For too long, too many in science and society alike viewed aging as offering little that was of value. There was a collective illusion of knowledge that aging was characterized by inevitable, unalterable decrements in functioning that led to a dismal destiny in later life. This was a widespread perspective on aging, especially in the scientific community. To the extent that scientists considered aging as a wasteland of scientific opportunity, they had little interest in studying it. By not studying aging, little new was discovered about it, thereby preserving negative assumptions about what later life held for all of us. Both Freud and Piaget, for example, viewed development of the mind as essentially a first quarter of the life-cycle phenomenon – psychologically for Freud, intellectually for Piaget (Freud, 1978; Piaget, 1972).

Professor David Ames, the editor-in-chief of International Psychogeriatrics, has kindly asked some of us who edited the journal at one time or another to write a personal piece. I was asked because I edited the journal longer than anyone else – from 1996 to 2003. I decided in 2003 that I would give up my editorship and my National Health Service (U.K.) consultant's post. It also coincided with my 65th birthday, which was declared by von Bismarck, the nineteenth-century Chancellor of Germany, to be the age of retirement when a pension would be received. The decision was not meant by me to be taken too seriously but it was convenient. My record will not last of course, since David Ames will have completed two terms, which will finish in 2011. The job is like that of the U.S. President, namely, two terms only!

Background: Challenges to wills on the basis of lack of testamentary capacity and/or undue influence are likely to increase over the next generation. Since contemporaneous assessment of testamentary capacity can be a powerful influence on the outcome of such challenges, there will be an associated increase in requests for expert assessment of testamentary capacity. There is a need to provide such potential experts with the knowledge and guidelines necessary to conduct assessments that will be helpful to the judicial system.

Methods: A subcommittee of the International Psychogeriatric Association (IPA) task force on “Testamentary Capacity and Undue Influence” was formed to establish guidelines for contemporaneous assessment of testamentary capacity.

Results: The task-specific criteria for testamentary capacity as outlined by Lord Chief Justice Cockburn in the well-known Banks v. Goodfellow case are described. Additional issues are identified for probing and documentation. This is designed to determine whether the testator can formulate a coherent, rational testamentary plan that connects his/her beliefs, values and relationships with the proposed disposition of assets. Rules of engagement by the expert assessor are defined as well as an approach to the clinical examination for testamentary capacity resulting in a clear and relevant report.

Conclusion: Guidelines for experts who are asked to provide a contemporaneous opinion on testamentary capacity should help to inform disputes resulting from challenges to wills. A consistent clinical approach will help the courts to make their determinations.

Background: While dementia is more common in older people and suicide rates in many countries are higher among the elderly, there is some doubt about the association between these two phenomena.

Methods: A search of the major relevant databases was carried out to examine the evidence for this possible association.

Results: The association between dementia and suicide and also non-fatal self-harm did not appear strong but many studies have significant methodological limitations and there are few studies of suicide or self-harm in vascular, frontotemporal, Lewy body and HIV dementia where such behavior might be expected to be more common. Rates of self-harm may be increased in mild dementia and are higher before than after predictive testing for Huntington's disease. Overall, the risk of suicide in dementia appears to be the same or less than that of the age-matched general population but is increased soon after diagnosis, in patients diagnosed with dementia during hospitalization and in Huntington's disease. Putative risk factors for suicide in dementia include depression, hopelessness, mild cognitive impairment, preserved insight, younger age and failure to respond to anti-dementia drugs. Large, good quality prospective studies are needed to confirm these findings.

Conclusions: Further research should be undertaken to examine how rates of suicide and self-harm change during the course of the illness and vary according to the specific sub-type of dementia.

Background: There is no consensus on the monitoring for rare but potentially serious cardiac adverse events associated with cholinesterase inhibitor drugs in the treatment of dementia. Different protocols have been proposed, with and without ECG examination. We surveyed an urban old age psychiatry service to investigate the variables that may influence the implementation of such protocols.

Methods: Case notes of 45 consecutive patients assessed for dementia were scrutinized, to establish how many underwent an ECG or other cardiac examination prior to drug treatments. Data were collected on demographics, medical conditions and drug treatments. Patient files were searched for indications of investigations and any outcomes.

