Background: The high prevalence of subjective memory impairment (SMI) in the elderly living in developed countries may be partly dependent on greater demand placed on them by new technologies. As part of a comprehensive study on cognitive impairment in a population living in the Amazon rainforest, we evaluated the prevalence of SMI and investigated the features associated with it.

Methods: We evaluated 163 subjects (82 females) with a mean age of 62.3 years (50–94 years), 110 of whom were illiterate, using the answer to a single question “Do you have memory problems?” to classify them into groups with or without SMI. The assessment involved application of the Mini-mental State Examination (MMSE), delayed recall from the Brief Cognitive Battery designed for the evaluation of low educated and illiterate individuals, the Patient Questionnaire (PQ) of the Primary Care Evaluation of Mental Disorders (PRIME-MD), and the Happiness Analogical Scale.

Results: A very high prevalence of SMI (70%) was observed, exceeding rates reported by similar studies conducted in developed countries. SMI was more frequent in women, whereas age and education did not impact on prevalence. Subjects with SMI had significantly more somatic and psychiatric symptoms on the PQ, as well as lower means on the MMSE, but not on the delayed recall test. Multiple logistic regressions showed that the most important factor associated with the presence of SMI was a high score on the PQ (OR: 3.84, p = 0.011).

Conclusion: Psychological and somatic symptoms may be the principal cause of SMI in this population.

Objective: Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities.

Methods: A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed.

Results: Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis.

Conclusion: A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Background: Osteoporosis causes much morbidity and mortality among elderly people. Older inpatients with severe mental illness may be at particular risk of osteoporosis because of factors including immobility, vitamin D deficiency and psychotropic medication.

Method: We screened predominantly older inpatients with severe mental illness for osteoporosis using a peripheral DEXA scanner. Associations were examined between patient variables and osteoporosis as detected by DEXA scan, Z-scores and history of fragility fractures. Patients were followed up to see how many subsequently received drug treatment for osteoporosis. Patient acceptability of the scanning technique was also assessed.

Results: It was possible to scan 72/89 (81%) of patients. Mean T-score was −2.79 (SD 1.50) and mean Z-score −0.76 (SD 1.34). Forty-two (58%) patients had osteoporosis and 23 (32%) osteopenia. Twelve (17%) patients with a history of fragility fractures had osteoporosis on DEXA scan. A scan suggestive of osteoporosis and a history of fragility fractures were both associated with age of 75 years and over and thoracic kyphosis. Low Z-scores were associated with longer hospital stay and osteoporosis-predisposing drugs. Patient acceptability of scanning was high. At follow-up, only 7/16 (44%) patients were suitable for central scanning and 9/40 (23%) for bisphosphonates.

Conclusion: Older institutional patients with severe mental illness are likely to be at high risk of developing osteoporosis. Peripheral DEXA scanning is acceptable to these patients and identifies those at high risk of fractures. Some behaviorally disturbed patients are not suitable for central scans or for some osteoporosis drug treatments.

Background: Falls are a major cause of morbidity and mortality among elderly people, and people with dementia run an increased risk of falling. The aim of this study is to identify risk factors for falls in people with dementia.

Method: The study was performed over a six-month period in northern Sweden using a sample of 160 residents living in 20 group dwellings for people with dementia.

Results: Sixty-four residents (40%) sustained at least one fall during the period. The total number of falls during the study period was 191, and the fall incidence was 2.6 per person year (169 falls/130 residents). Using logistic regression analysis, the independent risk factors strongly associated with falling were: requiring help with hygiene, displaying verbally disruptive/attention-seeking behavior, able to rise from a chair, walking with assistive devices, and participating in outdoor walks. These factors explained 36.1% of the variance in falls with a concordance of 79.6%. Thirty-five percent of the falls occurred between 9 pm and 6 am, with a peak between 5 pm and 6 pm. Symptoms preceding the falls were anxiety (31.1%) and confusion (13.3%).

Conclusion: Among residents with dementia it is important to identify those who run an increased risk of falling and need more careful supervision, especially in the evening and during the night. In addition, the causes of anxiety and confusion have to be prevented and treated.

Background: Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia.

Methods: The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. χ2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables.

Results: The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge.

Conclusion: Suboptimal medication use is a potential source of decreased function in older patients with dementia.

