The authors report a case of a 68-year-old man with an unrecognized insulinoma manifesting with neuropsychiatric symptoms.

For two years, he presented with unspecified behavior changes, autonomic and neuroglycopenic symptoms, which led him to be misdiagnosed with a neurologic and psychiatric disorder before the insulinoma was recognized.

Following neurological alterations in context of hypoglycemia, subsequent to longstanding food refusal, he was admitted in the psychiatric ward. Despite good global response and normal food intake, hypoglycemic episodes were still occurring and led to a careful evaluation which permitted the definitive diagnostic.

This case highlights the diagnostic difficulties of medical disorders presenting with clinical features overlapping neurological and psychiatric syndromes. It also reflects the diagnostic difficulties in rare clinical entities, particularly in patients previously followed in psychiatry and underlines the need for a constant dialogue and updating of clinicians.

I read with great interest the paper “Comparison of performance on three neuropsychological tests in healthy Turkish immigrants and Danish elderly” authored by Nielsen et al. (2012) in International Psychogeriatrics. In their study, 73 Turkish with lower educational level and 36 Danish older subjects were assessed on the Recall of Pictures Test (RPT), Clock Reading Test (CRT), and supermarket fluency (SF). They found significant effects of age and years of education on the Turkish performance, and significant differences between the Turkish and Danish samples on the CRT and SF performances, but not on the RPT. Despite these differences in performance, the authors suggested that these three tests are important neuropsychological instruments for the assessment of dementia in ethnic minority people. As the elderly population is increasing globally, the need for reliable cross-cultural measures suitable to assess this population at risk to develop dementia is also growing. In particular, normative data need to be appropriated ethnically and in terms of educational level, for example, to determine valid cut-offs for mild cognitive impairment (MCI) and patients with dementia. I would like to provide evidence on further neuropsychological instruments sensitive to memory and language deficits for different ethnic groups of Portuguese-speaking Brazilian individuals within the large geographical area of Brazil. Although they all speak Portuguese, they are of different ethnic background and therefore differ in their educational levels significantly. We assessed 411 healthy older subjects (61 to 85 years old and 0 to 17 years of education) from different states in Brazil on the Hopkins Verbal Learning Test – Revised (HVLT-R; Brandt and Benedict, 2001), a verbal episodic memory test, and on the Brief Visuospatial Memory Test – Revised (BVMT-R; Benedict, 1997), a visuospatial episodic memory test (Miotto et al., 2012). The results showed a significant influence of age on both tests, as well as in the original American normative data. Education also showed significant influence on the results, possibly due to the different levels of education of the sample, including illiterate subjects. Gender had no influence on subjects' tests results.

Self-neglect in old age is complex, challenging, and likely to increase in the future. Self-neglect is characterized as the behavior of an elderly person that threatens his or her own safety. Self-neglect is the most common form of abuse and neglect reported to Adult Protective Services in the United States (see Teaster, 2000). Self-neglect is also associated with a significantly increased mortality in victims (Dong et al., 2009). Self-neglect has become a significant public health problem affecting not just the victims but also family members, friends, and frequently the community at large. Characteristics of self-neglect include a failure to provide oneself with adequate food, water, clothing, shelter, or a safe environment and neglect of personal hygiene and medical treatment (O’Brien, 2011).

Background: Cognitively impaired older people fall twice as often as their cognitively intact counterparts. There is, however, limited information on factors that increase the risk of falls in this population. This study aimed to determine whether a group of cognitively impaired older people (CIG) perform worse than a matched group of cognitively intact older people (NCIG) on a profile of physical performance and mobility tests.

Methods: One hundred and thirty-eight cognitively impaired and 276 age and gender matched cognitively intact community-dwelling older adults (>60 years) took part in the study. Participants completed a detailed physical performance battery from which composite fall risk scores were derived. Falls were measured prospectively for 12 months with monthly falls diaries, telephone calls, and by regularly contacting participants’ “person responsible.”

Results: The CIG performed worse than the NCIG in tests of reaction time, muscle strength (grip and quadriceps), balance (sway on floor, sway on foam, controlled leaning balance and near tandem standing ability), and mobility (sit to stand, timed up and go (TUG) and steps required to turn 180 degrees). The CIG had significantly higher composite fall risk scores than the NCIG and fell significantly more during follow-up (Multiple falls (2+): CIG 43%; NCIG 21%).

Conclusions: Fall risk in the CIG was significantly increased due to multiple physical impairments. Physical profiles provide a means of quantifying the extent of impairment in older people with cognitive impairment and potential direction for targeting interventions for reducing fall risk.

Background: The characteristics and associated risks of spontaneously reported cognitive complaints have not been investigated due to the lack of a classification instrument.

Methods: In phase 1, a classification system with descriptive categories and cognitive domains was developed by experts through a modified Delphi technique. In phase 2, 180 elderly patients seeking medical attention for cognitive complaints provided free reports of their cognitive difficulties and each complaint was recorded verbatim. Three observers were asked to classify each complaint into a descriptive category. Perceived cognitive function was further characterized using the Memory Complaint Questionnaire (MAC-Q).

