Delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests delirium can be associated with incomplete recovery. Despite the growing body of relevant research, a lack of clarity exists regarding definition and outcomes.

To clarify the definition of recovery of delirium used in the literature.

A Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery, and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function.

Fifty-six studies met the inclusion criteria. Only 2 studies used clinical criteria alone for the diagnosis of delirium, most studies used at least one validated scale, either categorical or continuous severity scales. A variety of 16 different terms were used to define the 'recovery of delirium”. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments while others using dichotomous scales (yes/ no) defined as recovery one or more days of negative delirium as the end point.

An agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery as well as between long and short term outcomes. It is proposed that cognition recovery may be used as outcome to identify recovery of delirium.

Delirium is a common neuropsychiatric syndrome with considerable heterogeneity that includes a variety of clinical (motor) subtypes. Because delirium is typically highly fluctuating, understanding the longitudinal stability of subtypes is crucial to evaluating their relevance to treatment and outcome.

to examine the changes (variability) in motor subtype profile in patients with delirium over serial assessment using the Delirium Motor Subtype Scale, and to investigate predictors of variability.

We studied motor subtype profile of patients with delirium assessed daily over a week in elderly patients undergoing hip fracture surgery. A Generalized Estimating Equations Model examined possible predictors of change in motor subtype status, including baseline variables and delirium course.

We included 118 patients developing DSM-IV delirium after hip-surgery [mean age 87.0±6.5 years; range 65–102; 66% females]. At first assessment, hyperactive subtype was most common (49%), followed by hypoactive (31%) and mixed subtype (14%), with 6% of delirious patients not fulfilling criteria of any DMSS-defined motor subtype. Almost two-thirds (n=69) of these patients underwent at least one more assessment, and for these 45 (57%) remained stable in motor subtype over time, while the rest 34 (43%) underwent change. A range of baseline characteristics were not significant predictors of variability in subtype profile.

Motor subtype profile is typically stable for orthopaedic patients with delirium. Thus evidence from cross-sectional studies of motor subtypes can be applied to many patients with delirium. Further longitudinal studies can clarify the stability of motor subtypes across different clinical populations.

Memory services constitute a significant part of old age psychiatry. Part of the memory assessment includes discussion of driving status as legally there is a requirement to disclose a dementia diagnosis to the DVLA (Driving and Vehicle Licensing Agency). At assessment a driving assessment can be undertaken to establish whether a patient is safe to continue driving.

To establish if discussions regarding driving are taking place in memory assessment clinics, and if available guidance regarding dementia diagnosis and driving are followed. To then re-audit the department following dissemination of results from the initial audit.

Standards set were 100% of patients would have documented discussion of driving. 60 patients were randomly selected from 423 referrals to memory assessment clinic between August 2012 and January 2013. Their electronic records were accessed and audited for evidence regarding documented discussion of driving. The same process was repeated following dissemination of results, with 40 patients records audited between March and May 2014. Data was collected from Bristol Activity of Daily Living Scale (BADLS) and trust pro-forma.

Patients given a diagnosis of mild cognitive impairment were excluded. Of others, 55% of patients in the first audit and 56% of patients in the second audit had documented discussions regarding driving status.

Standards were not met in either audit for a multitude of reasons, including restructuring of services. Recommendations include improvement of information collection tools and further audit, allowing for a longer length of time for implementation of changes.

Rivastigmine is the only approved transdermal therapy for Alzheimer’s disease (AD). Reduced drug concentration variability compared to oral formulations may improve tolerability and optimize treatment effectiveness.

The EXEPT study evaluated patient compliance, caregiver treatment preference and clinical outcomes in patients with mild to moderate AD initiating oral monotherapy (OM) or transdermal monotherapy (TM) with approved AD drugs.

