Background: Advanced dementia may be accompanied by behavioral and psychological symptoms of dementia (BPSD). BPSD stemming from pain, depression, or psychosis benefit from treatment with drugs, but in other cases, medications have limited efficacy and may elicit adverse effects. Therefore, more attention has been paid to non-pharmacological interventions, which have fewer risks and can be successful in reducing agitation and negative mood. However, these interventions are frequently not implemented in nursing homes due to staffing constraints. This study explores the potential of volunteers to further assist staff.

Methods: We interviewed 18 staff members and 39 volunteers in 17 aged care facilities in southeast Melbourne, Australia.

Results: Three-quarters of the facilities in this region worked with at least one regular volunteer. Both self-interest and altruistic reasons were identified as motives for volunteering. Volunteers were perceived by facility representatives as helpful to residents through provision of stimulation and company. However, they were discouraged from engaging with individuals with prominent BPSD. A majority of facility representatives and volunteers had experienced some difficulties in negotiating working relationships but most were easily resolved. A large majority of volunteers expressed an interest in learning new methods of interacting with residents.

Conclusion: Despite their beneficial effects for agitated residents, non-pharmacological interventions are often not implemented in aged care facilities. Staff members often lack time but current volunteers in the sector are available, experienced, and interested in learning new methods of interacting. Volunteers therefore potentially are a valuable resource to assist with the application of new treatments.

Background: Elder abuse is often unreported, undetected, and underestimated by professionals. For the first time, we report the effectiveness of an educational elder abuse intervention over three months and its impact on professionals’ practice.

Methods: Forty trainee psychiatrists in two London National Health Service trusts completed the KAMA (Knowledge and Management of Elder Abuse) and CSQ (Caregiver Scenario Questionnaire) measuring knowledge about managing and detecting elder abuse, before and immediately after a brief group education session. We asked how often they considered, asked about, detected, and managed elder abuse and their confidence in doing so, at baseline and three months post-intervention.

Results: Compared with baseline, participants scored higher on the KAMA (paired t = 3.4, p = 0.002), and identified more definitely abusive (t = 3.0, p = 0.003) and possibly abusive (t = 2.1, p = 0.043) items immediately post-intervention. At three-month follow up, 24 (60%) participants reported higher confidence in managing abuse (Wilcoxon signed ranks test z = 3.7, p < 0.001) and considered it more frequently (z = 2.8, p = 0.006), but did not ask older people and their carers about abuse more frequently (z = 1.2, p = 0.24). Two (5%, 95% confidence interval 2%–17%) participants detected abuse in the three months before the intervention, compared with 2 (8%, 2%–26%) in the same period afterward.

Conclusions: This brief educational intervention increased trainee psychiatrists’ knowledge and vigilance for abuse immediately and after three months. They remained reluctant to ask about abuse for reasons including fear of causing offence or harming the therapeutic relationship and being unsure how to ask people with dementia. We postulate that changing doctors’ behavior may require a more complex intervention, focusing on communication skills.

Background: This study aimed to determine: (1) the prevalence of depression, anxiety, and depression associated with anxiety (DA); (2) the risk factor profile of depression, anxiety, and DA; (3) the course of depression, anxiety, and DA over 24 months.

Methods: Two-year longitudinal study of 20,036 adults aged 60+ years. We used the Patient Health Questionnaire and the Hospital Anxiety and Depression Scale anxiety subscale to establish the presence of depression and anxiety, and standard procedures to collect demographic, lifestyle, psychosocial, and clinical data.

Results: The prevalence of anxiety, depression, and DA was 4.7%, 1.4%, and 1.8%. About 57% of depression cases showed evidence of comorbid anxiety, while only 28% of those with clinically significant anxiety had concurrent depression. There was not only an overlap in the distribution of risk factors in these diagnostic groups but also differences. We found that 31%, 23%, and 35% of older adults with anxiety, depression, and DA showed persistence of symptoms after two years. Repeated anxiety was more common in women and repeated depression in men. Socioeconomic stressors were common in repeated DA.

Conclusions: Clinically significant anxiety and depression are distinct conditions that frequently coexist in later life; when they appear together, older adults endure a more chronic course of illness.

