Background: Maintaining and improving quality of life has become a major focus in geriatric medicine, but the oldest old have received limited attention in clinical investigations. We aimed to investigate the relationship between self-perceived and caregiver-perceived quality of life (QOL), cognitive functioning, and depressive symptoms in the oldest old.

Methods: This IRB-approved prospective study recruited community dwellers aged 90–99 years old. Collected data included neurological evaluation, DSM III-R criteria for dementia, Mini-Mental State Examination (MMSE), Dementia Rating Scale (DRS), Geriatric Depression Scale (GDS), Record of Independent Living (ROIL), and QOL assessment using the Linear Analogue Self Assessment (LASA).

Results: Data on 144 subjects (56 cognitively normal (normal), 13 mild cognitive impairment (MCI), 41 dementia (DEM), 34 dementia with stroke and parkinsonism (DEMSP)) over a three-year period were analyzed. Mean ages ranged from 93 to 94 years, and the majority were female with at least high school education. Overall functional ability was higher in groups without dementia (p < 0.0001). All subjects reported high overall QOL (range 6.76–8.3 out of 10), regardless of cognitive functioning. However, caregivers perceived the subjects’ overall QOL to be lower with increasing severity of cognitive impairment (p < 0.0001). Lower GDS scores correlate with higher self-perceived overall QOL (ρ = −0.38, p < 0.0001).

Conclusions: In our community sample of the oldest old, there was a fairly high level of overall QOL, whether or not cognitive impairment exists. Individuals perceive their QOL better than caregivers do, and the difference in subjects’ and caregivers’ perception is more pronounced for the groups with dementia. QOL is more strongly correlated with depressive symptoms than with dementia severity.

Background: Quality of life is important for all individuals, but is frequently overlooked in psychiatric populations. Our purpose was to assess the quality of life (QOL) of depressed psychiatrically hospitalized elderly patients, examine the association of QOL and depression, and explore any QOL differences related to electroconvulsive therapy (ECT).

Methods: This Institutional Review Board (IRB)-approved prospective study recruited geropsychiatric inpatients aged 65 years and older who were depressed, had Mini-mental State Examination (MMSE) scores >18/30, and adequate communication skills. Surveys were completed upon admission and discharge to measure depression (Hamilton Depression Rating Scale (HDRS)), quality of life (Linear Analogue Scales of Assessment (LASA); Medical Outcomes Short Form-36 Health Survey (SF-36)), cognitive function (MMSE; Executive Interview (EXIT 25)), and coping (Brief COPE Inventory (COPE)). Spearman correlations and Wilcoxon signed rank tests were used to assess changes in measures during hospitalization and relationships among variables.

Results: The 45 study participants who completed the study had a mean age of 74 years. The majority were female (67%), married (58%), Protestant (60%), with at least high school education (78%). Admission scores demonstrated severe depression (HDRS 24.88 ± 10.14) and poor QOL (LASA overall QOL 4.4 ± 2.79, and SF-36 mental [27.68 ± 9.63] and physical [46.93 ± 10.41] component scores). At discharge, there was a significant improvement of depression (HDRS 24.88v12.04, p < 0.0001) and QOL (LASA overall QOL 4.4v6.66, p < 0.0001; and SF-36 mental [27.68v39.10, p < 0.0001] and physical [46.93v50.98, p = 0.003] component scores). Not surprisingly, depression was negatively correlated with overall QOL, mental well-being, physical well-being, and emotional well-being at both admission and discharge. For the group who received ECT, there was a greater magnitude of improvement in SF-36 vitality (p = 0.002) and general health perception (p = 0.04), but also a reduction in EXIT 25 scores at discharge (p = 0.008).

Conclusions: There was improvement of both QOL and depression during the course of hospitalization. Additionally, improvement of QOL was associated with improvement of depression. Perhaps future studies could develop interventions to improve both mood and QOL in elderly depressed inpatients.

Background: The course of delirium in patients with dementia who are undergoing management of delirium with antipsychotics has not previously been studied. In order to investigate the treatment characteristics of patients with delirium superimposed on dementia in contrast to delirium in the absence of dementia we performed a secondary analysis of our delirium database.

Methods: We collected sociodemographic data and medical variables in addition to using the systematic rating scales of the Memorial Delirium Assessment Scale (MDAS) and Karnofsky Scale of Performance Status (KPS). These data were recorded in the delirium database. For this analysis we extracted all data pertaining to patients with delirium and dementia (DD) and compared them to those with delirium without dementia (i.e. non-demented with delirium; NDD).

Results: Out of 111 cases with a diagnosis of delirium we acquired 22 cases with a diagnosis of DD and 89 cases with NDD. The mean age was significantly different with 77.1 years for DD and 62.7 years for NDD. The MDAS scores at baseline were significantly higher in DD (21.1) compared to NDD (17.6). Over the course of treatment, MDAS scores were significantly higher in DD with 11.7 at T3 compared with 7.0 in NDD. After three days of management, delirium resolution rates were significantly lower in DD with 18.2% compared to 53.9% in NDD, and at seven days delirium resolution rates were 50% and 83% respectively. At the endpoint of the observation period, DD had a significantly more pronounced disturbance of consciousness and impairment in the cognitive domain. KPS scores were not significantly different between DD and NDD.

