Background: This research concerns the prevalence and course of depression in newly admitted nursing home residents. We attempted to recruit consecutive admissions into the study, irrespective of cognitive status, enabling a comparison of the prevalence and course of depression experienced by cognitively intact residents and those exhibiting all levels of cognitive impairment.

Method: Depression was assessed at one month, three months and six months post-admission. The assessment of mood in this study entailed the conduct of a semi-structured clinical interview, which encompassed DSM-IV criteria and Cornell Scale for Depression in Dementia (CSDD) items.

Results: Recruitment difficulties resulted in a sample of 51 newly admitted residents, drawn from six nursing homes located in Victoria, Australia. Of particular interest, throughout the duration of the study, only the cognitively impaired were diagnosed with major depression (MD). One month post-admission, 24% of the sample were diagnosed with MD, and a further 20% evidenced a non-major depressive disorder. At the second and third assessments, MD was observed in 14% and 15% of residents, respectively. For residents who completed all three assessments, there was no appreciable change in the proportion diagnosed with a depressive disorder, nor was there a change in the levels of depressive symptomatology.

Conclusion: Although subject to limitations, the current study indicated that clinical depression in nursing home facilities most often occurs in residents who also exhibit pronounced cognitive impairment. These depressions are unlikely to remit spontaneously. Accordingly, care staff and general practitioners must be trained in the identification of depression in dementia, and any interventions implemented in these facilities should be tailored to meet the unique needs of this group.

There is broad agreement that randomized controlled double-blind trials (RCTs) do reveal only small effects of the cholinesterase inhibitors donepezil, rivastigmine and galantamine in the treatment of Alzheimer's disease (AD) (Perras et al., 2005; Cummings et al., 2002; Schneider, 2004). Furthermore, it is controversial whether the small effects shown in the RCTs are reliable or due to bias. In 2005 we published a systematic review of all RCTs on cholinesterase inhibitors which came to the conclusion that the scientific basis for a general recommendation of cholinesterase inhibitors in the treatment of AD is questionable because of the methodological shortcomings of the studies (Kaduszkiewicz et al., 2005). Following numerous debates on this topic at congresses and enriched through reviews of the U.K. National Institute for Health and Clinical Excellence (NICE, 2006) and the German Institute for Quality and Efficiency in Health Care (IQWiG, 2007), we will here present our actual view on this controversy. The main part of this article focuses on the methodology of cholinesterase inhibitor trials and on the interpretation of their results. We conclude by discussing briefly the three Cochrane reviews on cholinesterase inhibitors for AD.

The cholinesterase inhibitors (tacrine, donepezil, galantamine and rivastigmine) were the first drugs licensed for mild to moderate Alzheimer's disease (AD). Recently, the use of donepezil has been extended to severe AD. Tacrine was the first to be marketed, which, although beneficial in AD, shows a high incidence of adverse effects and is rarely used. It will not be discussed further. The cholinesterase inhibitors are widely prescribed and continue to be the first line in the treatment of AD. Considering the mode of action of the cholinesterase inhibitors it is not expected that they will alter the course of the disease, but they may help with some of the manifestations of dementia.

Background: The potentially negative consequences associated with providing care to older adults are well documented. Recently, there has been an increasing interest in the positive aspects associated with caregiving. Both aspects are believed to represent a continuum of caregiving experiences. Long-term care (LTC) staff members often report high levels of burnout associated with their work. Whereas several job characteristics and objective indicators of socioeconomic status have been identified as potential predictors of LTC staff caregiving experiences, the role of subjective socioeconomic status (i.e. one's view of one's place in society) has not yet been evaluated.

Methods: A cross-sectional design of 122 LTC staff members. LTC staff completed the Maslach Burnout Inventory and the Positive Aspects of Caregiving questionnaire. They also completed questions about job characteristics (i.e. staff-to-resident ratio, number of hours worked per day, and years of experience working with older adults), objective sociodemographic variables (i.e. level of education, professional affiliation), and subjective socioeconomic indicator (i.e. MacArthur Scale of Subjective Social Status). Hierarchical regression analyses were conducted to identify the unique contribution of job characteristics, objective socioeconomic status, and subjective socioeconomic status to LTC staff caregiving experiences.

Results: Subjective socioeconomic status remained a significant predictor of LTC staff experience even once job characteristics and objective indicators of socioeconomic status were entered into the model. Those who placed themselves higher on the subjective social ladder reported higher levels of positive caregiving experiences and lower levels of burnout.

Conclusions: Building a sense of community identity and improving one's status within the community might result in lower levels of burnout and better caregiving experiences among LTC staff.

