Background: A large proportion of patients with amnestic mild cognitive impairment (MCI) progress to Alzheimer's disease (AD), but the rate of conversion is highly variable, depending on selection and inclusion criteria. In the present prospective study, amnestic MCI criteria were applied in order to enrich the study population with prodromal AD patients.

Methods: A composite CERAD word list learning z-score of −1 was applied as a cut-off for memory performance at baseline. Competing causes of memory impairment other than prodromal AD were actively excluded. A cohort of 88 amnestic MCI patients was included; 75 were available for follow-up.

Results: After a mean delay of 19 months, 44% were found to have converted to AD, corresponding to an annualized conversion rate of 28%. The rate of new diagnoses other than stable MCI or AD was 6%. Baseline neuropsychological variables were not instrumental to predict progression.

Conclusion: Amnestic MCI patients, as identified by the present set of criteria, carry a high risk of median-term progression to AD.

Background: This study aimed to examine the validity and reliability of an Arabic version of the 15-item Geriatric Depression Scale (GDS-15).

Methods: 121 community-dwelling older adults and primary care patients aged 60 and above participated in this study. Older adults with dementia, those with thyroid dysfunction, and hearing or speech impairments were excluded. Test-retest reliability was examined by re-administering the translated GDS-15 to a subset of 38 participants at least seven days after the initial interview.

Results: The Arabic GDS-15 had good psychometric properties, but the best properties were reported for the 7/8 cutoff. Cronbach's α as a measure of internal consistency reliability was high (0.88) and κ ranged from 0.57 to 0.75. The performance of the GDS-15 was equally good for both community-dwelling older adults and those in primary care settings, and for both forms of the GDS (examiner administered vs. self-administered).

Conclusion: The Arabic GDS is a useful measure to assess depression among community-dwelling older adults and primary care patients who do not have dementia. Because of the use of formal Arabic, GDS-15 can be widely used with all Arabic-speaking people.

Background: Many people with dementia exhibit some behavioral or psychological symptoms, e.g. aggressive or aberrant motor behavior, depression or hallucinations, at some time during the course of the disorder. The aim of the present study was to describe the probability of the occurrence of these symptoms of dementia in relation to the level of cognitive impairment.

Methods: 3404 people with cognitive impairment were selected from two large cross-sectional surveys of those in geriatric care settings, conducted in 1982 and 2000 in the county of Västerbotten, Sweden. Symptoms were assessed using the Multi-Dimensional Dementia Assessment Scale (MDDAS), subsumed with a rotated factor analysis, and investigated in relation to level of cognitive impairment, measured using the Gottfries cognitive scale.

Results: The passiveness factor had an almost linear correlation to the level of cognitive impairment (r2 = 0.237). Non-linear correlations, with highest prevalences in middle-stage cognitive impairment, were found for aggressive behavior (r2 = 0.057), wandering behavior (r2 = 0.065), restless behavior (r2 = 0.143), verbally disruptive/attention-seeking behavior (r2 = 0.099), regressive/inappropriate behavior (r2 = 0.058), hallucinatory symptoms (r2 = 0.021) and depressive symptoms (r2 = 0.029).

Conclusion: The relations between the behavioral and psychological symptoms of dementia and level of cognitive impairment were non-linear, with higher prevalence rates in the middle stages of dementia, apart from the symptom of passiveness, which increased almost linearly with the severity of cognitive impairment.

Objective: To review and summarize the currently available data on the use of anticonvulsant mood stabilizers (carbamazepine, valproic acid, gabapentin, lamotrigine, topiramate) in the treatment of behavioral and psychological symptoms of dementia (BPSD); to determine whether these medications can be recommended for routine clinical use.

Methods: Literature search in five databases (PubMed, MEDLINE, EMBASE, PsychINFO and COCHRANE collaboration) and analysis of the randomized controlled double-blinded clinical trials found therein.

Results: A total of seven RCTs were identified (two for carbamazepine and five for valproate). One study showed statistically significant improvement of BPSD in the medication group in comparison to the placebo group; five studies showed no significant differences; one study showed statistically significant worsening of the symptoms in the medication group vs. placebo. The majority of the studies reported significantly more frequent adverse effects in the medication group.

