Changes are afoot in the editorial office. I took early retirement from my tenured professorship at Saint Louis University last summer and have returned to the UK, my ancestral home, where I am enjoying reacquainting myself with the culture. Hence, the Deputy Editor, Rob Howard, and I are virtual neighbors.

This special issue of International Psychogeriatrics, “Behavioral and Psychological Symptoms of Dementia: A Clinical and Research Update,” contains the proceedings of a conference held in Lansdowne, Virginia, May 11–13, 1999. It is a sequel to a previous issue that was based on the first international Consensus Conference on Behavioral Disturbances of Dementia (Lansdowne, Virginia, March 31–April 2, 1996). The rationale for the second conference was the growing interest in the symptoms of dementia (e.g., physical aggression, delusions, wandering) that result in premature institutionalization, emotional suffering for patients and caregivers, increased financial costs, and excess disability.

From the title, you may be wondering whether this is another one of those esoteric, unintelligible statistics articles. Or whether the author is another pedantic statistician telling you how much you don't know. I hope that you will find that neither of these fears applies. There are no formulas, derivations, or complex figures here. And I am no “statistician,” at least not in the formal sense, although I do teach statistics. Rather, the focus of this article is to identify and explain, for the clinician consumer of the literature, four basic but often overlooked issues in statistics (as practiced in today's medical and social science journals). Although it is true that most clinicians are misinformed about things statistical (Wulff et al., 1987), it is also true that most academic psychologists and physician researchers—and a surprising number of statisticians—are too (Cohen, 1994; Falk & Greenbaum, 1995; Goodman, 1999a; Oakes, 1986).

There is probably no single reason that scientific authors choose a particular journal for the publication of their research papers. Most of us will have a feeling for the importance or otherwise of our work as we prepare it for submission and will want it to appear in the most prestigious and authoritative journal that will take it. Alternatively, we might want to reach a particular specialist audience because sometimes it is highly satisfying to know that your work has at least been read—even if it hasn't been cited! But why should you send your manuscripts for publication in International Psychogeriatrics rather than in one of the large number of competitor journals that have sprung up in the field in recent years? Here are four good reasons.

One of the pleasures of aging is observing the young: the intelligence, activity, curiosity, and imagination. When the young follow in one's footsteps, that is even better. It makes what we do seem important! This applies to our junior colleagues as well as to one's children.

DIAGNOSIS AND ASSESSMENT

Behavioral and psychological symptoms of dementia (BPSD) can be defined as “a term used to describe a heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology.” The basis of the diagnosis of individual components that make up BPSD revolves around a clinical interview, direct observation of the person with dementia, or a proxy report from a carer or other observer. The three approaches often need to be combined, and some assessment scales rely more on one approach than on another. The key to an accurate diagnosis of BPSD and its effective management lies in a careful assessment of the person with dementia, including carer input.

In recent years, pain control has become a topic of increased interest in the United States. Although the interest originated in professional societies (the American Pain Society has called for pain to be treated as a “fifth vital sign”), regulatory agencies have now picked up on the issue. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), probably the most important of the regulatory agencies, has established standards for pain assessment to be implemented by the upcoming year (JCAHO, 2000).

It is both an honor and a privilege to introduce the winners of the sixth biennial IPA Research Awards in Psychogeriatrics, sponsored by Bayer AG. On behalf of IPA and the entire psychogeriatric community, I want to thank Bayer for their very generous support of these awards since their inception in 1989.

In the 12 years of its existence, International Psychogeriatrics has never presented an editorial by its publisher. It seems fitting to write this editorial at this particular time because the year 2000 marks Springer's 50th anniversary in business. Bernhard Springer founded our publishing company in 1950, in New York. I became its owner and president after my husband's death in 1970.

Much has been learned since the International Psychogeriatric Association's initial consensus conference on behavioral and psychological symptoms of dementia (BPSD) in 1996. In this introduction to the 1999 conference proceedings, I review what we have learned, identify some remaining gaps in the knowledge base, and describe new areas for research and program development.