Background: The study investigated the change in proxy rated quality of life (QoL) of a large cohort of home living patients with Alzheimer's disease (AD) over a period of 36 months.

Methods: The sample consisted of 102 patients with mild AD and their primary caregivers from the Danish Alzheimer's Disease Intervention Study. QoL was assessed with the proxy-rated (primary caregivers) Quality of Life in Alzheimer Disease scale (QOL-AD) and the EuroQuol Visual Analogue Scale (EQ-VAS) scale. The Cornell Scale for Depression in Dementia (CSDD), Alzheimer's Disease Cooperative Study, Activities of Daily living Inventory (ADCS-ADL), Mini-Mental State Examination (MMSE) and Neuropsychiatric Inventory (NPI-Q) were also applied. Evaluations were conducted at baseline and at 12 and 36 months follow-up.

Results: There was a significant decline in mean QoL assessed by both the QOL-AD and the EQ-VAS (p < 0.001). There were vast individual differences in the QoL scores on both scales at 12 and 36 months’ follow-up. Mean change from baseline in QOL-AD was significantly associated with change in CSDD, ADCS-ADL and MMSE scores at 12 months and with ADCS-ADL score at 36 months.

Conclusion: QoL is a subjective concept and may not be influenced by the degree of cognitive dysfunction. Future studies should investigate the factors for individual variations in order to understand the nature of change of QoL in AD and the wide variation in QoL scores over time.

Background: Hospitalized frail older patients are usually assessed for their ability to perform some daily living activities in a clinical setting prior to discharge. However, assessments that take place in this unfamiliar environment might not be as representative of their functional performance as assessments at home. This may be related to a decline in some cognitive components, such as executive functions (EF), which enable one to cope with new environments. This study thus aims to compare cooking task performance in familiar and unfamiliar settings in a population of frail older adults with poor and preserved EF.

Methods: Thirty-seven frail older adults were assigned to one of two groups: poor EF or preserved EF. Participants performed two cooking tasks in familiar and unfamiliar settings, using a counterbalanced design. Their performance was assessed with a reliable tool based on observation of motor and process skills (Assessment of Motor and Process Skills).

Results: Thirty-three participants were retained for analysis. They demonstrated significantly better motor skills (F = 5.536; p = 0.025) and process skills (F = 8.149; p = 0.008) in the familiar setting. The difference between settings was particularly marked for process skills in participants with poor EF (F = 16.920; p < 0.001).

Conclusions: This study suggests that a home setting may be preferable for a more accurate assessment of cooking task performance in frail older adults, especially those with poor EF. These findings highlight the risk of underestimating frail older adults’ performance when assessed in an unfamiliar setting (e.g. hospital), which could lead to inefficient allocation of home care services.

Background: The survey “Quality of life in older adults-Spain” (CadeViMa-Spain) was designed to obtain information about objective and subjective determinants of Quality of Life (QoL) in old age, from a multidimensional perspective. This paper presents the overall description, methodology, sample characteristics and reliability of the measures used.

Methods: A cross-sectional survey was carried out in a representative sample of 1106 community-dwelling adults aged 60 years and over in Spain. The sample was obtained by a geodemographically-based proportional multistage stratified sampling. A home-based questionnaire included validated scales and questions about sociodemographic characteristics, global QoL, health, family and social networks, financial means and retirement, leisure and social participation, residential environment, and satisfaction with those issues. Face-to-face semi-structured interviews were conducted. Cronbach's α coefficients were used to assess internal consistency of the scales.

Results: This nationally representative survey furnishes information about global QoL, health-related QoL, resources availability, living conditions, and satisfaction with the assessed aspects, including life domains most valued by this group. In general, community-dwelling older adults reported positive assessments of health, living conditions, and high levels of satisfaction with the different aspects of QoL. The reliability of the measures in this population was good.

Conclusions: This survey provides comprehensive and useful information, based on the view of older people themselves, with potential to contribute to health and social policies towards promoting active aging. The database is available for in-depth comparisons.

Background: Depressive symptoms are prevalent among persons with dementia (PWD). Our aim was to assess the psychometric properties of the Spanish version of the Geriatric Depression Scale (GDS-15 and GDS-5) in PWD.