Conclusion: Although clearly beneficial in some patients, anticonvulsant mood stabilizers cannot be recommended for routine use in the treatment of BPSD at the present time.

Background: This study evaluates the predictive effects of different aspects of volunteering (e.g. volunteering status, number of hours, number of years, and type of volunteering activity) on all-cause mortality.

Methods: A seven-year follow-up dataset of a nationally representative sample of Israelis, 60 years and older was used.

Results: As expected, volunteering was associated with a reduced mortality risk even after adjusting for age, gender, education, baseline mental health and physical health, activity level, and social engagement. Those who volunteered for 10 to 14 years had a reduced mortality risk relative to non-volunteers. In addition, those who volunteered privately, not as part of an official organization, also had a reduced mortality risk compared to non-volunteers. The number of hours of volunteering was not a significant predictor of all-cause mortality in the fully adjusted model. In additional sensitivity analyses limited to those who volunteered, none of the various aspects of volunteering was associated with a reduced mortality risk.

Conclusions: Results suggest that not all aspects of volunteering have the same predictive value and that the protective effects of length of volunteering time and type of volunteering are particularly important. However, whether or not volunteering is the most consistent predictor of mortality and whether once a person volunteers the various aspects of volunteering are no longer associated with mortality risk.

Background: Fluctuating hormone levels are known to influence a woman's mood and well-being. This study aimed to determine whether lifetime hormonal markers are associated with late-life depression symptoms among elderly community-dwelling women.

Method: Detailed reproductive histories of 1013 women aged 65 years and over were obtained using questionnaires, and depressive symptoms were assessed using the Centre for Epidemiological Studies Depression Scale. Multivariate logistic regression models were generated to determine whether any lifetime endogenous or exogenous hormonal factors were associated with late-life depression.

Results: The prevalence of depressive symptoms was 17%. Age at menopause was associated with depressive symptoms, but only among women with a lower education level. For these women, an earlier age at menopause increased their risk of late-life depression (linear effect, OR = 0.95, 95%CI: 0.91–0.99). The odds of late-life depression were also increased for women who were past (OR = 1.6, 95%CI: 1.1–2.5), but were not current users. On the other hand, long-term oral contraceptive use (≥10 years) was protective against depression (OR = 0.3, 95%CI: 0.1–0.9). These associations remained significant even after extensive adjustment for a range of potential confounding factors, including sociodemographic factors, mental and physical incapacities, antidepressant use and past depression. The other factors examined – including age at first menses, parity, age at childbirth and surgical menopause – were not associated with late-life depressive symptoms.

Conclusions: Lifetime hormonal factors that are significantly associated with depression symptoms in later life have been identified. Further work is needed to determine how potential hormonal interventions could be used in the treatment of late-life depression in certain subgroups of women.

Background: Inadequate recognition of depression in old age in primary care and the consequences for individuals are now well reported, but little research has been undertaken on its impact on healthcare costs. It is not known whether these costs (i) differ between GP-recognized and -unrecognized depressed individuals, and (ii) differ between these groups and non-depressed individuals.

Methods: 451 primary care patients aged 75+ were interviewed face-to-face regarding depressive symptoms (Geriatric Depression Scale), chronic medical illness (Chronic Disease Score), resource utilization and healthcare costs (questionnaire of service utilization and costs). A general practitioner (GP) questionnaire was used to measure GPs' recognition of depression. Resource utilization was valued in monetary terms using 2004/2005 prices.

Results: Thirty-eight (60%) of the 63 depressed patients were not identified by the GPs. From a societal perspective, mean annual healthcare costs were €5,582 for unrecognized depressed and €4,722 for recognized depressed patients with no significant difference. Healthcare costs of recognized and unrecognized depressed exceeded the healthcare costs of non-depressed patients (€3,648) by 23% and 35% respectively (p < 0.05).