Results: Half of all patients treated with a cholinesterase inhibitor (11/22) had an ECG before treatment. In five cases no pulse or cardiac symptoms were recorded in the absence of an ECG. Medical history, findings on examination, seniority of the clinician, and patient cooperation all may have influenced whether patients had an ECG. In three cases treatment was not prescribed due to concerns over cardiac effects, and with five ECGs new diagnoses were made. A protocol based on pulse monitoring would only have indicated ECGs in two out of 22 cases.

Conclusions: Several factors may influence decisions on cardiac monitoring. Fewer ECGs could be done if only pulse and cardiac symptoms were monitored before cholinesterase inhibitor prescription, but new cardiac diagnoses might then be missed. Protocols can be devised to incorporate both cardiac investigation and cholinesterase inhibitor monitoring.

Background: A careful characterization of behavioral abnormalities in corticobasal degeneration syndrome (CBDS) and progressive supranuclear palsy (PSP) by reliable tools is still lacking. Literature data provided evidence of the usefulness of the Frontal Behavioral Inventory (FBI) to operationalize such disturbances, particularly in the frontotemporal lobar degeneration spectrum. The study aimed to evaluate the frequency and pattern of presentation of behavioral disturbances in a large sample of CBDS and PSP patients by FBI.

Methods: Sixty-eight CBDS and 57 PSP patients entered the study and underwent a standardized clinical and neuropsychological battery, and a structural brain imaging study. Behavioral disturbances were carefully analyzed by FBI.

Results: FBI scores were relatively low in both groups, being 6.7 ± 8.2 and 5.6 ± 6.1 in CBDS and PSP, respectively. Comparison of the behavioral profile between CBDS and PSP patients showed significant differences in apathy were more frequent in the latter (57.9% vs. 33.8%, P = 0.007), and the presence of alien hand/apraxia more frequent in the former group 39.7% vs. 10.5%, P = 0.001). Apathy correlated neither with age nor with motor disturbances as measured by UPDRS-III. Overall, the most frequent behavioral abnormalities present in both groups (>25%) were aspontaneity and logopenia. Aphasia (27.9%) and irritability (35.3%) were more frequent in CBDS compared to PSP, even if not statistically different.

Discussion: The present study has provided measures of behavioral disturbances in a population of PSP and CBDS patients, and further confirms the usefulness of the FBI scale.

Background: When a person has dementia, non-cognitive behaviors and symptoms might constitute a greater problem than the cognitive decline itself. Male or female sex might be a predisposing factor for certain types of behavior disturbances and symptoms. The aim of the present analysis was to explore the correlation between sex and the prevalence of behavioral and psychological symptoms of dementia.

Method: A total of 3395 people with cognitive impairment (1056 men and 2339 women) 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), and prevalence was compared using multivariate logistic regression. Drug data were obtained from prescription records.

Results: For 17 out of 39 behaviors and symptoms, the prevalence differed significantly between men and women. Men more often exhibited aggressive behavior and regressive behaviors, and women more often exhibited depressive symptoms. There were no sex differences for passiveness and hallucinations. The prevalence of antipsychotic drug use was higher among men (35.5% compared to 28.9%, p < 0.001) and antidepressant drug use higher among women (30.1% compared to 25.6%, p = 0.006). The prevalence of use of anxiolytics, hypnotics and sedatives did not differ.

Conclusion: There are some differences in the prevalence of behavioral and psychological symptoms of dementia between men and women. These different symptom profiles might possibly explain some of the differences found in the pharmacological treatment of men and women with a dementia disorder.

Background: There are limited cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD). The aim of the present study was to increase understanding of the effects of culture on BPSD by comparing the rates of BPSD in nursing home residents across three residential facility types: (1) mainstream nursing homes in Sydney, (2) ethno-specific Chinese nursing homes in Sydney, and (3) a long-term high care facility in Shanghai known as a dementia hospital.

Methods: 149 residents and their caregivers voluntarily participated in this study. The rates and levels of BPSD were assessed by interviewing staff with the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Clinical interviews using the Mini-mental State Examination (MMSE) and Global Deterioration Scale (GDS) were conducted with residents to assess dementia severity.

Results: The mean NPI-NH total score for the sample was 28.5 (SD = 17.2) with no significant differences across the three facility types. Comparison of NPI-NH subscales showed residents from the ethno-specific Chinese facilities had lower rates of hallucinations than Shanghai residents (p = 0.003), but no differences from those in mainstream facilities. Shanghai residents had lower frequencies of disinhibition and irritability than ethno-specific Chinese residents (p = 0.003, p = 0.004 respectively), but no differences with mainstream residents.