Methods: In this cross-sectional study, five healthcare centers providing care for PWD from two cities in Spain participated. Ninety-six community-dwelling PWD aged 55 years and older, living with a known caregiver, completed a battery of scales including the GDS-15 and GDS-5, the Cornell Scale Depression in Dementia (CSDD), a list of self-reported chronic health conditions (yes/no), severity of dementia (Mini-Mental State Examination), functional status (Barthel Index), generic quality of life (WHOQOL-BREF), and sociodemographic information.

Results: Cronbach's α coefficients were 0.81 and 0.72 for GDS-15 and GDS-5, respectively, providing evidence for acceptable internal consistency. Significant associations between the GDS-15/GDS-5, the Barthel Index, CSDD, and the WHOQOL-BREF were found. No significant differences were found on GDS-15/GDS-5 scores among dementia diagnostic groups (Alzheimer's disease, vascular dementia, mixed dementia, other dementia) or between mild (MMSE 21–26) and moderate (MMSE 10–20) dementia. Participants self-reporting depression on the comorbid condition list (yes) scored significantly higher on the GDS-15 and GDS-5 compared to those who reported not having depression. Exploratory factor analyses suggested a two-factor structure on GDS-15 which accounted for 41.6% of the variability, while the one-factor structure on the GDS-5 accounted for 48.1% of the variability.

Conclusions: In general, this study provides evidence that GDS-15 and GDS-5 are suitable measures for screening depressive symptoms in community-dwelling PWD.

Background: Antonovsky's salutogenic model of the “Sense of Coherence” (SOC) is an important resource in dealing with chronic diseases. The aim of this study was to investigate SOC as a psychological factor and its correlation with illness, subjective well-being, and health-related quality of life (QoL) in patients with Parkinson disease (PD) compared to patients with other chronic diseases.

Methods: Fifty-one patients suffering from PD and 59 participants with other chronic non-neurological diseases took part in this study. The PD patients were assessed through medical routine examinations and all participants were asked to complete several questionnaires for psychological assessment. In order to compare controls with the PD group, t-tests, U-tests, and multivariate analysis were conducted. Multiple regression analysis was calculated to identify predictor variables.

Results: Patients with PD were characterized by lower SOC and higher scores concerning depression compared to the control group (CG). Furthermore, the PD group showed fewer active coping strategies and lower scores concerning well-being. There were correlations between depression, coping, well-being and QoL, and SOC. The SOC had a particular predictive value with regards to the outcome “quality of life” and coping strategies.

Conclusions: There are a number of differences regarding psychological characteristics of coping mechanisms in neurological and non-neurological patients. The SOC correlated with several psychological factors; however, there was no correlation with medical data. The SOC predicts scores pertaining coping mechanism and health-related QoL.

Background: Antipsychotics (APs) are usually prescribed to deal with behavioral and psychological symptoms of dementia (BPSD), but poor outcomes, important side effects, and high mortality risk should be addressed. The aim of this study was to estimate the prevalence of AP consumption in patients with dementia, and to describe and compare the sociodemographic and clinical characteristics of patients consuming APs.

Methods: This was a cross-sectional study using 1,894 cases of dementia registered from 2007 to 2009 by the Registry of Dementias of Girona (ReDeGi), which is a population-based passive surveillance system of dementia diagnoses. APs were categorized according to the anatomical therapeutic chemical (ATC) classification, and grouped as typical antipsychotics (TAPs) or atypical antipsychotics (AAPs). Binary logistic regression analyses were used to detect the predictors of AP use as well as the variables associated with TAP or AAP prescription.

Results: APs were used in 29.6% of the cases, with Parkinsonian syndromes (PSd) being the subtype of dementia with the highest AP prescription (50.6% of the patients with PSd). AAPs were mainly prescribed in all subtypes of dementia, except in vascular dementia (VaD) and PSd, where no preference in TAP or AAP use was found. Psychotic antecedents, dementia with Lewy bodies (DLB) diagnoses, cognitive impairment, and BPSD were AP use predictors. AAP use was related to higher severity of dementia.