Conclusion: Although mean annual healthcare costs for GP-unrecognized depressed patients exceed the costs of GP-recognized depressed patients in absolute numbers, differences were not found to be statistically significant. Both groups differ from non-depressed individuals regarding their healthcare costs. Results encourage further research into the effect of recognition on healthcare costs of depression in large-scale studies.

Background: The aim of the study was to determine the amount of trauma impact and significant post-traumatic stress symptoms, which can indicate a possible post-traumatic stress disorder (PTSD), in a sample of former German child soldiers of World War II.

Methods: 103 participants were recruited through the press, then administered a modified Post-traumatic Diagnostic Scale (PDS).

Results: Subjects reported a high degree of trauma exposure, with 4.9% reporting significant post-traumatic stress symptoms after WW II, and 1.9% reporting that these symptoms persist to the present.

Conclusion: In line with other studies on child soldiers in actual conflict settings, our data document a high degree of trauma exposure during war. Surprisingly, the prevalence of significant post-traumatic stress symptoms indicating a possible PTSD was low compared to other groups of aging, long-term survivors of war trauma. Despite some limitations our data highlight the need for further studies to identify resilience and coping factors in traumatized child soldiers.

Objective: This cross-sectional study investigated the prevalence of disturbed sleep and the association of disturbed sleep with medical conditions and service use among older adults.

Methods: A sample of 6961 household residents aged 60 and over was recruited from a population-based random sample. Each subject was examined in a face-to-face interview.

Results: The overall prevalence of disturbed sleep was 33.7%, with the condition being more prevalent in women (37.2%) than in men (27.4%). The overall rate of medical consultations was 78%, and higher in those with sleep disturbance (males 73% vs 27%; females 80% vs 20%) compared to persons without disturbed sleep. The overall rate of hospitalizations was 20.2%. In logistic regression analyses, being female, of low income, low education, younger age, with psychiatric morbidity, pneumonia, urinary infection, dermatological problems and/or hypertension were significantly associated with self-reported sleep disturbance. Ethnicity, civil status or outpatient visits in the previous six months and hospitalizations in the previous year were not associated with self-reported sleep disturbance.

Conclusion: Self-reported sleep disturbance was a frequent problem in the study population and was associated with gender, income, education, lower age and medical conditions. There was no association between sleep problems and use of medical services in the surveyed population.

Objective: The relationship of apolipoprotein E (APOE) genotype to lifetime cognitive decline was examined over 22 years in a large community-based population study.

Method: The sample for the present study was derived from follow-up of a probability sample of the adult household residents of East Baltimore. From the Baltimore cohort of the Epidemiologic Catchment Area Study, genotype data were collected on 818 participants at the study's fourth wave between 2003 and 2004. Participants were administered the Mini-mental State Examination (MMSE) at all four study waves. Three tests of verbal learning – immediate recall, delayed recall, and word recognition – were completed at waves 3 and 4. The 659 participants for whom genetic data were available had also completed cognitive testing at all time points. Test scores and changes in these scores were examined by APOE genotype group (x/x or 4/x) in younger and older subcohorts defined by age at wave 4 (< or ≥ age 65).

Results: Cross-sectional wave 4 scores on all four cognitive tasks were lower in APOEε4 carriers when compared to non-carriers. In longitudinal univariate models ε4 carriers in the younger cohort demonstrated a greater annual rate of decline on a delayed recall task and MMSE. After adjusting for covariates only the decline in the delayed recall task was significant.

Conclusion: We report an association between APOE genotype and decline in delayed recall and possibly MMSE over this extended time period limited to younger individuals. The lack of an association between APOE and decline in older individuals is likely to be the result of survival bias. Although a clear association exists between APOE genotype and cognitive decline or dementia in late life, these findings suggest that over the lifespan the relationship between APOE and cognitive decline is more complicated.

Background: Antipsychotics are widely used for the treatment of behavioral and psychological symptoms of dementia (BPSD). In the light of the increased risk of cerebrovascular events, many countries have issued guidelines concerning their use in treating BPSD.

Methods: We carried out an audit of antipsychotic prescribing practice for inpatients with BPSD at a tertiary referral centre using standards derived from two U.K. dementia guidelines. We collated case note and prescription data and interviewed consultant psychiatrists.