Conclusion: The prevalence of BPSD does not differ among nursing home populations of different cultural backgrounds. Longitudinal community studies among different cultural groups would better elucidate the effects of culture on BPSD at different stages of dementia.

Background: Neuropsychiatric symptoms in dementia patients are common and are often treated with psychotropic drugs. The aim of this study was to determine the prevalence and correlates of psychotropic drug use in Dutch nursing home patients with dementia.

Methods: Psychotropic drug use of 1322 patients on 59 dementia special care units (SCUs) in 25 nursing homes was registered. Drugs were categorized according to the Anatomical Therapeutical Chemical classification (ATC). The influence of age, gender, dementia stage measured by the Global Deterioration Scale (GDS), and type of neuropsychiatric symptoms on psychotropic drug use was analyzed using binomial logistic regression analysis.

Results: 63% of the patients used at least one psychotropic drug. Psychotropics in general and antipsychotics in particular were most frequently prescribed in GDS stage 6, and in patients aged between 65 and 75 years. Psychotropics in general were positively associated with depression, night-time behavior and agitation. Antipsychotic drug use was positively associated with psychosis, agitation and night-time behavior and was negatively associated with apathy. Anxiolytics were associated with age, psychosis, agitation and night-time behavior. Antidepressants were most frequently prescribed in GDS stage 6 and associated with female gender, agitation and depression. Sedatives were only associated with night-time behavior.

Conclusion: Nursing home patients with dementia have a high prevalence of psychotropic drug use. In particular, the association with neuropsychiatric symptoms raises questions of efficacy of these drugs and the risk of chronic use.

Background: The role of technology to facilitate independent living for people with dementia is not fully realized, with initial attempts (e.g. tracking devices) being considered unacceptable from a practical and ethical perspective. The aim of this study is to create acceptable and effective prototype technologies to facilitate independence for people with dementia through a user-centered design process involving them and their carers.

Method: The study comprised a three-stage participatory design process: scoping stage (five focus groups, 10 people with dementia and 11 carers); participatory design stage (five workshops, 22 participants) and prototype development stage (four meetings with two people with dementia and one carer). Focus groups and workshops were digitally recorded, fully transcribed and subjected to constant comparative analysis.

Results: People with mild to moderate dementia enjoy a variety of activities both on their own and with their families; however, concerns included getting lost, a loss of confidence with curtailment of usual activities, and carer anxiety. Existing technologies (mobile phones) were used intermittently. Participants felt strongly that future devices should be disguised and be integrated easily into their daily routines. Suggested areas for functional improvement included two-way communications, flexibility of function as the illness progresses, and something to “guide” them home when out walking or driving. Attention should also be focused on minimizing the size, weight and visibility of devices to reduce stigmatization.

Conclusion: Prototypes for two devices (armband and electronic notepad) were developed. The study showed that involving people with dementia in the process of participatory design is feasible and could lead to devices which are more acceptable and relevant to their needs.

Background: The differential outcomes procedure (DOP) has proved useful to improve discrimination learning in both animals and humans. Here we adapted DOP to assess its utility to overcome the memory loss commonly associated with normal aging.

Methods: In a delayed matching-to-sample task, subjects were exposed to a man's face, and after a delay, they were required to decide if the previously seen face was within a set of six men's faces. For half the subjects, each sample face was paired with its own outcome (differential outcomes condition); outcomes were randomly arranged for the remaining half of subjects (non-differential condition). Either short (5 second) or long (30 second) delays were interposed between the sample and the comparison stimuli.

Results: Results showed that relative to younger adults, older adults' performance decreased with the longer delay. However, the use of differential outcomes was able to reverse the detrimental effect of the increased delay in the elderly group, raising their performance to the level shown by younger adults.

Conclusions: These findings demonstrate, for the first time, that DOP can help elderly people overcome their memory limitations, and they draw attention to the potential of this procedure as a therapeutic technique.

Background: Dementia and visual impairment are among the most common medical conditions in later life. Almost nothing is known about the experiences and needs of older adults with both conditions.

Method: In this qualitative study using in-depth individual interviews, multiple perspectives were sought through a case-study approach. Fifty-two interviews were conducted: 17 with older adults with visual impairment and dementia, 17 with family caregivers, and 18 with care professionals.