Conclusions: Despite their disputed benefit–risk ratios, APs are extensively used, off-label, to treat BPSD, and AAPs are more commonly prescribed than TAPs. AP consumption was frequent in DLB, and was related to dementia severity indicators.

Background: Clinical guidelines have the potential to assist in the management of aggression in dementia. This study aims to develop a conceptual framework for the construction of individualized guidelines for this group.

Methods: A concept map of the topic “How to manage aggression in dementia” was developed by reviewing research papers, clinical guidelines, and gray literature. Titles and abstracts of papers that met search criteria were manually scanned in an iterative process for the extraction of key ideas and terminology commonly used to describe the field. Essential ideas and concepts were recorded on a concept map and hierarchically arranged. The concept map was converted into an interactive PDF document for easy distribution and sharing.

Results: Ten key concepts were found to be important when managing aggression in dementia clustered along three major dimensions: Patient, Disorder and Treatment. The dimension Patient was defined by the “Patient's individual characteristics,” the “Personal life story,” and the “Patient's environment.” Disorder was defined by the “Presentation of symptoms” and “Theory of causation.” Treatment was defined by “Goals and expectations,” “Non-pharmacological interventions,” “Pharmacological interventions,” “Ethics and Restraint Use,” and “Emergency treatment.” Concepts relating to clinical guidelines themselves were also included in the interactive map, including “Support from evidence-based medicine,” “Regular updates,” “Disclosures,” and “Usability.”

Conclusion: Managing aggression in dementia requires consideration of a wide range of factors relating to the patient, the dementia and behavioral disturbance, and possible treatment options. An interactive and hierarchical concept map provides a framework to develop individualized clinical guidelines.

Background: Neuropsychiatric symptoms (NPS) are common in patients with dementia associated with Parkinson's disease (PDD). The relationship between cognition and NPS in PDD has not been well studied.

Methods: Patients diagnosed with PDD were assessed for cognitive function and NPS. The instruments used were the Neuropsychiatric Inventory (NPI), Mini-Mental State Examination (MMSE), and semantic verbal fluency according to the recommendation of the Movement Disorder Society Task Force.

Results: We evaluated 127 PDD patients (76 males/51 females; mean age 77 ± 6.3 years). Their mean MMSE score was 17 ± 6.5 and the mean NPI score was 19 ± 20.4. The most prevalent NPI items were anxiety (57.5%), sleep problems (53.5%), and apathy (52.0%). Principal component factor analysis revealed that 12 items formed three factors, namely “mood and psychosis” (delusion, hallucination, agitation, depression, anxiety, apathy, and irritability), “vegetative” (sleep and appetite problems), and “frontal” (euphoria, disinhibition, and aberrant motor behavior). Symptoms of hallucination were significantly associated with MMSE score, even after controlling for the confounding variables.

Conclusion: NPS are common and diverse among patients with PDD. Three specific subgroups of NPS were identified. Hallucination was significantly correlated with cognitive impairment, and could be a predictor of cognition in PDD patients.

Background: There are discrepant findings regarding which subscales of the Cambridge Cognitive Examination (CAMCOG) are able to predict cognitive decline. The study aimed to identify the baseline CAMCOG subscales that can discriminate between patients and predict cognitive decline in Alzheimer's disease (AD) and mild cognitive impairment (MCI).

Methods: This was a five-year case-control study of patients with cognitive impairment and a control group. Participants were grouped into AD (n = 121), MCI converted to dementia (MCI-Ad, n = 43), MCI-stable (MCI-St, n = 66), and controls (CTR, n = 112). Differences in the mean scores obtained by the four groups were examined. Receiver operating characteristic curves were used to compare subscale scores in the AD and MCI-Ad groups with those of controls. The influence of age, gender, schooling, and depression on baseline subscale scores was assessed.

Results: Of the CAMCOG subscales, Orientation and Memory (learning and recent) (OR + MEM) showed the highest discriminant capacity in the baseline analysis of the four groups. This baseline analysis indicated that OR + MEM was the best predictor of conversion to AD in the MCI-Ad group (area under the curve, AUC = 0.81), whereas the predictive capacity of the global MMSE and CAMCOG scores was poor (AUC = 0.59 and 0.53, respectively).