EXEPT was a Portuguese observational multicentre trial that prospectively evaluated two cohorts of patients over 6 months (± 3 months): OM and TM, to which patients were assigned according to clinical criteria. Endpoints included patient compliance (evaluated by caregivers on a 0-10 scale), caregiver treatment preference and change in Mental State Examination (MMSE) and Neuropsychiatric Inventory domains scores.

Eighteen investigators recruited 190 patients (63.5% female, mean age 75.99 [± 7.67]), of which 69.5% were initiated on TM. Patient compliance at study end was significantly higher in the TM group (9.4 versus 8.6 points, p<0.001); 95.3% of caregivers in TM cohort preferred this formulation. MMSE increased by a median of 2.0 points in both cohorts (p<0.001 versus baseline) but no difference was observed between groups (p=0.790). A higher proportion of patients on TM showed reduced agitation/aggression (30.9% versus 15.4%, p=0.035); after controlling for baseline MMSE and use of antipsychotics this difference remained significant (OR=2.795; p=0.030).

Transdermal rivastigmine was associated with higher compliance and caregiver preference and reduced agitation/aggression compared to OM. These findings may impact treatment decisions in AD patients with agitation and aggression and high caregiver burden.

The World Health Organization recognizes the gender as an ageing determinant. Thus, apart from biological differences, there is a need of a gender approach in health that includes an analysis of how differences in gender roles affect the health status.

To assess the functional status in two areas of the elderly's life (mental and physical health), analyzing the impact of gender as a determinant of health in aging.

Quantitative and descriptive study. Probabilistic sample stratified by age, gender and area of residence, constituted by 1153 older persons aged ≥75 years (N=16474), consisting of 422 men (36.6%) and 731 women (63.4%). The instrument for data collection was the Questionário de Avaliação Funcional Multidimensional para Idosos/Older Americans Resources and Services (QAFMI/OARS).

With regard to gender differences in the areas of physical and mental health the results evaluated with the QAFMI/OARS model stand women with worse scores in this two functional areas. Although men, and especially the older age group, mentioned that have had more need for a physician visit. Related to mental health the self-evaluation is worse in women, and also in the assessment of the QAFMI/OARS model, were it was a notorious difference between genders, observing a decline in mental health among women.

The feminization of aging implies an adequate public policies and the organization of health services, and social support, based on the understanding of the differences between aging as a man and as woman.

Evaluation of non-medical interventions on cognitive and emotional competence in old age is among the goals of research in clinical gerontopsychology.

The goals of our study were to assess the impact of and analyze the differences between a cognitive training program, relaxation training according to Jacobson and a combination of both forms of intervention on cognitive performance, well-being and pain in older people.

26 care home residents (group 1) underwent the Jacobson relaxation training first, followed by a combination of relaxation and cognitive training. 24 participants (group 2) underwent a cognitive training program in the first instance followed by the combined intervention. Various psychological tests were implemented at three time points of measurement.

• - Significant improvement in dementia screening, in visual short-term memory and working memory both after the relaxation training only as also after combination training

• - Relevant improved performance in ultra short-term memory after combination training

• - Significant reduction in depression scores in both study groups

• - Relevant improvement in state of well-being after all training variants

Jacobson relaxation has a markedly stronger positive effect in optimizing the cognitive and emotional status of elderly persons compared to the more frequently propagandized and implemented cognitive training.

The aim of the present study is to estimate the prevalence of impulse control disorders (ICDs) and obsessive compulsive disorder (OCD) in a population of elderly patients with Parkinson's Disease living in the community.

This is a monocentric cross sectional study in which a total of 250 subjects with Parkinson's Disease aged 65 or more will be selected during a period of one year, from all the outpatients referring to the Geriatric Day Hospital of Policlinico A. Gemelli in Rome. An age matched reference group will be selected from all the subjects without Parkinson's Disease attending the Elderly Fitness Center in the same hospital. During a preliminary phase, a linguistic validation of the Italian version of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP) will be conducted. Afterwards, every enrolled patient will be evaluated through a clinical interview in order to obtain socio-demographic and clinical data and to assess mood status and quality of life. ICDs and OCD will be assessed respectively, using the Italian versions of self reported scales QUIP and OCI-R.