Results: Impaired memory and a lack of visual cues created profound disorientation and distress, which could be manifested in disruptive behavior. Visual hallucinations compounded older adults' disorientation, and caregivers were uncertain about how to manage them. Visual impairments reduced the ability of older adults to perform certain activities safely, while dementia impaired their ability to assess the risks accurately. Concerns about safety prompted family members to limit their relatives' activities even in early stages of dementia. Low-vision services perceived themselves to be ill equipped to manage dementia-related needs, while visual needs were accorded a low priority by dementia services. A lack of joint working by the two services led to an overcautious approach.

Conclusions: The research identified considerable unmet needs and opportunities to improve care. The provision of clear verbal communication and optimized visual inputs is likely to reduce disorientation, distress and agitated behavior, while one-to-one contact is needed to overcome feelings of isolation. Family caregivers require additional respite services and advice on managing hallucinations. Increased sharing of information and skills between mental health and low-vision professionals would help maximize older adults' independence.

The authors regret that they omitted to include an acknowledgment of financial support in the original publication. The acknowledgment should have read:

This work was funded by a grant from the Thomas Pocklington Trust.

Background: Eating problems occur frequently in patients with dementia, and almost half of all patients with Parkinson's disease have such problems. It has therefore been assumed that eating problems are also common in patients with dementia with Lewy bodies (DLB). However, few systematic studies have investigated eating problems in DLB patients. The aim of this study was to clarify the frequency and characteristics of eating problems in patients with DLB.

Methods: We examined 29 consecutive patients with DLB and 33 with Alzheimer's disease (AD) in terms of age, sex, education, Mini-mental State Examination, clinical dementia rating (CDR), neuropsychiatric inventory (NPI), Unified Parkinson disease rating scale (UPDRS), fluctuations in cognition, and usage of neuroleptic drugs / antiparkinsonian drugs. We employed a comprehensive questionnaire comprising 40 items and compared the scores between the two groups.

Results: DLB patients showed significantly higher scores than AD patients for “difficulty in swallowing foods,” “difficulty in swallowing liquids,” “coughing or choking when swallowing,” “taking a long time to swallow,” “suffering from sputum,” “loss of appetite,” “need watching or help,” and “constipation”. Only the UPDRS score significantly affected the scores for “difficulty in swallowing foods,” “taking a long time to swallow” and “needs watching or help” score, whereas only the NPI score affected the score for “loss of appetite.” The scores for UPDRS, NPI and CDR significantly affected the scores for “difficulty in swallowing liquids.” No significant independent variables affected the scores for “coughing or choking when swallowing,” “suffering from sputum” and “constipation.”

Conclusion: Although DLB patients show many eating problems, the causes of each problem vary, and the severity of dementia or Parkinsonism is not the only determinant.

Objective: The study aimed to assess the clinical utility of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) in patients referred to memory clinics, alone and in combination with the Addenbrooke's Cognitive Examination-Revised (ACE-R) and the Mini-mental State Examination (MMSE).

Methods: This pragmatic prospective study was based on consecutive referrals attending with an informant (n = 144) to two memory clinics over a 12-month period. Patients were diagnosed using standard clinical diagnostic criteria for dementia (DSM-IV) as gold standard (dementia prevalence = 59%). The IQCODE was administered to informants, and the ACE-R and/or MMSE to most patients.

Results: The IQCODE proved acceptable to informants, and was quick and easy to use. Using traditional parameters of diagnostic utility (sensitivity, specificity, positive predictive value, likelihood ratios), the performance of the IQCODE at optimal test accuracy was highly sensitive (0.86) for the diagnosis of dementia but specificity was poor (0.39) with suboptimal positive predictive value (0.67) and small or unimportant likelihood ratios. Overall diagnostic accuracy based on area under the receiver operating characteristic (ROC) curve was 0.71. Combining the IQCODE with either ACE-R or MMSE greatly improved accuracy, specificity and positive predictive value when the tests were used in series, but not when used in parallel.

Conclusion: In a memory clinic based population, the IQCODE proved sensitive for the diagnosis of dementia but overall diagnostic accuracy was suboptimal. Combining the IQCODE in series with the ACE-R or MMSE greatly improved diagnostic utility.

Background: Dementia screening in elderly people with low education can be difficult to implement. For these subjects, informant reports using the long (L) (26 items) and short (C) (16 items) versions of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) can be useful. The objective of the present study was to investigate the performance of Brazilian versions of the IQCODE L, S and a new short version (SBr) (15 items) in comparison with the Mini-mental State Examination (MMSE) for dementia screening in elderly people with low education.