Background: Previous assessments of informal care time have tended to consider only the amount of time spent with the patient by the primary informal caregiver; however, in many cases, more than one person is providing care for the patient. We assess total informal care time of people caring for patients with dementia, and estimate the bias that can arise if consideration is not made of the time spent by all participating informal caregivers.

Method: We used an extended version of the questions on informal care time from the Resource Utilization in Dementia (RUD) instrument. Caregivers were asked to state the number of days and the number of hours on a typical day they had assisted the patient in activities of daily living (ADL), instrumental ADL (IADL), and supervision during the last four weeks. Multivariate regression analyses were conducted to identify factors that could account for the amount of informal care time.

Results: 357 informal caregivers took part. Values were missing from only 4.5% of all interviews. On average, the primary informal caregiver cared for the patient 1.5, 2.1 and 1.9 hours per day in ADL, IADL and supervision respectively. Fifty-seven percent of all patients had more than one informal caregiver. Total informal care time was underestimated by about 14% if the time of caregivers other than the primary caregiver was not taken into account. The informal care time was significantly higher if the caregiver was the patient's partner and the patient's health status was lower.

Conclusion: Our results show that most previous studies probably underestimated costs of informal care because the time of informal caregivers other than the primary caregiver was not considered.

Background: Apathy and depression may be strongly associated with executive dysfunction in Alzheimer's disease (AD). The Frontal Assessment Battery (FAB) is an instrument for assessing executive function. The dual task paradigm is also useful for assessing divided attention. However, the association between apathy/depression and these tasks is unclear.

Methods: Both the FAB and the dual task were used to evaluate AD patients. A two-way analysis of variance was then conducted between the FAB and dual task results and the absence versus the presence of depression or the absence versus the presence of apathy.

Results: Of 88 patients with AD, 26 had both apathy and depression, 26 had depression only, 18 had apathy only, and 18 had neither. Total FAB scores and dual task scores differed significantly between the AD patients with depression and those without depression; the scores were also different between those with apathy and those without apathy. Also, a significant interaction between depression and apathy was noted for the total FAB and dual task scores.

Conclusions: The deficits in the total FAB and dual task scores were larger in AD patients with both apathy and depression compared with patients with either apathy or depression alone. AD patients with both symptoms may have greater deficits in frontal lobe function relative to AD patients with either apathy or depression alone.

Background: Matrix metalloproteinases (MMPs) are elevated in the brain tissue of patients with dementia and may play a role in the pathophysiology of dementia. MMP-9 and tissue inhibitors of MMPs (TIMPs) are elevated in postmortem brain tissue of patients with Alzheimer's disease (AD). In a previous study we showed that circulating levels of MMP-9 are elevated in AD patients. The aim of the present study was to examine circulating levels of MMP-1, MMP-2, MMP-9, TIMP-1 and TIMP-2 in the plasma of patients with mild cognitive impairment (MCI), AD, vascular dementia (VaD), dementia with Lewy bodies (DLB) and frontotemporal dementia (FTD), to determine, whether plasma profiles of MMPs and TIMPs differ in various types of dementia.

Methods: Gelatinolytic activity (MMP-2 and MMP-9) was measured in all plasma samples by zymography. Levels of MMP-2, MMP-9, MMP-1 as well as TIMP-1 and TIMP-2 were measured by ELISA.

Results: We found constitutive expression of MMP-1, -2 and -9 as well as TIMP-1 and -2 in all the samples investigated. As shown previously, MMP-9 was significantly elevated in the plasma of AD patients (p = 0.004) as compared to controls and MCI patients. Plasma levels of TIMP-1 were significantly lower in VD samples as compared to all other groups. Levels of TIMP-2 were significantly lower in patients with FTD as compared to AD, VaD and MCI patients. There were no significant changes of MMP-1 and MMP-2 levels in the samples.

Conclusion: These findings suggest that circulating levels of MMP-9, TIMP-1 and TIMP-2 and changes in the MMP/TIMP balance in plasma differ in various types of dementia.

Background: This longitudinal study aims to describe the prevalence and characteristics associated with persistent risk of depression in a group of older, hospitalized patients.

Methods: We examined patients at two time-points: baseline and one month post-discharge from hospital. Patients in this study comprised those who had been admitted to the cardiology unit, with no cognitive impairment, aged 60 years and over, and those who were followed up at both time points (N = 155). Questionnaires administered included risk of depression (Geriatric Depression Scale-15; GDS-15), cognitive impairment (Mini-mental State Examination), social support (7-Item Subjective Social Support Index), co-morbidity (Charlson's Comorbidity Index), sociodemographic variables, physical functioning (Modified Barthel's Index) and clinical variables.