Conclusions: In the baseline analysis, the Orientation and Memory (learning and recent) subscales showed the highest discriminant and predictive capacity as regards both cognitive decline in the AD group and conversion to AD among MCI-Ad patients. This was not affected by age, gender, schooling, or depression.

Background: The risks of financial exploitation and abuse of people with dementia remain under-researched. Little is known of the views of those responsible for local adult safeguarding systems about prevention and redress. We explore current repertoires of responses of such persons and consider barriers and facilitators to minimizing risks of financial abuse for people with dementia.

Methods: Fifteen qualitative interviews were undertaken with a purposively sampled group of Adult Safeguarding Co-ordinators in England in 2011. Framework analysis delineated themes in the transcripts; these were included in an iteratively developed coding framework.

Results: Five themes were explored: (1) incidence of financial abuse; (2) impact of dementia on safeguarding responses; (3) warning signs of financial abuse, including neglect, unpaid bills, limited money for provisions; (4) encouraging preventive measures like direct debit to pay for bills, advance care plans, appointing Lasting Power of Attorney; and (5) barriers and facilitators in safeguarding, including the practice of financial agencies, cultural barriers, other systemic failures and facilitators. Not all systems of financial proxies are viewed as optimally effective but provisions of the Mental Capacity Act 2005 were welcomed and seen as workable.

Conclusions: Healthcare professionals may need to be more alert to the signs and risks of financial abuse in patients with dementia both at early and later stages. Engaging with safeguarding practitioners may facilitate prevention of abuse and effective response to those with substantial assets, but the monitoring of people with dementia needs to be sustained. In addition, professionals need to be alert to new risks from electronic crime. Researchers should consider including financial abuse in studies of elder abuse and neglect.

Background: There is considerable debate about the ability of proxies to adequately reflect patients' preferences regarding end-of-life care, when patients are no longer capable of stating their preferences. This study evaluated concordance in end-of-life preferences between patients with mild cognitive impairment (MCI) or dementia and their spouses.

Methods: A cross-sectional sample of 106 respondents (53 couples) was recruited in two psychogeriatric clinics. Bivariate analyses were conducted to evaluate the degree of agreement between the patients' preferences and those of their spouses.

Results: Patients were more likely to opt for more treatment than their spouses. Moderate agreement between patients and spouses was evident for preferences regarding end-of-life decisions for the patients. There was little concordance between the wishes of spouses regarding their own preferences and what they wanted for the patient or what the patient wanted. When incorrectly predicting patients' preferences, spouses were more likely to ask for treatment.

Conclusions: Our results show that regarding end-of-life preferences for patients, there is moderate agreement between patients and their spouses, but limited evidence for projection of spouses’ preferences on patients (i.e. spouse making a prediction based on own wishes). Potential differences in end-of-life preferences between older adults with MCI or mild dementia and their caregivers should be taken into consideration in the preparation of advance care planning.

Background: Studies on functional capacity in community-dwelling older people have shown associations between declines in instrumental activities of daily living (IADL) and several factors. Among these, age has been the most consistently related to functional capacity independent of other variables. We aimed at evaluating the performance of a sample of healthy and cognitively intact Brazilian older people on activities of daily living and to analyze its relation to social-demographic variables.

Methods: We conducted a secondary analysis of data collected for previous epidemiological studies with community-dwelling subjects aged 60 years or more. We selected subjects who did not have dementia or depression, and with no history of neurological diseases, heart attack, HIV, hepatitis or arthritis (n = 1,111). Functional capacity was assessed using the Brazilian version of the Older American Resources and Services Questionnaire (BOMFAQ). ADL performance was analyzed according to age, gender, education, and marital status (Pearson's χ2, logistic regression).

Results: IADL difficulties were present in our sample, especially in subjects aged 80 years or more, with lower levels of education, or widowed. The logistic regression analysis results indicated that “higher age” and “lower education” (p ≤ 0.001) remained significantly associated with IADL difficulty.

Conclusions: Functional decline was present in older subjects even in the absence of medical conditions and cognitive impairment. Clinicians and researchers could benefit from knowing what to expect from older people regarding IADL performance in the absence of medical conditions.

