Few of our regular readers will fail to note the bold new cover of this issue of International Psychogeriatrics or the subtle changes in internal layout. We have changed publishers and the journal is now produced by Cambridge University Press, of Cambridge UK, an independent academic publisher of high repute and venerable traditions which operates under a unique University of Cambridge charter. We have joined a stable of 170 academic journals whose flagship psychiatric journal (Psychological Medicine) is one of the most respected in the world.

There has been longstanding interest in the relationship of depression to vascular disease and this has received renewed interest since the publication of the “vascular depression” hypothesis by Alexopoulos and colleagues (Alexopoulos et al., 1997). They proposed that cerebrovascular disease (CVD) predisposed, precipitated or perpetuated late-life depression by its impact on frontal-subcortical circuits (FSC). However, whilst several lines of research strongly support this proposal, we still have no useful working criteria for vascular depression, assuming such a nosological entity exists.

As chairman of the International Psychogeriatric Association (IPA)'s Research Awards Committee, it is a pleasure and an honor for me to introduce the winners of the IPA's Eighth Biannual Research Awards in Psychogeriatrics competition. These awards are given for the best submitted research in psychogeriatrics. For the 2003 research awards competition, there were 25 submissions from 15 nations on five continents.

Objective: To develop and validate a simple method for detecting dementia that is valid across cultures, portable and easily administered by primary health care clinicians.

Design: Culture and Health Advisory Groups were used in Stage 1 to develop culturally fair cognitive items. In Stage 2, clinical testing of 42 items was conducted in a multicultural sample of consecutive new referrals to the geriatric medicine outpatient clinic at Liverpool Hospital, Sydney, Australia (n=166). In Stage 3, the predictive accuracy of items was assessed in a random sample of community-dwelling elderly persons stratified by language background and cognitive diagnosis and matched for sex and age (n=90).

Measurements: A research psychologist administered all cognitive items, using interpreters when needed. Each patient was comprehensively assessed by one of three geriatricians, who ordered relevant investigations, and implemented a standardized assessment of cognitive domains. The geriatricians also collected demographic information, and administered other functional and cognitive measures. DSM-IV criteria were used to assign cognitive diagnoses. Item validity and weights were assessed using frequency and logistic regression analyses. Receiver-operating characteristic (ROC) curve analysis was used to determine overall predictive accuracy of the RUDAS and the best cut-point for detecting cognitive impairment.

Results: The 6-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, drawing and body orientation. It appears not to be affected by gender, years of education, differential performance factors and preferred language. The area under the ROC curve for the RUDAS was 0.94 (95% CI 0.87–0.98). At a cut-point of 23 (maximum score of 30), sensitivity and specificity were 89% and 98%, respectively. Inter-rater (0.99) and test-retest (0.98) reliabilities were very high.

Conclusions: The 6-item RUDAS is portable and tests multiple cognitive domains. It is easily interpreted to other languages, and appears to be culturally fair. However, further validation is needed in other settings, and in longitudinal studies to determine its sensitivity to change in cognitive function over time.

Background: To date, no firm conclusions can be reached regarding the effectiveness of reminiscence for dementia. Researchers have emphasized that there is an urgent need for more systematic research in the area.

Objective and Method: A single-blinded, parallel-groups (one intervention, one comparison, and one no-intervention group) randomized controlled trial (RCT) was adopted to investigate whether a specific reminiscence program leads to higher levels of psychosocial well-being in nursing home residents with dementia. The intervention adopted a life-story approach, while the comparison group provided friendly discussions to control for any changes in outcome as a result of social contacts and attention. The Social Engagement Scale (SES) and Well-being/Ill-being Scale (WIB) were the outcome measures used. The outcomes of the groups were examined with reference to the baseline (T0), immediately (T1), and six weeks (T2) after intervention. The final sample had 101 subjects (control group: n=30; comparison group: n=35; intervention group: n=36). Using multivariate analysis with repeated measures, no significant differences in outcome were found between groups at either T1 or T2. Wilcoxon signed rank tests were performed for each group comparing outcomes between T1 and T0, T2 and T1, and T2 and T0. Significant differences were observed in the intervention group when comparing T1 and T0 WIB (p=.014), but not for the other groups.

Conclusion: Although the intervention did not lead to significant differences between the three groups over time, there was a significant improvement in psychosocial well-being for the intervention group.

Background: There is inadequate information regarding the neuropsychiatric aspect of Mild Cognitive Impairment (MCI).

Objective: To determine the neuropsychiatric profile of MCI, and compare this with normal controls and patients with mild Alzheimer's Disease (AD).

Design: Cross-sectional assessment of psychiatric symptoms in subjects that are enrolled in Mayo Clinic's longitudinal study of normal aging, MCI and dementia.

