Anxiety has reported prevalence rates between 38 and 72% among people with dementia. It has a negative impact on cognitive impairment and is associated with agitation and poor quality of life. The presence of excessive anxiety can be difficult to establish in people with dementia, especially when expressive or receptive speech is impaired. Unfortunately, there is a lack of research on the treatment of anxiety in dementia, and also on the wider issue of the management of anxiety disorders in old age. We explore the prevalence, presentation and diagnosis of anxiety in dementia and discuss the therapeutic options available.

Man can change and go on changing as long as he lives (Horney, 1942)

Both antidepressants and psychological treatments are effective in the management of late-life depression. Nevertheless, there remains a considerable challenge to improve the prognosis for depression in older people. Endlessly increasing the range of antidepressants does not seem to be the answer, so attention is turning to new combinations of treatments and new ways of delivering care and improving treatment uptake. Collaboration between specialist and primary care, case management and multifaceted interventions are currently the most exciting prospects. There is good evidence for the role of both medication and psychological treatment in keeping the patient well after recovery.

A growing body of evidence suggests that the most common type of dementia in schizophrenia differs from Alzheimer's disease in its clinical features, natural course, neuropathology, neuroanatomical substrates and prognosis. Furthermore, there is some evidence that the risk of developing cognitive impairment and its progression in early-onset schizophrenia differ compared with late- or very-late-onset schizophrenia. The diagnosis and management of dementia in schizophrenia is challenging for both general adult and old age psychiatrists. This article reviews the evidence base regarding dementia in schizophrenia. It discusses the diagnosis of dementia in schizophrenia, its management and prognosis, and identifies some future research opportunities.

Bipolar disorder is less prevalent in older people but accounts for 8–10% of psychiatric admissions. Treating and managing bipolar disorder in older people is challenging because of medical comorbidity. We review the cognitive problems observed in older people, explore why these are important and consider current treatment options. There are very few studies examining the cognitive profiles of older people with bipolar disorder and symptomatic depression and mania, and these show significant impairments in executive function. Most studies have focused on cognitive impairment in euthymic older people: as in euthymic adults of working age, significant impairments are observed in tests of attention, memory and executive function/processing speeds. Screening tests are not always helpful in euthymic older people as the impairment can be relatively subtle, and more in-depth neuropsychological testing may be needed to show impairments. Cognitive impairment may be more pronounced in older people with ‘late-onset’ bipolar disorder than in those with ‘early-onset’ disorder. Strategies to address symptomatic cognitive impairment in older people include assertive treatment of the mood disorder, minimising drugs that can adversely affect cognition, optimising physical healthcare and reducing relapse rates.

A growing body of evidence suggests that late-onset depression (depression occurring for the first time in later life) differs from early-onset (recurrent) depression in terms of clinical features, aetiology, neuroanatomical substrates and prognosis. Some evidence suggests that late-onset depression is more associated with somatic symptoms, cognitive deficits, cerebral structural abnormalities, vascular disease (‘vascular depression’) and poorer treatment outcomes than is early-onset depression. Both general adult and old age psychiatrists face the challenges of managing late-onset depression. In this article we attempt to clarify specific issues relating to late-onset depression in terms of clinical features, aetiology, treatment response and prognosis.

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

Epidemiological evidence has identified key strategies that may be used in the prevention of both Alzheimer's disease and vascular dementia. These strategies may be loosely divided into three areas: treatment of vascular risk factors, neuroprotection and increasing neuronal reserves. Evidence from randomised controlled trials already exists for treatment of hypertension but results for statins have been disappointing. Most of the intervention trials currently in progress focus on one or two risk factors and include cognition or dementia only as a secondary outcome. The potential of intervention strategies awaits confirmation by randomised controlled trials that target multiple risk factors in at-risk people with mild cognitive impairment, with incident dementia as the primary outcome.