Results: Of the 60 patients with dementia 50 (83%) had BPSD; of these, 28 (56%) were receiving antipsychotics. Those prescribed antipsychotics were more likely to have severe BPSD and to be aggressive and/or agitated. Audit of the 28 patients receiving antipsychotics for BPSD showed generally satisfactory results but there was room for improvement in case note documentation of off-label usage, screening for risk factors of cerebrovascular disease, consultation with relatives and use of an appropriate starting dose and slow titration of the antipsychotic.

Conclusion: Audit of the use of antipsychotics for BPSD is important given the increased mortality associated with their use. Simple audit tools as used in this study can inform clinical practice. Even at a tertiary referral centre prescribing practice could be improved.

Background: Rapid response to antidepressant therapy is desirable and may be particularly critical in elderly patients with major depressive disorder (MDD).

Methods: Findings are based on post-hoc analyses from a double-blind trial of elderly patients with MDD ≥ 65 years, randomly assigned 2:1 to duloxetine 60 mg QD (N = 207) or placebo (N = 104) for 8 weeks. Depression and pain measures included the Geriatric Depression Scale (GDS), 17-item Hamilton Depression Scale (HAMD17), CGI-Severity, and Visual Analog Scale (VAS) for overall pain. The time to response and remission for duloxetine compared with placebo was evaluated using Cox proportional hazards (PH) modeling, Kaplan-Meier estimation, and categorical repeated measures analysis.

Results: Significant improvements of estimated HAMD17 response and remission rates for duloxetine started at week 2 (P = 0.022 and P = 0.033, respectively). Time to HAMD17 response and remission were significantly shorter for duloxetine versus placebo (P < 0.001 and P = 0.004, respectively). Placebo-referenced duloxetine hazard ratios (HR) for HAMD17 response and remission were 2.03 (P = 0.002) and 2.01 (P = 0.006), respectively. Results for GDS-based response (HR = 1.54, P = 0.023) and remission (HR = 1.54, P = 0.104) rates were consistent with the HAMD17 findings. Patients ≥75 years (n = 93) responded with similar rapidity to duloxetine compared with those <75 years (n = 199, P > 0.10 for all PH treatment-by-age interactions). The placebo-referenced duloxetine HR for time to 50% reduction in overall pain was 1.75 (P = 0.024) for patients with moderate to severe pain.

Conclusion: Duloxetine demonstrated a faster time to antidepressant response and improvement in self-reported pain as compared with placebo.

Clinical trial registry number for this study: NCT00062673, at www.clinicaltrials.gov.

Background: Cultural factors may influence cross-national variations in elderly suicide rates.

Methods: A cross-national study examining the relationship between elderly suicide rates and elderly dependency ratios was conducted with the a priori unidirectional hypothesis that lower elderly dependency ratios (ratio of people over the age of 65 years to people under the age of 65 years) may imply a greater number of younger people being potentially available to provide support and respect to the elderly and to hold them in high esteem, and this would lead to a reduction in elderly suicide rates. Data on elderly suicide rates, and the total number of elderly and young people were ascertained from the World Health Organization website.

Results: Significant positive correlations were found between the natural logarithm of suicide rates, in both sexes in two elderly age-bands (65–74 years and 75+ years), and the elderly dependency ratio for males, females and both sexes combined.

Conclusions: The impact of elderly dependency ratios on elderly suicide rates may interact with and be modified and mediated through cultural factors. The contribution of cross-national differences in cultural factors on elderly suicide rates require further study by formally measuring cultural factors with validated instruments.

Background: Maintaining continuous pharmacological treatment of patients with dementia is often difficult. In the current study we surveyed the discontinuation of donepezil, a cholinesterase inhibitor, for the treatment of Alzheimer's disease in a Japanese geriatric outpatient clinic in a university hospital.

Methods: Using a retrospective chart review from 1 July 2003 to 30 June 2005, prescriptions of donepezil and the reasons for discontinuing the prescription in a university hospital were determined. The severity of dementia was evaluated by the clinical dementia rating (CDR).