Results: The prevalence of risk of depression (GDS-15 score ≥ 5) among older inpatients at baseline was 34%. At one month post-discharge this had fallen to 17% and this group was identified as those at persistent risk of depression. Factors associated with a risk of persistent depression were: hospitalization within the last six months; length of stay of four days or more; discharge diagnosis of angina; and impaired Subjective Social Support Score.

Conclusion: Depression occurs commonly among older hospitalized patients and may resolve spontaneously. The identification of factors associated with persistent risk of depression can be helpful when looking at which patients may benefit most from screening and treatment for depression after discharge.

Background: No specialized geriatric psychiatry consultation services are available for elderly people in the institutional care system in Turkey. Our aim was to evaluate psychiatric consultations among the residents of three homes for the elderly in a country with a rapidly aging population, and to investigate possible problems regarding psychiatric consultations.

Methods: The residents of three homes for the elderly, which served partially as “care and rehabilitation centers” (equivalent to nursing homes), were chosen for the study. Data on the use of psychiatric services (mainly patient consultations with a visiting psychiatrist) were collected and analyzed.

Results: The percentage of patients in the three homes for the elderly who had psychiatric consultations between 2005 and 2007 was 31.8% (172/540). The main reasons for referral were forgetfulness (61%), depressive symptoms (37.7%), agitation and disruptive behavior (29.6%), and psychotic symptoms (27.9%). Of these patients, 46.5% were diagnosed with dementia, 20.9% with depression, 20.5% with behavioral and psychotic symptoms of dementia, and 18.6 % with primary psychotic disorders such as schizophrenia.

Conclusion: Homes for the elderly in Turkey are not adequate in terms of consultations for psychiatric problems. Integration of these institutions with hospitals and organizing routine consultation visits from the psychiatry units would enhance the mental health of the elderly. Supporting the staff, maintaining good cooperation between them, and organizing educational programs in the field of mental health of the elderly are also required.

Objectives: The aim of the study was to assess the attitudes of clinicians to the diagnostic construct of mild cognitive impairment (MCI), their approach to relaying the diagnosis to patients and families, and recommended treatment and follow-up.

Method: An anonymous questionnaire was sent out to 503 members of the Australian Society for Geriatric Medicine (ASGM) and New Zealand Geriatrics Society (NZGS), of whom 163 replied.

Results: Most responders (83%) had diagnosed MCI. About 70% rated the importance of separating MCI from dementia, or MCI from normal cognition, as 4 or 5 on a scale from 1 (not very important) to 5 (very important). Most responders reported that they would inform their patients and families of a diagnosis of MCI, and used that term. A minority used the term “early Alzheimer's disease,” but 44% of NZGS members used other terms to relay the diagnosis compared to 13% of ASGM members. Follow-up was most often recommended at 6–12 months. Non-pharmacological treatment (such as mental stimulation strategies) was recommended most often, followed by no treatment.

Conclusions: The diagnostic entity of MCI appears to have a general acceptance among those who responded to the survey, and the term has gained use in clinical practice. Most clinicians are recommending follow-up, recognizing the high risk for progression. Treatment recommendations do not favor pharmaceuticals, reflecting the current evidence for lack of effect.

Objective: To examine, in an exploratory analysis, the association between vascular conditions and the occurrence of neuropsychiatric symptoms (NPS) in a population-based sample of incident Alzheimer's disease (AD).

Methods: The sample consisted of 254 participants, identified through two waves of assessment. NPS were assessed using the Neuropsychiatric Inventory. Prior to the onset of AD, data regarding a history of stroke, hypertension, hyperlipidemia, heart attack or coronary artery bypass graft (CABG), and diabetes were recorded. Logistic regression procedures were used to examine the relationship of each vascular condition to individual neuropsychiatric symptoms. Covariates considered were age, gender, education, APOE genotype, dementia severity, and overall health status.

Results: One or more NPS were observed in 51% of participants. Depression was most common (25.8%), followed by apathy (18.6%), and irritability (17.7%). Least common were elation (0.8%), hallucinations (5.6%), and disinhibition (6.0%). Stroke prior to the onset of AD was associated with increased risk of delusions (OR = 4.76, p = 0.02), depression (OR = 3.87, p = 0.03), and apathy (OR = 4.48, p = 0.02). Hypertension was associated with increased risk of delusions (OR = 2.34, p = 0.02), anxiety (OR = 4.10, p = 0.002), and agitation/aggression (OR = 2.82, p = 0.01). No associations were observed between NPS and diabetes, hyperlipidemia, heart attack or CABG, or overall health.