Methods: Thirty-four patients with mild to moderate dementia, diagnosed according to ICD-10 criteria, and 57 controls were evaluated and divided into three groups based on their socioeconomic status and level of education. Patients were evaluated using the MMSE and the informants were interviewed using the IQCODE by interviewers blind to the clinical diagnosis.

Results: Education was correlated with MMSE results (r = 0.280, p = 0.031), but not with the versions of the IQCODE. The performance of the instruments, evaluated by the ROC curves, was very similar, with good internal consistency (Cronbach's α = 0.97). MMSE correctly classified 85.7% of the subjects while the three IQCODE versions (L, S and SBr) correctly classified 91.2% of the subjects.

Conclusions: The long, short and the new short Brazilian IQCODE versions can be useful as a screening tool for mild and moderate patients with dementia in Brazil. The IQCODE is not biased by schooling, and it seems to be an adequate instrument for samples with low levels of education.

Background: Many screening instruments for the diagnosis of dementia are not education and culture fair. In addition, despite good sensitivity and specificity, they result in unacceptable levels of false positives when used in the community. This study aimed to develop appropriate instruments for populations with low literacy and to consider strategies to reduce the false positive rates in low prevalence settings.

Methods: Activities of daily living, which are not influenced by education and culture, were used to develop a patient screen and an informant version to identify people with dementia. The instruments were validated in the hospital and in the community setting against the standards of DSM-IV and the education-adjusted 10/66 Dementia Research Group diagnosis of dementia.

Results: The instruments were administered to 90 patients attending a hospital and 101 subjects living in the community in Vellore, South India. The psychometric properties and inter-rater reliability of these screening instruments were good. While the sensitivity and specificity of the patient screen and the informant version were good their false positive rates were high in the community setting. However, the false positive rates reduced when these instruments were used in combination.

Conclusion: The patient screen and the informant version are short culture- and education-fair instruments. They reduce false positive rates, when used in combination in the community.

Background: To date, no single instrument has proved to be adequate for screening for Alzheimer's dementia (AD). The aim of this study was to identify a combination of instruments which were highly sensitive for screening late onset AD.

Methods: Subjects were drawn from the Vienna TransDanube Aging (VITA) study. This is an interdisciplinary, longitudinal community-based cohort study of the 21st and 22nd district of Vienna (Austria). Data refer to the cohort of 478 individuals at age 78 who took part in the first follow-up investigation of the VITA study. The psychometric instruments which were investigated were: the Ten-Point Clock Test, the Human-Figure Drawing Test, a Delayed Selective Reminding Test, Naming, the Trail Making Test-B, and Verbal Fluency. Further instruments were the Pocket Smell Test, and Subjective Memory Complaints. Data were analyzed using logistic regression analyses and cross validation.

Results: A combination of the Delayed Selective Reminding Test and Verbal Fluency was best for screening AD (R2 = 0.38, main model). An area under the ROC curve of 0.829 was reached. This model discriminated between subjects with incident AD and subjects who did not have incident AD with a sensitivity of 91% and a specificity of 56%.

Conclusion: The combination of an episodic memory test and a test of verbal fluency was an effective way of screening for AD.

Objective: The purpose of the present study was to investigate the influence that education and depression have on the performance of elderly people in neuropsychological tests.

Methods: The study was conducted at the Institute of Psychiatry, University of São Paulo School of Medicine, Hospital das Clínicas. All of the individuals evaluated were aged 60 or older. The study sample consisted of 59 outpatients with depressive disorders and 51 healthy controls. We stratified the sample by level of education: low = 1–4 years of schooling; high = 5 or more years of schooling. Evaluations consisted of psychiatric assessment, cognitive assessment, laboratory tests and cerebral magnetic resonance imaging.

Results: We found that level of education influenced all the measures of cognitive domains investigated (intellectual efficiency, processing speed, attention, executive function and memory) except the Digit Span Forward and Fuld Object Memory Evaluation (immediate and delayed recall), whereas depressive symptoms influenced some measures of memory, attention, executive function and processing speed. Although the combination of a low level of education and depression had a significant negative influence on Stroop Test part B, Trail Making Test part B and Logical Memory (immediate recall), we found no other significant effects of the interaction between level of education and depression.

Conclusion: The results of this study underscore the importance of considering the level of education in the analysis of cognitive performance in depressed elderly patients, as well as the relevance of developing new cognitive function tests in which level of education has a reduced impact on the results.