence) is more common in certain sociodemographic groups (men, younger elderly, lower income, non-whites). With the exception of vascular conditions, it is associated with smoking, poorer functional status, respiratory problems, and psychiatric disorder. Endorsing only one item has a reduced association, significant only for male gender, smoking, and psychiatric disorder.

A 69-year-old man presented with Cotard's delusions, insomnia, profound depression, amnesia, difficulty concentrating, and cognitive deficit after two different surgical interventions. Brain imaging showed frontotemporal-subcortical atrophy and lateral ventricular enlargement. He responded poorly to a combination of sertraline, amisulpride and mirtazapine, with modest benefit on insomnia, and developed hypotension. After 18 days he was switched to olanzapine and venlafaxine, but his cognition worsened. He underwent bilateral electroconvulsive therapy (ECT). His mood improved, cognitive performance increased and anxiety symptoms remitted. This improvement persisted through the one-month post-discharge follow-up and depression eventually remitted.

Aggression and violence are frequent events in healthcare settings across the globe, with mental health and old age settings often frequenting top spot in incidence lists (Hodgson et al., 2004, Behar et al., 2008). Some may underestimate the challenging nature of older age psychiatric patients, but the reality is that this population can display high levels of aggressive and violent behavior (Stewart et al., 2008). The potentially challenging nature of this population was revealed in a recent study in the U.K., which reported 2753 episodes of aggressive behavior over a three month period (Stewart et al., 2008). Over half of these aggressive displays were in the form of physical aggression, and displays of this type of behavior increase the likelihood of healthcare staff having to employ physical intervention (Stewart et al., 2008). Physical intervention is a form of hands-on physical restraint that involves trained staff employing physical holding techniques to move and restrict the movement of the aggressive patient.

Background: Seeking medical advice for dementia involves an understanding of norms, values and attitudes towards care-giving and inter-dependency, which are culturally bounded. We hypothesize that local culture and socioeconomic structure affect our Chinese patients who present with forgetfulness to our memory clinic.

Methods: A retrospective case notes review was undertaken on 454 consecutive patients referred to the memory clinic at Princess Margaret Hospital, Hong Kong.

Results: 385 patients were diagnosed with dementia and 27 had mild cognitive impairment. Reversible dementia was identified in 24 patients and normal cognition in 18. In patients with dementia, 55.8% had Alzheimer's disease, 26.2% had vascular dementia, 6.0% had other irreversible dementia, 5.2% had dementia with Lewy bodies, 4.9% had undetermined dementia and 1.8% had frontotemporal dementia. The median duration from symptom onset to medical consultation was two years; 66.5% had advanced disease with initial Mini-mental State Examination scores ≤ 17. On their first visit, 85% of patients were living in the community; after two years this proportion had fallen to 63%.

Conclusions: Dementia patients in Hong Kong apparently enjoy a long subclinical period and only seek medical attention at late stages. Local Chinese culture and socioeconomic backgrounds could be the main reasons that underlie these observations.

Suicide rates increase with aging in many countries. In a recent study of 62 developed and developing countries, suicide rates increased with age for males and females in 25 and 27 countries respectively, and in both sexes in 17 countries (Shah, 2007). Suicide rates increased with age in 47 of the 49 medium- and high-income countries (Keimo, 2004). Comprehensive understanding of the substantial worldwide variation in population patterns of suicide may be critical for developing prevention programs (Knox et al., 2004). Much is known about individual level proximal risk factors and preventative strategies can be targeted at identified high risk groups (Shah and De, 1998). Also, proximal risk factors for elderly suicide victims are generally different from those for younger suicide victims (Shah and De, 1998). However, distil risk factors may be similar for elderly and younger suicide victims. Such distil risk factors include societal socioeconomic status (Kennedy et al., 1999; Shah et al., 2008), societal income inequality (Kowalski et al., 1987; Shah et al., 2008), education (Kowalski et al., 1987; Agbayewa et al., 1998), degree of urbanization (Stack, 1993), degree of social integration (Durkheim, 1992) and provision of health and mental health service provision (Shah and Bhat, 2008). In general, preventative measures targeting distil risk factors require development of public health strategies at a societal level. Should research focus specifically on elderly suicide rates in cross-national ecological studies designed to identify distil risk factors?

A recent review of the prevalence of dementia in all world regions revealed a particular paucity of data from the Middle Eastern region (Ferri et al., 2005). Iran is one of the largest countries in this region, with a population of 70 million, of whom 5.2% are aged 65 years and over and where life expectancy is already 71 years (www.amar.ir – Iranian Government Statistics site). Our best estimates suggest that there may be nearly 200,000 people living with dementia in Iran at the moment (Ferri et al., 2005). The 10/66 Dementia Research Group developed and validated a cultural- and education-fair dementia diagnosis in 26 centers worldwide (Prince et al., 2003). We have now assessed the feasibility and validity of a Farsi version of the 10/66 dementia diagnostic system in Ekbatan, Tehran, Iran.