Suicide rates increase with aging in many countries. In a recent study of 62 developed and developing countries, suicide rates increased with age for males and females in 25 and 27 countries respectively, and in both sexes in 17 countries (Shah, 2007). Suicide rates increased with age in 47 of the 49 medium- and high-income countries (Keimo, 2004). Comprehensive understanding of the substantial worldwide variation in population patterns of suicide may be critical for developing prevention programs (Knox et al., 2004). Much is known about individual level proximal risk factors and preventative strategies can be targeted at identified high risk groups (Shah and De, 1998). Also, proximal risk factors for elderly suicide victims are generally different from those for younger suicide victims (Shah and De, 1998). However, distil risk factors may be similar for elderly and younger suicide victims. Such distil risk factors include societal socioeconomic status (Kennedy et al., 1999; Shah et al., 2008), societal income inequality (Kowalski et al., 1987; Shah et al., 2008), education (Kowalski et al., 1987; Agbayewa et al., 1998), degree of urbanization (Stack, 1993), degree of social integration (Durkheim, 1992) and provision of health and mental health service provision (Shah and Bhat, 2008). In general, preventative measures targeting distil risk factors require development of public health strategies at a societal level. Should research focus specifically on elderly suicide rates in cross-national ecological studies designed to identify distil risk factors?

A recent cross-national study of 62 developing and developed countries reported an increase in suicide rates with aging in males and females in 25 and 27 countries respectively (Shah, 2007). Longitudinal studies over time have reported a decline in elderly suicide rates in England and Wales (Gunnell et al., 2003; Lodhi and Shah, 2004), Sweden (Carlsten et al., 1999) and Australia (Hall et al., 2003) with an increase in prescription rates of antidepressants, particularly selective serotonin reuptake inhibitors. The vast majority of elderly suicide victims have depressive illness (Shah and De, 1998). The pathway to elderly depressed individuals acquiring a prescription of antidepressants includes the following sequential steps: recognition by individuals or their carers that there is problem and consulting a healthcare professional; recognition of depression by the healthcare professional; prescription of antidepressants by the healthcare professional; and, purchasing of the antidepressants by the patient. Different methods of acquiring the prescribed antidepressants exist in different countries including: healthcare professionals dispensing the antidepressant free or at a cost; and obtaining the prescribed antidepressant from a pharmacist free (either through state welfare system or insurance schemes) or at a cost. We have examined the relationship between elderly suicide rates and the affordability of psychotropic medication in a cross-national study.

Marin et al. (2003) have suggested that apathy may be independent of executive functions in older-aged patients with major depression, although the correlation between apathy and the “controlled oral word association test,” a test of executive measures, approached significance. However, Feil et al. (2003), using the same definition and measure of apathy, observed a strong correlation between apathy and both verbal and non-verbal executive cognitive measures. The question thus arises as to whether apathy contributes to executive cognitive dysfunction in non-demented patients with late-life depression. We therefore re-examined this issue, looking particularly at whether apathy distinctly affects executive control functions. Our hypothesis was that apathy would contribute to cognitive impairment in depressed elderly patients independently of the severity of depression.

Although not approved by the Food and Drug Administration (FDA) for behavioral disturbances, the largest number of antipsychotic prescriptions in older adults is for this indication associated with dementia (Sultzer et al., 2008). In 2005, the FDA determined that atypical antipsychotic medications were associated with a 1.6 to 1.7 greater risk of mortality compared with placebo when administered to older patients with dementia (De-Deyn et al., 2005). Psychosis and agitation symptoms in patients with dementia are common, disruptive, and costly but there are no well-established, evidenced-based effective treatment alternatives (Jeste et al., (2008). A limited amount of mostly anecdotal scientific data suggests that anticonvulsant medications, including some of the newer agents like lamotrigine, may be helpful for agitation and psychosis in older patients with dementia (DeLeon, 2004). Lamotrigine is an anti-epileptic drug whose mechanism of action is thought to be linked to voltage-sensitive sodium channel blockade in the neuronal membrane and inhibition of presynaptic glutamate and aspartate release (Baumann et al., 2007). Lamotrigine has a safe profile and has documented efficacy in delaying recurrence of mood episodes in patients with bipolar disorder in trials conducted for up to 18 months.