Background: “Vascular depression” has recently been proposed. It is characterized by magnetic resonance imaging (MRI) T2-weighted subcortical lesions, a late onset of first episode of depression, and reduced heritability; a cerebrovascular etiology is suggested. The validity of “vascular depression” might be strengthened if an association was found between the subcortical lesions used to define it and particular depressive symptoms. Methods: A blinded cross-sectional examination of DSM-III-R depressive symptoms (American Psychiatric Association, 1987) and MRI T2-weighted subcortical lesions in 44 patients with late-life depression. Results: Many associations were found; however, because of multiple comparisons, their significance is viewed with caution. The most robust finding was that psychomotor retardation was independently related to total white-matter score. The odds of showing psychomotor retardation was increased 1.9 times for every point increase in severity of white-matter change. Conclusion: In late-life depression the clinical expression of the depression is influenced by the pattern of MRI T2-weighted subcorticallesions. This gives some validity to the concept of an MRI-defined “vascular” subtype of late-life depression and strengthens the argument for including neuroimaging in the classification of late-life depression.

Background: Religion has been found to be important in the lives of many elderly people, but it has been claimed that psychiatrists ‘neglect’ the religious issues of their patients. This study examines the question: Do psychogeriatricians ‘neglect’ religion in the assessment and treatment of their patients? Method: A sample of 207 psychiatrists with an interest in psychogeriatrics was surveyed using a 14-item questionnaire. Items addressed attitudes and behaviors of psychiatrists towards religion in relation to their clinical practice. Results: Of the 143 (69%) who responded, 43% have no religious affiliation and only 25% participate at least monthly in organized religion. Nevertheless, 85% think that there are links between religion and mental health, and only one respondent stated that psychiatrists should never concern themselves with the religious issues of their patients. A total of 34%, however, had never referred a patient to a pastoral counselor. Training in religious issues is lacking. Conclusions: Psychogeriatricians think that religion is relevant in the assessment and treatment of elderly patients. In view of the lack of training in religious issues, revisions to the psychiatric training curriculum would be appropriate. This would promote dialogue between psychiatrists and religious caregivers.

We used data from a 4-year prospective study of 2,558 primary care patients age 65 and older in a large staff model health maintenance organization to examine the association of clinically significant depressive symptoms and eight other chronic medical conditions with quality adjusted life years (QALYs). We developed linear regression models to examine the association of clinically significant depressive symptoms as defined by a score of 16 or greater on the Center for Epidemiological Studies Depression Scale and eight common chronic medical disorders at baseline with QALYs over the 4-year study period. Estimates of QALYs were derived from Quality of Well-Being Scale scores at baseline, at 2-year follow-up, and at 4-year follow-up. Individuals with clinically significant depressive symptoms at baseline had significantly lower QALYs over the 4-year study period than nondepressed subjects, even after adjusting for differences in age, gender, and the eight other chronic medical conditions. In terms of the entire study population, only arthritis and heart disease were more strongly associated with QALYs than depression.

The purpose of the study was to investigate the natural history of insomnia and its association with depression and mortality. In 1983, 1,870 randomly selected subjects aged 45–65 years answered a questionnaire on sleep and health. Of the 1,604 survivors in 1995, 1,244 (77.6%) answered a new questionnaire with almost identical questions. Mortality data were collected for the 266 subjects that had died during the follow-up period. Chronic insomnia was reported by 36.0% of women and 25.4% of men (χ2 = 9.7; p < .01). About 75% of subjects with insomnia at baseline continued to have insomnia at follow-up. Insomnia in women predicted subsequent depression (odds ratio [OR] = 4.1; 95% confidence interval [CI] 2.1–7.2) but was not related to mortality. In men, insomnia predicted mortality (OR = 1.7; 95% CI 1.2–2.3), but after adjustment for an array of possible risk factors, this association was no longer significant. Men with depression at baseline had an adjusted total death rate that was 1.9 times higher than in the nondepressed men (95% CI: 1.2–3.0).