Enrollment should end in July 2015. Preliminary results from ad interim analyses will be presented.

Data on the prevalence of ICDs and OCD in elderly population, particularly in subjects with Parkinson's Disease, are still lacking in medical literature. Nevertheless, they can be clinically relevant and may have implications on the specific approach to this subgroup of patients.

Many nurses feel that they are stressed and their attitudes towards the care of older people with cognitive impairment and disturbed behavior in the acute hospital care sector has sometimes been shown to be negative.

The aim of this study was to determine the effectiveness of a person-centred approach to care for older patients with cognitive impairment and disturbed behavior in terms of decreased nursing stress, enhanced patient care practices and improved patient outcomes.

This was an exploratory before and after-intervention study, which employed mixed methods, in one Portuguese 25-bed acute aged care hospital ward over a 12-month period.

During the study there were few apparent adverse patient outcomes with significant improvements in patient analgesic administration, relatives´ satisfaction with care, nursing care practices involving the completion of a communication and care cues form and nurses´ interactions with the patients. Conversely, there was a significant increase in the nurses´ stress levels when caring delirious patients, a trend towards more emotional exhaustion, high nursing turnover and increased sick leave rates.

The quest for the study goals has shown that some progress occurred in changing the culture of care. Given the ‘chaos’ occurring in the ward and throughout the hospital during the study period, ongoing nursing support and patient care enhancement can still be achieved in some degree at such times. It is the ingrained barriers to systems change in the way nursing care is organized and practiced at a structural level, which presents the main impediments to practice improvement.

In almost all Western countries more and more people are living to advanced age. This demographic change will lead to a society with many elderly people that are in good health and good condition and many very old people in poorer conditions and in the need for significant help.

Understanding the meaning of lived experience of growing very old with respect to losses and gains.

To reveal the meaning of becoming and being very old, the transcribed interviews were analyzed using a phenomenological hermeneutic method.

The transcribed interviews of 15 Portuguese 85-year-old people were analyzed and disclosed growing old as: maintaining one’s identity in spite of the changes that come with aging—that is, being able to balance change with feeling the same. This was based on four themes: balancing weakness and strength, balancing slowness and quickness of time, balancing reconciliation and regret, and balancing connectedness and loneliness.

Growing very old means to be dependent on others, this perhaps leads to frequent encounters with various caring organizations. Attitudes towards aged and aging in nursing are decisive for how the old person is met. Consoling care is to be open and available in the situation when meeting the old person. It is important to see the person behind the mask of aging.

Although the original diagnostic criteria for mild cognitive impairment (MCI) highlighted the importance of memory impairment, more recently the MCI classification was expanded to encompass other cognitive domains, allowing the diagnosis of amnestic or non-amnestic MCI.

The primary aim of this study was to identify cognitive tests and illustrate a neuropsychological profile of cognitive subtests of persons with amnestic MCI (aMCI) and non-amnestic MCI (naMCI).

Material and Methods: The study used a cross-sectional design. The study group consisted of 35 aMCI and 16 naMCI subjects matched for age, sex and years of education. The groups did not differ according to CDR. All subjects underwent a wide range of psychological tests including MMSE, TYM, DemTect, FAS, CDT, IADL and GDS. The following tests were completed to measure episodic memory, working memory, executive functions, perception and language. The analysis of variance (ANOVA) was used to analyze the differences between group means.

The statistical analysis illustrated that total scores of MMSE, TYM, DemTect and FAS to differentiate the aMCI from naMCI subjects. Compared to naMCI, aMCI subjects scored lower in MMSE (p=0.0104) and in DemTect (p=0.0002) while they had higher scores in TYM (p=0.0067) and FAS (p=0.0427).