Methods and Participants: The Neuropsychiatric Inventory (NPI) was administered to normal control subjects, MCI subjects and patients with early AD. Individual NPI domain scores and total NPI scores were compared among the three groups after controlling for age, educational status, Dementia Rating Scale (DRS) and Mini-Mental State Examination (MMSE) scores. Statistical analysis was performed by utilizing ANOVA, χ2 and Fisher's exact test.

Results: Data were analyzed on 514 normal controls, 54 MCI subjects, and 87 subjects with mild AD (CDR of 0.5 or 1); females consisted of 60.3%, 53.7% and 57.5%; and, the average ages (SD) were 77.8 (1.95), 79 (4.6), 80.5 (14.6) respectively. ANOVA pair-wise comparison revealed that both MMSE and DRS differences among the three groups were significantly different at (p=0.05). The total NPI scores were significantly different (p=0.0001, F=107.93) among the three groups using ANOVA. Pair-wise comparison of individual behavioral domain of NPI showed statistically significant differences between MCI and normals; and MCI and AD (p=0.001). Group differences on NPI remained after controlling for age and education at p=0.0375 and p=0.0050 respectively.

Conclusion: The neuropsychiatric pattern is reminiscent of the clinical, neuroimaging and neuropsychological profile of MCI. It gives further credence to the view that MCI is indeed the gray zone, with overlap on both ends of the pole.

Objectives: To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of psychotropic medications to these patients.

Methods: 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient.

Results: Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used.

Conclusion: Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.

Background: There is compelling evidence of an inverse relationship between level of education and increased mortality. In contrast to this, one study showed that among subjects with Alzheimer's Disease, those with high education are more than twice as likely to die earlier; however, this result has proven difficult to replicate. We examine the relationship between education and mortality by cognitive status, using a large, nationally representative sample of elderly people.

Patients: A representative sample of 10 263 people, aged 65 or over, from the 10 Canadian provinces, participated in the Canadian Study of Health and Aging in 1991.

Methods: Information about age, gender, education, and an initial screening for cognitive impairment were collected; those who screened positive for cognitive impairment were referred for a complete clinical and neuropsychological examination, from which cognitive status and clinical severity of dementia were assessed. Vital status and date of death were collected at follow-up in 1996. The analysis was conducted using survival analysis.

Results: Cognitive status modifies the relationship between education and mortality. For those with no cognitive impairment, an inverse relationship between education and mortality exists. Elderly people with cognitive impairment but no dementia, or those with dementia, are more likely to die early than the cognitively normal at baseline, but no relationship exists between education and mortality.

Interpretation: These findings do not support previous work that showed a higher risk of mortality among highly educated dementia subjects.

Background: Computerized testing in the elderly has multiple advantages, including increased time-efficiency, a wider range of stimulus options and response forms, and increased psychometric reliability. The French-language ECO (Examen Cognitif par Ordinateur, Ritchie et al., 1993) computerized cognitive battery is investigated in this study.

Objective: The purpose of the study was to yield normative data for an English-language version of the ECO, test the effects of age and education on test scores, to observe individual subtest sensitivity to cognitive impairment, and to examine participants' receptivity to this form of testing.

Method: A sample of 129 community-dwelling elderly with normal cognitive functioning and 56 cognitively impaired older adults living in both independent and supported accommodation were tested using the ECO at either their own residence or an outpatient facility.

Results: Standardized scores for three different age bands are given for both impaired and non-impaired groups. Age and education effects varied between subtests. A discriminant analysis of subtest-sensitivity to group prediction is reported using a stepwise regression model.

Conclusion: The English version of the ECO appears to be a sensitive and practical cognitive battery that is highly acceptable to older people.

Background: Large randomized controlled trials have shown that risperidone reduces the frequency and severity of behavioral and psychological symptoms of dementia (BPSD) in patients with dementia. Since such trials are obliged to use very strict inclusion and exclusion criteria, their information about the efficacy is limited by the criteria used. Thus, the aim of the present study was to investigate the efficacy of risperidone on BPSD in a sample of patients routinely treated by their primary care physicians.

Methods: A total of 938 elderly patients in Austria suffering from BPSD and routinely treated by their primary care physicians were included in this open-label prospective study. Patients received a flexible dose of risperidone, starting with 0.5 mg daily, for at least 6 weeks. Questionnaires were filled in before the start and after 6 weeks of treatment.

Results: Before starting treatment with risperidone, BPSD were severe in 36.6% of the patients, moderate in 49.3%, and mild in 14.1%. The overall efficacy of risperidone was judged as “excellent” by the general practitioners and caregivers in about half the patients. The treatment was judged as “not satisfactory” in only a very small proportion (3.3% and 4.3%, respectively). According to the physicians' judgement, the tolerability of risperidone was “excellent” in 81.5% of the patients and “satisfactory” in 17.8%. The tolerability was “not satisfactory” in only 0.7% and only 7.4% of the patients reported any adverse event.

Discussion: Overall, the results of this survey indicate that risperidone is both efficacious and well tolerated for the treatment of elderly primary care patients with BPSD.