Conclusions: Results suggest that a history of stroke and hypertension increase the risk of specific NPS in patients with AD. These conditions may disrupt neural circuitry in brain areas involved in NPS. Findings may provide an avenue for reduction in occurrence of NPS through the treatment or prevention of vascular risk conditions.

Background: This study aims to establish the incidence rates of Alzheimer's disease (AD) and to understand the relations between illiteracy and AD in the Korean Yonchon survey cohort.

Methods: A community-based, dementia-free cohort of 966 people aged 65 years and older was followed up for an average of 5.4 ± 1.60 years to detect incident AD cases using a two-phase procedure. Age-specific incidence rates were calculated using a person-years approach with Poisson distribution confidence intervals. Data were analyzed using the Cox proportional hazards model to find the hazard ratio of illiteracy.

Results: The participating percentage of the survivors was 86.4% and 74 subjects were diagnosed with AD. Incidence rates per 1000 person-years were 20.99 (95% CI 16.48 to 26.35) for AD. The hazard ratio of illiteracy was 1.78 (95% CI 1.08 to 2.93) adjusted for age, sex, educational level. AD developed more rapidly with aging in the illiterate group than in the literate group.

Conclusions: Illiteracy is associated with a higher risk of AD and the risk increases with age.

The emergence of evidence-based medicine has challenged many conventional ideas about medical research. Instead of focusing just on individual studies, a science of systematic reviews has evolved. The Cochrane Collaboration, still only 15 years old, aims to collate systematically all randomized controlled trials through regularly updated systematic reviews to provide the best current evidence on different therapies. The most recent update has over 3000 reviews and over 1700 more protocols registered. Many expected that methodologically rigorous systematic reviews would bring clarity and agreement on the evidence for each therapy, so at first sight the disagreements between Kaduszkiewicz et al. and Birks seem surprising.

Background: This study was designed to determine the effectiveness of a psychosocial intervention for family caregivers in delaying nursing home placement of individuals with dementia.

Methods: The participants comprised 153 family caregivers of persons with dementia who underwent intervention and 155 family caregivers who did not. The intervention consisted of five weekly counselling sessions and a three-month conversation group. All patients with dementia underwent a standardized assessment of cognitive and functional ability. The degree of burden and the subjective health of family caregivers were assessed. Participation continued until the patient moved to a nursing home or died, or until five years of living at home had passed.

Results: There were significant delays (6 months) in nursing home placement, and a longer time at home for persons with dementia with adult children as caregivers in the intervention group compared to the control group at follow-up (p = 0.004). A greater delay of institutionalization was found where intervention-group caregivers were daughters (p = 0.028). The proportional hazards regression showed factors associated with nursing home placement to be the family caregiver's influence on intervention (OR = 1.55, p = 0.019), caregiver gender (OR = 0.66, p = 0.033) and the patient's severity of dementia (OR = 1.45, p = 0.002).

Conclusion: Family caregiver intervention for adult children was significantly associated with prolonged time to nursing home placement.

Background: Mild cognitive impairment (MCI) may be accompanied by extra pyramidal signs (EPS), which are related to the severity and type of cognitive impairment. We aimed to elucidate further the relationship between MCI and EPS, analyzing the correlation between the severity of EPS and cognitive functions, and the presence of EPS and neuro-psychiatric features.

Methods: Data were obtained from a longitudinal study of 150 MCI outpatients. Participants underwent a clinical assessment including the Unified Parkinson Disease Rating Scale, the Neuropsychiatric Inventory, the Tinetti Scale, and a standardized neuropsychological battery. Mild EPS could be defined as being present (MCI with mild EPS) using a subscale of UPDRS, based on three specific symptoms: bradykinesia, rigidity and tremor.

Results: The two groups, one with mild EPS (24%) and one without EPS (76%), differed in gait abnormalities and presence of extrapyramidal symptoms. Groups did not differ in terms of general cognitive functions evaluated using the Mini-mental State Examination, while subjects with MCI with mild EPS performed significantly worse than those with MCI without EPS in total global score and in non-memory items of the Alzheimer's Disease Assessment Scale. Moreover, severity of EPS was significantly correlated with low performance on executive functions and with high performance on episodic memory. The group with MCI with mild EPS were observed to have a greater prevalence of patients with anxiety, depression, apathy and sleep disturbances than in MCI without EPS.

Conclusion: MCI may be associated with mild parkinsonian signs, the severity of which are related to the severity of cognitive impairment, in particular of non-memory functions, and to a differential pattern of psycho-behavioral symptoms.