A recent cross-national study reported that elderly suicide rates in both sexes were significantly negatively correlated with household size and the percentage of extended households and positively correlated with the percentage of single-person households (Shah, 2009). Speculative explanations for these findings were based on cultural factors, including (i) a mismatch between the traditional dependence of elderly relatives on their children for emotional and financial support and their children's ability to provide this support (Yip et al., 1998, 2000; Liu et al., 2006); (ii) the unmet traditional expectation of the elderly person being able to live with their children or grandchildren (Yip et al., 2000; Liu et al., 2006); (iii) the effect on the elderly of their children's negative attitudes (Yip et al., 2000); (iv) the migration of children to urban areas or to other countries (Yip and Tan, 1998; Yip et al., 2000); and, (v) the number of available caregivers, household size and family size (Kua et al., 2003). Countries with larger household sizes and a greater number of extended households potentially have a greater number of people available within the household and within close geographical proximity who can contribute positively to these cultural issues, and this may ultimately lead to a reduction in elderly suicide rates – the “emotional proximity” explanation. However, there may also be other explanations for these findings (Shah, 2009). Having more people in a household implies that there are more people to identify suicidal ideation and support the suicidal individual in seeking approprate help. Also, in larger households elderly people are likely to be alone for shorter periods of time, which would reduce the opportunity to implement any suicidal plans. Both these possibilities form part of the “geographical proximity” explanation.

Background: Knowledge about the daily life of older adults with psychiatric disabilities is extremely limited, especially from the standpoint of the individual. The overall aim of this study was to describe and analyze the ways in which older adults with a psychiatric disability experience places, social relations and activities in different arenas of their everyday lives.

Method: Twelve older adults (>55 years) with a psychiatric disability were interviewed either once or twice, using different interview techniques. The first interviews were semi-structured and the second were in-depth interviews guided by a site-map. The interview texts were analyzed using qualitative content analysis, proceeding from open to focused coding in several steps.

Results: Although the respondents spent most of their time in their own homes, some also spent a lot of time at day-care centers and other similar places. The amount of time spent in places in the public arena varied a great deal. The interviewees' experiences of the places, relationships and activities in their everyday lives can be related to aspects of freedom and coercion, internal and external structure, and relationships and support.

Conclusion: The provision of a varied range of services and support in diverse settings in order to make these accessible to persons of different ages and needs is an important challenge for welfare politics.

A recent cross-national study of 62 developing and developed countries reported an increase in suicide rates with aging in males and females in 25 and 27 countries respectively (Shah, 2007). Longitudinal studies over time have reported a decline in elderly suicide rates in England and Wales (Gunnell et al., 2003; Lodhi and Shah, 2004), Sweden (Carlsten et al., 1999) and Australia (Hall et al., 2003) with an increase in prescription rates of antidepressants, particularly selective serotonin reuptake inhibitors. The vast majority of elderly suicide victims have depressive illness (Shah and De, 1998). The pathway to elderly depressed individuals acquiring a prescription of antidepressants includes the following sequential steps: recognition by individuals or their carers that there is problem and consulting a healthcare professional; recognition of depression by the healthcare professional; prescription of antidepressants by the healthcare professional; and, purchasing of the antidepressants by the patient. Different methods of acquiring the prescribed antidepressants exist in different countries including: healthcare professionals dispensing the antidepressant free or at a cost; and obtaining the prescribed antidepressant from a pharmacist free (either through state welfare system or insurance schemes) or at a cost. We have examined the relationship between elderly suicide rates and the affordability of psychotropic medication in a cross-national study.

Because suicide rates have traditionally increased with age (Shah and De, 1998; Shah, 2007), the observed reduction in suicide rates among older people may be an important contributor to the U.K. government's target to reduce suicide rates in the general population by at least one-sixth of the 1996 baseline by 2010 (Department of Health, 1999). Previous studies have observed that suicide rates in older people have declined in both sexes over the 12-year period (1985–1996) and 24-year period (1979–2002) in England and Wales (Hoxey and Shah, 2000; Shah et al., 2001), although the rates are still considerably higher than those among younger adults. It is believed that a better understanding of the methods used by older people for suicide may lead to the development of targeted preventative strategies, which are expected to meet the challenge of sustaining this observed decline in suicide rates among older people over time in England and Wales (Lindesay, 1991; Dennis and Lindesay, 1995).