This study shows that cognitive screening tests provide valuable information regarding the differential diagnosis of aMCI versus naMCI. MMSE and DemTect may be seen as superior screening tests in aMCI, while TYM and FAS in naMCI subjects.

In the course of demographic change an increasing number of dementia patients is predicted. More elderly desire to remain longer self-determined at their familiar domestic surroundings while declining disposability of nursing staff is prognosticated. Modern AAL-systems offer the opportunity to tackle this challenge.

In order to meet the needs of dementia patients, a prospective AAL-system should discern people's activities of daily living (ADLs). Regarding to their complexity, in order to generate sophisticated assistance, the system needs to integrate harmonically into the domestic environment without any interference on ongoing activities of those concerned.

OPDEMIVA ascertains possibilities in real-time-recognizing of ADLs applying innovative contactless optical measurement sensors with focusing on the detection of high-risk behavioural patterns.

An interdisciplinary research team of technical and health-care experts was involved in the mutual project. Based on examination of the list of ADLs and preconceiving both aspects of medical importance and technical feasibility, a subset of relevant behavioural patterns was identified. An appropriate technical system based on optical smart sensor technology for ADLs detection was developed and preliminarily tested.

In preliminary tests several fundamental ADLs, e.g. movement and recreation could be detected with high reliability while possible deficits like motionlessness over a defined period became derivable.

Smart sensor based detection of dementia-related high-risk behavioural patterns requires extensive detailed examination of capabilities and needs of persons concerned. Patient's privacy and ethic concerns are of high relevance. Results gained as yet imperatively demand further research.

Delusional parasitosis (DP) is a disorder in which the patient believes that he is infested by a parasite. Although this is a psychiatric disorder, patients usually seek care from dermatologists. A dermatology-psychiatry liaison is advocated for establishing a viable differential diagnosis and selecting appropriate therapy.

To review the literature through a case report.

To highlight the incidence, the causes, the typical characteristics of patients with DP, the best approach when dealing with a patient with DP

Case report.

A 75 year-old widow was referred to the outpatient psychiatric department of Razi Hospital by a dermatologist because of hyperchromic pruritic skin lesions in arms. The illness began 2 years ago, after the death of her husband, with itching sensations on her arms that the patient attributed to “bugs” under her skin. She used to put the 'animals” in a piece of paper to prove their existence. She tried various strategies for eradicating the alleged parasites, such as using pesticides on herself and her possessions. Risperidone was started up to 3mg per day. She had a progressive clinical improvement.

Ekbom’s syndrome is a delusion of hallucinatory mechanism that might have different cultural presentations and could be favored by social vulnerability. The typical patient is an elderly woman who is unmarried or living along. Rather than a unique illness, DP is a neuropsychiatric syndrome that can follow primary psychotic and depressive disorders, dementia or other organic diseases. Treatment is based on antipsychotic agents, psychotherapy and cooperation between dermatologists and psychiatrists.

An ageing population requires new and different approaches to care. In institutionalized settings it is well known that depression, among other psychiatric symptoms, is presented by a high proportion of residents, associated with an increase in needs, which are nevertheless often underestimated.

To analyze the relation between met/unmet needs and depression in an elderly institutionalized sample.

This cross-sectional study included an elderly sample (≥50years) recruited from three Portuguese residential homes. All permanent residents were eligible, but residents with delirium or who were unresponsive or unwilling to complete the assessment were not included. Participants were assessed with Geriatric Depression Scale/GDS and Camberwell Assessment of Needs for the Elderly/CANE.

The sample (n=175) had a mean age of 81(sd=10), the majority were female (90%), widowed (51%), had a low educational level (86.1%, 0-4 years) and had been institutionalized for 7(sd=11) years on average. According to GDSscore, 45.2% presented depression. Daytime activities (73.1%), Eyesight/Hearing (67.4%), Psychological distress (52.0%), Company (40.6%) and Memory (37.1%) were the most frequent unmet needs. A significant correlation between the GDSscore and the total of unmet (rs=0.683,p<0.05) and global needs (rs=0.407,p<0.05) was found in contrast to no significant correlation with met needs.