Conclusion: In our sample of patients with delirium superimposed on dementia the delirium resolution rates were lower than in patients without dementia at one week of treatment. The data suggest that when delirium is superimposed on dementia the delirium may resolve at a slower rate.

Background: The aim of this study was to identify long-term effects of diagnostic criteria on the Post Traumatic Stress Disorder Checklist (PCL-C) for a test group of Finnish evacuees from World War II and compare the outcome effect with a control group of children who lived in Finland during the war in 1939–1945.

Methods: 152 participants were recruited by the local leader of the Finnish War Child Association in Sweden and Finland. The selected group answered questions on the Post Traumatic Stress Disorder Checklist (PCL-C) and the EMBU (Swedish acronym for “Own Memories of Parental Rearing”).

Results: Evidence suggests a link between childhood parental separation and termination of the internalized attachment hierarchy of origin in a detachment process among Finnish evacuees. Based on the Post Traumatic Stress Disorder Total (PCL-C) diagnosis an extreme traumatization for 36.7% of the test group subjects was identified, including a hidden Holocaust trauma in the population of Finnish evacuees.

Conclusions: The study met the criteria for satisfying global evidence value. Sixty-five years after the end of World War II and in line with other studies on war children, the data show high levels of different trauma exposures from the war with 10.6 higher risk (odds ratio) for the exposed group of Finnish evacuees. Despite some limitations, the data highlight the need for further investigation into different parts of the detachment process among seriously traumatized groups to reveal resilience and other dimensions of importance in professional mental health creation.

Background: The underlying goals of the present study were (i) to assess knowledge of and attitudes towards aging in a sample of Portuguese undergraduate students undertaking various degrees in health and welfare subjects, and (ii) to analyze the extent to which knowledge, attitudes and other factors were associated with interest in working with older adults.

Methods: The study was cross-sectional in design. The sample comprised 460 Portuguese undergraduate students enrolled in degrees in nursing, social work, and psychology. They were asked to complete questionnaires and quizzes, which were analyzed using contingency tables and one way analysis of variance for inter-group comparison, and then subjected to multivariate logistic regression analysis.

Results: Significant differences emerged between groups on knowledge, attitudes towards aging and interest in working with older adults, with both nursing and social work students displaying more positive attitudes, knowledge, and interest in working with older adults, when compared with psychology students. A regression analysis indicated that attitudes, knowledge, and previous formal contact were significant predictors of interest.

Conclusion: Interest in working with older adults was significantly related to positive attitudes, more knowledge and formal previous contact. Positive attitudes towards older adults can be promoted through interaction with faculty members and experts, knowledge acquisition about normative changes with age, and contact with healthy and impaired older adults.

Background: This study applies the updated HIV-Associated Neurocognitive Disorders (HAND) diagnostic algorithm.

Methods: Participants were 210 HIV-infected-adults, classified using proposed HAND criteria: HIV-Associated Dementia (HAD), Mild Neurocognitive Disorder (MND), Asymptomatic Neurocognitive Impairment (ANI).

Results: The algorithm yielded: normal = 32.8%, ANI = 21.4%, MND = 34.3%, and HAD = 11.4%. Normal participants performed superior to HAND-defined participants on cognition, and HAD participants performed more poorly on global cognition and executive functioning. Two distinct subgroups of interest emerged: (1) functional decline without cognitive impairment; (2) severe cognitive impairment and minimal functional compromise.

Conclusions: The algorithm discriminates between HIV-infected cognitively impaired individuals. Diagnosis yields two unique profiles requiring further investigation. Findings largely support the algorithm's utility for diagnosing HIV-cognitive-impairment, but suggest distinct subsets of individuals with discrepant cognitive/functional performances that may not be readily apparent by conventional application of HAND diagnosis.

Background: Late life depression is often accompanied by slowed information processing during neuropsychological testing, and this has been related to underlying cerebrovascular disease. We investigated whether changes in electrophysiological markers of information processing might share the same pathological correlates.

Methods: Differences in power spectra frequency, contingent negative variation (CNV), post-imperative negative variation (PINV), and auditory P300a amplitude and latency in 19 patients with DSM-IV major depression aged ≥ 60 years were compared with 25 recordings in age-matched healthy controls. Associations with total brain volume and degree of white matter hyperintensities (WMH) were examined in those who had undergone additional magnetic resonance imaging (MRI).

Results: Compared with healthy controls, patients had more slow-wave delta (group difference: p = 0.024) and theta activity (p = 0.015) as well as alpha activity (p = 0.005) but no decrease in beta band frequency (p = 0.077). None of these changes related differently to brain volume or WMH in patients or controls. Patients further showed prolonged P300a latencies (p = 0.027), which were associated with decreased total brain volume in patients but not controls (interaction by group: p = 0.004). While there were no overall differences in PINV between both groups, patients showed a decrease in PINV magnitude with increasing WMH, a relation that was not seen in controls (interaction by group: p = 0.024).