Background: Aggressive behavior is common in nursing homes for the elderly. It causes distress to carers and can lead to hospitalization, overmedication, and physical restraint. Method: A 6-month prospective study examining the characteristics of aggressive subjects in 11 nursing homes in Melbourne using validated, reliable instruments. Results: During the study, 121 and 143 subjects were rated aggressive on the Rating Scale for Aggressive Behavior in the Elderly and the Staff Observation Aggression Scale, respectively. Aggressive behavior was associated with younger age, men, subsequent mortality, and prescription of psychotropic drugs including neuroleptics, antidepressants, and benzodiazepines. Conclusions: Educational programs in the use of psychotropic drugs directed at staff involved in the care of nursing home residents may be of value because these drugs have modest efficacy, have significant side effects, and may simply sedate the patient rather than treat aggressive behavior.

Objective: To validate a shorter version of the Geriatric Depression Scale (GDS) for older, visually impaired patients. Participants: Subjects were 70 visually impaired adults over age 65 who were presenting for services at a low vision clinic. Method: Subjects were interviewed by a geriatric nurse practitioner. A structured clinical interview was used to ascertain major depression, and the 15-item GDS was used to assess depressive symptoms. A multiple logistic regression was performed in which the dependent variable was clinical diagnosis of major depression and the independent variables were the 15 GDS items. Four items were significant, and were used to form the GDS-Abbreviated (GDS-A) scale. Sensitivity and specificity analyses were performed on various combinations of these four items to generate an effective cutoff score. Results: Endorsing any two or more of the following four items—(a) dissatisfied with life, (b) feeling helpless, (c) reporting problems with memory, and (d)lost activities and interests—yielded the best results with a sensitivity of .71 and a specificity of .88. This GDS-A cutoff score better differentiates depressed from nondepressed individuals than the cutoff score of 5 that is recommended for the GDS-15. Conclusion: The GDS-A's short format and strong discriminating ability make it an effective convenient tool for screening visually impaired, older patients for depression.

In traditional medical use, a categorical diagnosis conveys essential (although stereotypic) information about the signs and symptoms of a disease, its treatment, and its prognosis. Its utility derives from its generalizability. However, many of the shortcomings of categorical classification also reflect these same qualities. Diagnoses too often fail to capture important qualities of a disorder or do not sufficiently characterize a patient's particular symptoms. Recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which have emphasized highly specific entry criteria to establish psychiatric conditions in a more homogeneous fashion, have sometimes resulted in enhanced reliability at the cost of diminished validity. The variability of psychiatric disorders often defies attempts to create strictly defined clusters amenable to syndrome classifications.

This was an epidemiological study funded by the Indian Council of Medical Research and conducted in a representative rural geographical area in northern India. The study aimed to determine the pattern of psychiatric morbidity in those aged 60 years or above and to ascertain the causative/contributory role of biosociodemographic factors, if any. Three groups of subjects formed the sample: the geriatric psychiatrically ill and non-ill and the nongeriatric psychiatrically ill. The prevalence of psychiatric morbidity was found to be much higher in the geriatric group (43.32%) than in the nongeriatric group (4.66%). The psychiatric morbidity pattern consisted of neurotic depression, manic-depressive psychosis depression, and anxiety state in descending order of frequency. Socially, economically, and educationally disadvantaged subjects were found to be more psychiatrically ill. The data indicate that by the year 2000, there will be about 28 million psychiatrically ill geriatric persons in the country requiring the attention of health policy planners. The implications of these findings in light of the available services for psychiatrically ill geriatric persons have been discussed and future directions identified.

Considerable burden is reported by informal caregivers of older individuals with cognitive impairment. Significant progress in the understanding of determinants of this burden has been achieved. However, further progress could be attained if we considered important methodological issues that may have limited our understanding of caregiver burden. These issues include subgroups of care recipients and caregivers, measurement issues, research design, and statistical techniques. Fifty-three studies published between 1980 and 1997 (inclusive) that focused on caregiver burden were abstracted to determine the extent to which the methodological issues discussed above were considered. Overall, we found considerable variability among the studies surveyed. Further understanding of the caregiving process and reductions in caregiver burden will depend on the attention to methodological issues and understanding of burden across the whole caregiving career.