In this residential sample the presence of depressive symptoms was correlated with the number of needs. This association is coherent with previous findings and highlights the importance of an early assessment of these symptoms, in order to cover the unmet needs that were mostly psychological and amenable to interventions with improvement in wellbeing.

Cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL) is the most common hereditary subcortical vascular dementia, and it is caused by a broad spectrum of mutations in the NOTCH3 gene on chromosome 19.

The authors intend to review the clinical patterns of the condition and expose the variability of its radiological and genetic data. Furthermore, its diagnostic strategies and available treatments are also clarified.

Brief description of a clinical case and review of literature collected from online medical databases under the keywords ‘CADASIL’, ‘dementia” and ‘genetic’.

The authors report a case of a 67-year-old woman with history of late onset migraine and polymorphic psychiatric and neurologic symptoms, which further evaluation confirmed the CADASIL diagnosis. The involutive course of her condition is also emphasized as well as its devastating social and familiar consequences.

Literature on CADASIL is vast and confirm that its phenotype is variable between and within affected families, with new clinic features continually arising. Nevertheless, main pattern consists in migraine with aura (often atypical or isolated), strokes, cognitive decline/dementia and psychiatric symptoms. Diagnosis is confirmed either by identifying a pathogenic NOTCH3 mutation or by the demonstration of specific granular osmiophilic material in skin biopsies. So far, only symptomatic treatment is available.

CADASIL is notably underrecognized and underdiagnosed. Authors consider it deserves greater awareness from psychiatrists, since it brings great suffering for the patients and their families, as well as high demand for non-psychiatric care.

Delirium is an increasingly common multifactorial condition, especially in elderly and debilitated patients often undiagnosed and therefore untreated properly. It is a medical emergency with significant mortality rates.

Clarification about what delirium is and how to act upon suspicions of this clinical condition.

A non-systematic literature review was performed in PubMed (1990-2014), using the keyword “delirium” in combination with one other major search term to review areas including the Following: “epidemiology”, “clinical features”, “pathogenesis” and “evaluation”. Only original articles in english language were included.

The clinical presentation of delirium is variable but can be classified broadly into three subtypes—hypoactive, hyperactive and mixed. Risk factors for delirium are presented. The diagnosis of delirium is made on the basis of clinical history, behavioral observation and cognitive assessment. In view of the fact that cognitive impairment can be missed during routine examination, a brief cognitive assessment should be included in the physical examination of patients at risk of delirium. An algorithm of action in case of suspicions of delirium is proposed in this study.

Delirium is a serious cause and complication of hospitalization in elderly patients and should be considered to be a medical emergency until proven otherwise. Irrespective of the specific etiology, this condition has the potential to markedly affect the overall outcome and prognosis of severely ill patients, as well as substantially increasing health-care utilization and costs. For these reasons, prevention, early recognition and effective treatment of delirium are essential.

Frailty is a geriatric syndrome that entails an increased risk of clinically significant adverse outcomes. There are different approaches regarding frailty’s clinical operationalization.

To compare how different frailty measures (the Frailty Phenotype/FP, Groningen Frailty Indicator/GFI and the Tilburg Frailty Indicator/TFI) predict short-term adverse outcomes.

A longitudinal study was designed recruiting 95 community-dwelling elderly. Participants were assessed at baseline for frailty, determinants of frailty and adverse outcomes, and 10 months later for the same outcomes (healthcare utilization, quality of life, disability in basic and instrumental activities of daily living/ADL and IADL).