It has been common clinical practice for staff members to make an application to a mental health tribunal (the First-tier Tribunal (Mental Health) in England or the Mental Health Review Tribunal in Wales) on behalf of a patient detained in hospital for psychiatric treatment who may lack capacity to make that application, for example in dementia in-patient settings. Following a series of cases in the Upper Tribunal, such practice may not be appropriate and there is now a risk that the application will be struck out. It is important that clinicians are aware of developments in case law and therefore we provide guidance on how clinicians should approach applications to the tribunal and the assessments of capacity that may be required.

Clozapine is one of the most effective drugs available to psychiatrists for treating psychosis. It is currently licensed for use in treatment-resistant schizophrenia and psychosis in Parkinson's disease, but its use in old age psychiatry is very uncommon. With the ageing population, and the increased incidence of psychosis in older patients, it is important to consider whether this is a drug that is not being used to its full advantage.

Despite the enormous amount of literature on medical care of older people, personality disorders in late life have been given little attention. Clinicians tend not to assign this diagnosis to older adults in view of limited research into, and therefore limited awareness of, this topic. This article aims to promote better understanding of this subject in view of the growing population of older people and hence an expected increase in the number of personality disorder cases.

Personality disorder is likely to be common in late life, but our ignorance is such that, at present, we can only speculate about its frequency and importance. The only firm evidence we have is that antisocial personality features tend to be attenuated in older age and obsessional and detached features accentuated. Differentiating personality change following organic disease from personality disorder requires more attention as it is important for good clinical management.

Bright light therapy is an accepted and commonly used treatment for seasonal affective and circadian rhythm disorders. In the past 20 years, researchers have examined the effectiveness of bright light therapy in improving depression and agitation in older adults with dementia. This article provides clinicians with a summary of the neurophysiology of bright light therapy, bright light research considerations, an evidence-based bright light protocol, problems related to bright light therapy, and clinical implications for bright light therapy in older adults with dementia. Bright light exposure is a safe, non-pharmacological treatment that is currently underutilised in this population. Clinicians may find bright light therapy beneficial as a primary or adjunctive treatment in reducing depression and agitation in older adults with dementia.

Sensory (visual and hearing) impairment has significant detrimental impact on sociocognitive and language development. Despite this, it is very much underrecognised and underdiagnosed in people with intellectual disability. Raising awareness of sensory impairment among professionals and carers is extremely important for early management to prevent further social handicap in people with intellectual disability. This article reviews sensory impairment in intellectual disability and its association with autism-spectrum disorder and mental illness.

Stratified medicine has been successfully used in many areas of medicine, perhaps most notably oncology. There is now both a growing evidence base and mounting enthusiasm, supported at a governmental level and across industry, academia and clinical medicine, to apply this approach to neurodegenerative illnesses, including dementia, as these provide the greatest clinical and social challenge of our times. In this article we consider definitions of stratified medicine, look at its application in other medical specialties, review the national context in the UK and consider the current state, future potential and specific considerations of applying stratified medicine to dementia.

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

Advance statements, originally designed for situations of terminal illness, are becoming increasingly relevant in psychiatry. This article examines their background, rationale and use in old age psychiatry. The difference between advance statements and advance directives is highlighted, and different roles are suggested for each. We discuss the advantages, and the possible limitations, of advance statements, including the unique issue of the Mental Health Act 1983.

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting.

This article aims to provide a practical overview concentrating on civil legal aspects of psychiatric care for the elderly. We limit ourselves to English law (which also has jurisdiction in Wales; Scottish and Northern Irish law may be similar, but not identical). Civil law can, in turn, be divided into statute law (legislation provided by Parliament) and common law (the UK, unlike some European countries, has a strong tradition of law based on previous rulings by judges).

Managing isolation protocols for distressed, cognitively impaired COVID-19-positive patients presented a range of new challenges to our liaison psychiatry for the elderly service. In this article we present some of the scenarios we have experienced, our own reflections on the needs of this specific group and how this has challenged us in terms of tolerating risk, prescribing off-label, collaborating with distressed colleagues, professional boundaries and being creative in non-pharmacological interventions.