Background: During last few decades, the proportion of elderly persons prescribed with antidepressants for the treatment of depression and anxiety has increased. The aim of this study was to evaluate prevalence of antidepressant prescription and related factors in elderly in-patients, as well as the consistency between prescription of antidepressants and specific diagnoses requiring these medications.

Methods: Thirty-four internal medicine and four geriatric wards in Italy participated in the Registro Politerapie SIMI–REPOSI study during 2008. In all, 1,155 in-patients, 65 years or older, were enrolled. Prevalence of the use of antidepressants was calculated at both admission and discharge. Logistic regression was used to evaluate the association between patients’ characteristics (age, gender, Charlson Index, number of drugs, specific diseases, other psychotropic medications) and the prescription of antidepressants.

Results: The number of patients treated with antidepressant medication at hospital admission was 115 (9.9%) and at discharge 119 (10.3%). In a multivariate analysis, a higher number of drugs (OR = 1.2; 95% CI = 1.1–1.3), use of anxiolytic drugs (OR = 2.1; 95% CI = 1.2–3.6 and OR = 3.8; 95% CI = 2.1–6.8), and a diagnosis of dementia (OR = 6.1; 95% CI = 3.1–11.8 and OR = 5.8; 95% CI = 3.3–10.3, respectively, at admission and discharge) were independently associated with antidepressant prescription. A specific diagnosis requiring the use of antidepressants was present only in 66 (57.4%) patients at admission and 76 (66.1%) at discharge.

Conclusions: Antidepressants are commonly prescribed in geriatric patients, especially in those receiving multiple drugs, other psychotropic drugs, and those affected by dementia. There is an inconsistency between the prescription of antidepressants and a specific diagnosis that the hospitalization only slightly improves.

Background: Loneliness is widespread among older adults, in particular among those who are chronically ill and functionally limited. The aims of the paper are: (i) to examine the extent to which users of day care centers experience loneliness compared to their peers who are non-users; and (ii) to explore the relationships between length of use and frequency of weekly attendance at day care centers and loneliness among users of day care centers.

Methods: A case-control study was used with a sample of 817 respondents of whom 417 were users of 13 day care centers and 400 were non-users, matched by age, gender, and family physician in the southern region of Israel. Data collection included face-to-face interviews using a structured questionnaire.

Results: The vast majority in both groups (79.3% and 76.3%, respectively) reported moderate to severe levels of loneliness. Perceived economic status and self-rated health were the most significant variables in explaining loneliness. No significant differences were found between users and non-users of day care centers in the level of loneliness. Attendance at day care centers, as well as length and frequency of use, had no significant association with loneliness.

Conclusion: More research, which will include quasi-experimental and longitudinal research designs, is necessary to examine the causal relationships between attendance at day care centers and loneliness. This can provide information on the effectiveness of day care centers in reducing loneliness among frail older adults.

Background: Clinicians and researchers working with dementia caregivers typically assess caregiver stress in a clinic or research center, but caregivers’ stress is rooted at home where they provide care. This study aimed to compare ratings of stress-related measures obtained in research settings and in the home using ecological momentary assessment (EMA).

Methods: EMA of 18 caregivers (mean age 66.4 years ±7.8; 89% females) and 23 non-caregivers (mean age 66.4 years ±7.9; 87% females) was implemented using a personal digital assistant. Subjects rated their perceived stress, fatigue, coping with current situation, mindfulness, and situational demand once in the research center and again at 3–4 semi-random points during a day at home. The data from several assessments conducted at home were averaged for statistical analyses and compared with the data collected in the research center.

Results: The testing environment had a differential effect on caregivers and non-caregivers for the ratings of perceived stress (p < 0.01) and situational demand (p = 0.01). When tested in the research center, ratings for all measures were similar between groups, but when tested at home, caregivers rated their perceived stress as higher than non-caregivers (p = 0.02). Overall, caregivers reported higher perceived stress at home than in the research center (p = 0.02), and non-caregivers reported greater situational demand in the research center than at home (p < 0.01).

Conclusions: The assessment method and environment affect stress-related outcomes. Evaluating participants in their natural environment provides a more sensitive measure of stress-related outcomes. EMA provides a convenient way to gather data when evaluating dementia caregivers.