The mean age of the participants was 78.5±6.2 years, and most were women (67.4%). Being classified as frail at baseline by each operationalization of frailty was associated with specific healthcare utilization indicators at follow-up: the FP with a greater utilization of informal care; GFI with increased contact with healthcare professionals; and TFI with more contact with a general practitioner. In general, after controlling for the effect of life-course determinants, comorbidity and the same adverse outcome at baseline, GFI predicted IADL disability and TFI predicted total quality of life and most of the quality of life domains. The effect of the FP on the outcomes was not significant, when compared with the other measures.

Frailty at baseline was associated with adverse outcomes at follow-up. In this study, multidimensional measures of frailty (GFI and TFI) were better predictors of the selected outcomes in a 10-month follow-up than an exclusively physical one (FP).

With approximately 35.6 million people with dementia worldwide, dementia has become a major focus of attention and intensive research in developed countries. In Portugalthere is still little informationabout this disease, and that’s why wepropose to characterize apopulation of patients with dementiafollowed in the outpatient neurology department of UnidadeLocal de Saúde do Alto Minho (ULSAM).

Description of a population of 103 patientsfollowed in the outpatient neurology department of ULSAM in 2014.

103 patients followed in the outpatient neurology department of ULSAM between January and March 2014 were randomly chosen. We collectedSocio-demographic and medical data by consulting the electronic records ofpatients. Data were analyzed using SPSS version 20.0.

The average age of patients was 77 years. There wasa predominance of females with61.17% women. The most frequent diagnosis was of mixed dementiawith 26 cases, followed by Alzheimer's disease with 24 cases and 17 cases with vasculardementia. The most widely usedanti-dementia drug was memantine. About 83% ofpatients were on some type of psychotropic medication, over 50% of patients werebeing treated with antidepressants, 42% with antipsychotic drugs, 33% with anxiolytic / hypnotic and15% with mood stabilizers. Around one third ofthe total patients had been followedin psychiatry in the last five years, mainly for depressivesymptoms, psychotic symptoms ofsenility, or behavioral disturbances. More than 50% ofpatients had 2 or more risk factors for cardio-vasculardisease, and 76.60% had high bloodpressure. Conclusion: Interestingly, in our sample there isan over representation of vascularetiology as a primary cause, orcofactor of dementia, and there is a high prevalence ofcardiovascular risk factors andparticularly arterial hypertension. Thisleads us to think that better prevention of cardio-vascular disease risksfactors and particularly hypertension could have a significant impact in the prevention of dementia in the Alto Minho. Finally we realize through the great use of psychotropicdrugs in these patients that theinvolvement of psychiatrists in their attendance is essential.

Diabetes mellitus is reaching epidemic proportions globally and is associated with a number of long-term central nervous system complications in older diabetic adults which are potentially modifiable. Improving diabetic brain health literacy among the public, diabetic individuals and healthcare staff has the potential to reduce the incidence of such complications as depression, cognitive impairment and dementia, leading to healthier ageing.

To establish diabetic brain health literacy levels among the general public, healthcare professionals and diabetic outpatient attendees using a knowledge questionnaire.

A self-administered questionnaire was made available to the public for completion via an Irish website. An adapted questionnaire was disseminated among medicine for the elderly nursing staff and diabetes outpatient attendees in a large urban teaching hospital in Dublin, Ireland. Questions assessed knowledge of potential brain health diabetic complications and garnered pertinent demographic information.

Graph 1- Knowledge of potential brain health complications of diabetes.

Graph 2 – Knowledge of potential non-central nervous system complications of diabetes

This study demonstrates poor knowledge among the public of the increased risk of brain health complications in older diabetic adults. Nursing staff members had greater knowledge and diabetic patients had the greatest, but less than satisfactory knowledge. This contrasts with greater awareness of non-brain diabetic complications such as eye disease and neuropathy among all three groups. Results suggest a need for expansion of health literacy campaigns to promote awareness, and to highlight potentially modifiable risk factors to aid in disease prevention, control and prevention of brain health complications.