Results: Out of 264 patients, 140 (53.1%) discontinued taking donepezil during the two-year observation period. The mean age of the continued group and the discontinued group did not differ significantly (79.5 ± 6.7, 79.8 ± 6.4, respectively). Kaplan-Meier analysis showed that the patients with more severe cognitive impairment (CDR score = 3) discontinued donepezil earlier and more frequently. The reasons for discontinuation were a change in the doctors treating the patients (n = 71), ineffectiveness (n = 16), gastrointestinal side-effects (n = 11), and others (n = 41). In patients with CDR = 1 or 2, changes of doctors were the most frequent reason for discontinuation. However, in patients with CDR = 3, ineffectiveness of the medication was the major reason for discontinuation.

Conclusion: Donepezil was frequently discontinued, and the rate of discontinuation was higher in patients with advanced dementia.

Background: Apathy is defined as lack of motivation and occurs in a variety of neuropsychological disorders. The Apathy Evaluation Scale (AES) has been shown to be valid and reliable for assessing apathy in depression but the validity and reliability of the Chinese version has never been examined. The aims of the study were to (1) evaluate the validity and reliability of the Chinese version of the AES in late-life depression and (2) evaluate the severity of apathy in late-life depression.

Methods: We translated the AES into Chinese and used a cross-sectional design to evaluate apathy in elderly subjects. Diagnostic and Statistical Manual of Mental Disorders (DSM) -IV criteria and Hamilton Depression Rating Scale (HDRS) were applied for diagnosis and assessment. Three groups of subjects were recruited including one group (n = 31) of patients with major depressive disorder with current depression, the second group (n = 30) with major depressed disorder with remission, and the third group (n = 31) of healthy controls. Convergent validity was tested using four apathy-related items from the HDRS (loss of interest, psychomotor retardation, loss of energy, and loss of insight). Multiple forms of reliability (including internal consistency, test-retest, and interrater) and discriminant validity were examined.

Results: We demonstrated that the internal consistency (coefficient α = 0.90) and test-retest reliability (p < 0.001) were satisfied. Discriminant validity of apathy severity among these three groups was significant. The convergent validity and correlation coefficients based on the four apathy-related items from the HDRS and AES were acceptable.

Conclusion: Apathy is a distinct syndrome which may be treatable when depression is effective managed. Further application of the Chinese version of the AES to study the association of apathy with other neuropsychological symptoms is necessary.

Background: The ability to remember to complete future intentions, prospective memory, often begins to fail in old age. The aim of the present study was to examine the sensitivity of a computer-based procedure using naturalistic stimuli to age-related increases in forgetting under conditions of high (increased visual and auditory noise) or low distraction.

Methods: Participants were tested in a virtual shopping precinct constructed from linked photographs, sounds, and video segments. Groups of 32 older and younger persons completed two concurrent memory tasks while moving along the street. In one task, participants were given errands to complete with an accessible checklist, in the other, they were required to remember to respond to three different targets that appeared repeatedly.

Results: The results confirmed previous findings that older adults have difficulty remembering future intentions, even on a self-paced task using naturalistic stimuli, and showed that this was accentuated in noisy environments.

Conclusions: Older persons have particular difficulty remembering in noisy environments, and results from testing in the clinic may underestimate the practical memory problems experienced by older adults with mild cognitive impairments. The findings provide encouragement for the construction of computer-generated environments to measure functional deficits in cognition.

Background: Few studies have looked at healthcare professionals' knowledge of and attitudes to later life sexuality in both Western and Eastern cultures. Here we examine the attitudes and knowledge of Turkish medical doctors toward sexuality in older people.

Method: Eighty-seven doctors, from various specialties, who were directly involved in the care of older people, were contacted by post and asked to complete the Turkish version of the Aging Sexual Knowledge and Attitudes Scale (ASKAS).