Results: The patients reported 493 spontaneous complaints, with a range of 1–6 complaints per patient and a mean of 2.7 (±1.3). The proportion of complaints that could be classified into a category by each of the three observers varied from 91.9% to 95.7%. Inter-observer agreement assessed using the κ statistic varied from 0.79 to 1 for descriptive categories and 0.83 to 0.97 for domains. Compared with the MAC-Q, spontaneously reported complaints provided complementary information by avoiding the cueing effect provoked by the questionnaire. The total number of complaints and their occurrences in specific domains were associated with important sociodemographic and clinical factors, indicating that their meaning and associated risks need to be further investigated.

Conclusion: The instrument developed in this study proved to be a practical tool for classifying the majority of spontaneously reported cognitive complaints with high reliability. Further studies are needed to investigate clinical usefulness of this approach.

The phenomenon of population aging which was defined as an increase in the median age of the population is already a major social and health problem in a developing country such as Saudi Arabia and represents a challenge to the psychiatric profession (Hafez et al., 2000).

There are various approaches to providing specialist care for patients with delirium in general hospitals. Those described in the literature include joint geriatric/psychiatric units and consultation–liaison (CL) psychiatry services. The Ferdinande Johanna Kanjilal Travelling Fellowship, from the Royal College of Psychiatrists, UK, provided an opportunity to more fully understand each model. This letter outlines observations of the Australian Fellow (AW) of different service structures in the care of hospitalized older people with delirium in the United Kingdom and Ireland.

Background: The provision of mental health care for older people will become increasingly important with rising demand related to global demographic changes. This project aimed to identify changes in work patterns of UK consultant old age psychiatrists between 1993 and 2012.

Method: A link to an online questionnaire was circulated to consultant old age psychiatrists through the Faculty of Old Age Psychiatry, Royal College of Psychiatrists.

Results: In all 210 usable responses were received. On the survey day 71% of old age psychiatrists arrived at work before 9 am, and 40% left work after 6 pm. Over one-third (35%) worked for another hour or more at home. The range of activities was broader than previously reported. Administrative activity was undertaken by over 60% and acute ward work by only 26%. Few consultants reported time in long-stay care or day hospitals. Outpatient activity included Memory Clinics and Health Center Clinics. The main stressors reported by consultants were lack of resources and pressures from management-imposed, financially driven service changes. Relationships with people at work (including patients and their families) and outside work were the main identified support.

Conclusions: Consultants’ working hours have changed little since 1997, but the range and emphases of activities have changed. Changes in service organization are stressful and consultants are supported by relationships with colleagues and patients. Work patterns are changing in response to demands and constraints on the specialty. Research is needed into service design and work patterns, which can provide humane care in the current economic climate.

Background: Casenote studies have characterized late onset schizophrenia (LOS) and related psychoses as somewhat different symptomatically from patients with an early onset schizophrenia (EOS). This study examined a range of phenomenological aspects of delusions and hallucinations as well as traditional symptom measures in both groups.

Methods: 34 LOS and 235 EOS completed the Positive and Negative Syndrome Scale, the Psychotic Symptom Rating Scales, and the Beck Depression and Anxiety inventories. Subgroups experiencing delusions were compared matching for chronological age and gender, and also when matched for chronicity and gender.

Results: Delusions were very common at over 80% in both groups. LOS participants with delusions exhibited greater suspiciousness/paranoia, greater belief-conviction, and reduced insight when compared with the EOS group. These findings remained when matching for chronicity of illness, but disappeared when matching for chronological age. Hallucinations were surprisingly rarer in LOS (35%) than EOS (57%), with half the LOS group reporting whispers rather than clearly audible sounds. In general, anxiety, depression, and distress were as marked in LOS and EOS.

Conclusions: Similarities between EOS and LOS far outweighed the differences across a range of symptoms and measures. Greater delusional conviction, paranoia, and poorer insight in LOS were associated with the later age of onset rather than relating to chronicity of illness. As belief-conviction in LOS was not associated with increased grandiosity, disorientation, or unusualness of thought content, as it was in EOS, delusional conviction may be determined somewhat differently later in life.

Dystonic reactions are adverse extrapyramidal side effects and are common to antipsychotics, antiemetics, and a variety of other drugs. Rivastigmine, an anticholinesterase of carbamate variety, is well tolerated. A case of acute dystonic reaction with rivastigmine patch is being reported.

The use of anti-dementia medication is expected to rise with increasing demand and a growing elderly population. With the implementation of the “Living well with Dementia: National Dementia Strategy” document in the United Kingdom, there is an increased awareness along with an urge for early diagnosis and initiation of treatment.

We read the review by Moore et al. (2012), recently published in this journal, with great interest and compliment the authors for their thorough review of cognitive impairment and its relation to vitamin B12.