Background: The literature on health services (HS) use for mental health problems by community-living seniors with depression is sparse. This study aimed to characterize patterns of HS use for mental health problems by seniors with depressive disorders and symptoms during the previous 12 months.

Method: The study used data from the Canadian Community Health Survey Cycle 1.2: Mental Health and Well-Being (N = 7736). Information was collected on demographic, social, mental, physical and functional variables and HS use for mental health problems. We obtained simple univariate and bivariate descriptions of the data and developed multivariate predictive models for each of the HS utilization variables.

Results: Rates of any HS use for mental health problems ranged from 1.8% for those with no depressive symptoms to 31.1% for those with major depression. Variables predicting increased HS use were: depressive disorder or symptoms, clinically significant distress or impairment, age 65–84, single, post-secondary education, religiousness, disability, co-morbid mental disorder and fewer friends and positive social interactions. Variables predicting HS use among depressed seniors were physical health, psychiatric co-morbidity and activity limitation.

Conclusion: Community-living seniors with major depression, co-morbid major depression and depressive symptoms were more likely to use psychiatrist, family physician, other professional and self-help services for mental health problems but less than a third actually did so.

Background: Practice effects have been widely reported in healthy older adults, but these improvements due to repeat exposure to test materials have been more equivocal in individuals with mild cognitive impairment (MCI).

Methods: The current study examined short-term practice effects in MCI by repeating a brief battery of cognitive tests across one week in 59 older adults with amnestic MCI and 62 intact older adults.

Results: Participants with amnestic MCI showed significantly greater improvements on two delayed recall measures (p < 0.01) compared to intact peers. All other practice effects were comparable between these two groups. Practice effects significantly improved scores in the MCI group so that 49% of them were reclassified as “intact” after one week, whereas the other 51% remained “stable” as MCI. Secondary analyses indicated the MCI-Intact group demonstrated larger practice effects on two memory measures than their peers (p < 0.01).

Conclusions: These results continue to inform us about the nature of memory deficits in MCI, and could have implications for the diagnosis and possible treatment of this amnestic condition.

David Ames has undertaken research with cholinesterase inhibitor drugs supported by Eisai, Janssen, Parke-Davis and Pfizer. He has received honoraria for talks and consultancies and some financial support to enable conference attendance from those four companies and from Novartis, the other pharmaceutical company to market a cholinesterase inhibitor in Australia.

Background: Clinical experience suggests that the work characteristics of staff in residential care may influence the well-being of residents with dementia. However, few studies have explored those anecdotal experiences. The aim of this study was to investigate associations between work characteristics of nursing staff and prevalence of behavioral symptoms among people with dementia in residential care settings.

Methods: The self-report job strain assessment scale was used to measure staff perceptions of their working environment, and the Multi Dimensional Dementia Assessment Scale to measure the occurrence of behavioral symptoms among residents in 40 residential care units for people with dementia.

Results: The findings show that in settings where staff reported high job strain, the prevalence of behavioral symptoms was significantly higher compared to settings where staff reported low job strain. Furthermore, settings characterized by staff having a more positive caring climate had significantly less prevalence of escape, restless and wandering behaviors compared to settings having a less positive caring climate. There was no statistically significant association between staff members' self-reported knowledge in caring for people with dementia and prevalence of behavioral symptoms.

Conclusions: This study provides evidence for the oft-cited clinical experience that the well-being of nursing staff is associated with the well-being of people with dementia in residential care settings.

Background: Too little is currently known about the prevalence of and risk factors for depression and carer strain among informal carers of community-dwelling elderly mentally ill. This study seeks to assess the prevalence of depression, using the Geriatric Depression Scale-15 (GDS-15), the degree of carer burden/strain, and their risk factors among the primary informal carers of patients referred to our community-based old age psychiatry service.

Methods: A cross-sectional study design was used, with the subjects comprising 100 primary informal carers of patients who live at home and were referred to our service. The main carer measures were the GDS-15 and an adapted version of Gilleard's Strain Scale. Patients were assessed the Clifton Assessment Procedure for the Elderly–Survey version, the GDS-15 and the Mini-mental State Examination.

Results: Depression was found in 21% of the carers (a score of 5 or more on the GDS-15). The more problem behaviors identified and the greater the functional impairment of the patient, the higher the strain score deciles and the more likely the carer was to be depressed. Spouses were associated with lower carer strain scores. Patient diagnoses did not affect carer depression or carer strain.

Conclusion: We found high levels of depression in the primary carers of community-dwelling patients attending an old age psychiatric service. The patients' behavior and their cognitive and functional ability conferred greater risk of carer depression or strain than their diagnosis. These risk factors may help identify carers at risk of strain and depression.