Results: A majority of physicians indicated that they had limited information and knowledge regarding sexual health issues in older people (69%). Although a small percentage (14.5%) reported that they “always” discuss sexuality and sexual problems with older patients, the majority (69%) indicated that they “sometimes” raise questions about sexuality with these patients. A high percentage (81%) stated that they would be helpful and receptive should an elderly patient initiate a discussion about sexual issues. Most participants (77%) thought that the patient's gender was of no importance when taking a sexual history. Overall, the responses to ASKAS showed that physicians had limited knowledge but their attitude was positive toward sexuality in the elderly. Female physicians had less knowledge than males and had more negative attitudes toward sexuality in this age group. Total and knowledge subscale scores of ASKAS showed that older physicians had more knowledge than younger physicians but similar attitudes. A comparison of the knowledge and attitude scores of psychiatrists, surgeons and non-surgeons showed no significant difference among the three groups.

Conclusion: This study identified a low level of awareness of later life sexuality among Turkish medical doctors. These findings identify a need to improve the education and training of doctors at both undergraduate and postgraduate levels to enable them to provide better sexual health care to older people.

Background: Elderly suicide rates may be influenced by mental health service provision.

Methods: A cross-national study examining the hypothesis that the relationship between elderly suicide rates and markers of mental health service provision would be curvilinear (inverted-U shaped curve) and fit the quadratic equation y = a + bx − cx2 (where y is the elderly suicide rate, x is a marker for mental health service provision, and a, b and c are constants) was undertaken by utilizing data from the World Health Organization.

Results: The relationship between the logarithm of suicide rates in both sexes in both the elderly age-bands and the percentage of the total health budget spent on mental health, the total number of psychiatric beds per 10,000 population and the total number of psychiatrists per 10,000 population were curvilinear (inverted U-shaped curve) and fitted the quadratic equation y = a + bx − cx2 with statistical significance.

Conclusions: The direction of the causal relationship could be examined in longitudinal studies, after further improvement in levels of mental health service provision, in individual countries segregated by low and high levels of existing mental health service provision.

Background: Brief cognitive tests represent a first step in the assessment of elderly people referred to outpatient clinics because of cognitive impairment. The aim of this study is to determine sensitivity, specificity and likelihood ratio for a positive result (LR+) for the brief cognitive tests Seven Minute Screen (7MS) and Syndrom Kurztest (SKT) in an outpatient sample of elderly patients with no dementia or mild dementia.

Methods: Ninety-five patients aged 65 years or more from 10 Norwegian geriatric and psychogeriatric outpatient clinics were included in the study. All the subjects had a Mini-mental State Examination score of 22–30. A consensus diagnosis of dementia according to ICD-10 was established by an expert panel that considered data from a standardized assessment protocol blinded for 7MS and SKT results.

Results: Subjects were diagnosed with mild dementia (n = 69) or no dementia (n = 26). Sensitivity for 7MS was 71%, specificity 73% and LR+ was 2.6. Sensitivity for SKT was 65%, specificity 65% and LR+ was 1.9.

Conclusion: Sensitivity, specificity and LR+ for 7MS and SKT were unacceptably low in this outpatient sample.

Background: This study aims to evaluate the prevalence of depressive symptoms and associated factors among elderly hospital inpatients.

Methods: A cross-sectional study evaluated 189 participants using the Geriatric Depression Scale, the Mini-mental State Examination and the Katz and Lawton Index, to assess dependence regarding activities of daily living (ADL).

Results: Most of the participants were women, aged between 60 and 92 years, with low levels of educational attainment and personal income, and non-qualified occupations. The prevalence of depressive symptoms was 56%, but only 3% had a psychiatric diagnosis registered in their medical records. Univariate analysis showed significant associations between depressive symptoms and low educational level and income, marital status, number of hospitalizations in the previous year, cognitive decline, dependence regarding basic and instrumental ADL, and death. After logistic regression, the only variables that remained significantly associated with depression were low educational level, dependence regarding basic ADL, and death.

Conclusions: Depressive symptoms were independently associated with low educational level and dependence regarding basic ADL. Hospitalized elderly people with depressive symptoms were more likely to die. It is essential to diagnose and treat depression properly in this population to minimize its negative impacts.