Conclusion: Patients with late life depression show changes in several electrophysiological markers of cerebral arousal and information processing, some of which relate to brain atrophy and WMH on MRI.

Background: Few studies have examined alterations of the brain in elderly bipolar patients. As late-onset mania is associated with increased cerebrovascular morbidity and neurological damage compared with typical/early-onset mania, we investigated differences in the volume of various cortical regions between elderly patients with early-onset versus late-onset mania.

Methods: We recruited 44 bipolar patients aged over 60 years, who underwent volumetric magnetic resonance imaging at 1.5 T. The analytic method is based on the hidden Markov random field model with an expectation-maximization algorithm. We determined the volume of each cortical region as a percentage of the total intracranial volume. The cutoff age for defining early versus late onset was 45 years.

Results: The study participants consisted of 25 patients with early-onset mania and 19 patients with late-onset mania; their mean ages were 65.7 years and 62.8 years, respectively. The demographic variables of the two groups were comparable. The volumes of the left caudate nucleus (p = 0.022) and left middle frontal gyrus (p = 0.013) were significantly greater and that of the right posterior cingulate gyrus (p = 0.019) was significantly smaller in the late-onset group. More patients with late-onset mania had comorbid cerebrovascular disease (p = 0.072).

Conclusions: The right posterior cingulate gyrus is smaller and the left caudate nucleus and left middle frontal gyrus are larger in patients with late-onset mania compared with those with early-onset mania. Volumetric change in brain regions may vary in elderly bipolar patients with early and late-onset mania.

Behavioral and psychological symptoms of dementia (BPSD) are common, distressing and compromise care. Their diverse etiology necessitates targeted, individualized treatment. We present a case of an 82-year-old with severe dementia and BPSD, and with limited response to a range of pharmacological and non-pharmacological treatments. Individualized art therapy was developed in an inpatient setting using felt material cut into shapes and coloring with stencils and pre-drawn line drawings utilizing preserved skills of coloring, while supporting frontal-executive and language deficits. The activity was replicable and carried over to the residential care setting and supported by family and professional carers.

We report the case of JW, a 66-year-old woman who presented with musical hallucinations and multiple etiological factors for these rare phenomena. We discuss these factors and the successful amelioration of her symptoms with lamotrigine.

Background: Both passive death wishes and loneliness are prevalent in old age and both have been shown to be associated with a variety of detrimental effects. The overall goal of the present study was to evaluate the relationship between loneliness and passive death wishes in the general population of Europeans over the age of 50 years.

Methods: Passive death wishes were evaluated in waves 1 and 2 of the Survey of Health, Ageing and Retirement in Europe, using the question “in the past month, have you felt that you would rather be dead?” Loneliness was evaluated by the question: “how frequently have you felt lonely over the past week?” taken from the Center for Epidemiological Studies of Depression questionnaire. All predictors were gathered in wave 1. Analysis was stratified into three age groups (50–65, 66–75, >75 years).

Results: Both passive death wishes (15.6%) and loneliness (mean (SE) = 1.68(0.03)) were highest in those over the age of 75, relative to the other two age groups (age 50–65: 4.6%, mean (SE) = 1.43(0.01); age 66–75: 7.3%, mean (SE) = 1.50(0.02), respectively). Loneliness remained a significant risk for passive death wishes, net of the effect of demographic, health, mental health, and various social indicators in those aged 50–65 years (OR = 1.47, 95%CI: 1.10–1.97) and 65–75 (OR = 1.74, 95%CI: 1.28–2.38), but not in those over the age of 75 (OR = 1.12, 95%CI: 0.84–1.47). None of the objective social indicators was associated with passive death wishes.

Conclusions: The present study emphasizes the differential role of loneliness across the lifespan. Any intervention to alleviate passive death wishes in the general population will benefit from addressing the subjective sense of loneliness more so than objective indicators of social interaction.

Background: Delirium occurs frequently in the intensive care unit (ICU), but its pathophysiology is still unclear. Low levels of insulin-like growth factor 1 (IGF-1), a hormone with neuroprotective properties, have been associated with delirium in some non-ICU studies, but this relationship has not been examined in the ICU. We sought to test the hypothesis that low IGF-1 concentrations are associated with delirium during critical illness.

Methods: Mechanically ventilated medical ICU patients were prospectively enrolled, and blood was collected after enrollment for measurement of IGF-1 using radioimmunometric assay. Delirium and coma were identified daily using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale, respectively. The association between IGF-1 and delirium was evaluated with logistic regression. In addition, the association between IGF-1 and duration of normal mental state, measured as days alive without delirium or coma, was assessed using multiple linear regression.

Results: Among 110 patients, the median age was 65 years (IQR, 52–75) and APACHE II was 27 (IQR, 22 –32). IGF-1 levels were not a risk factor for delirium on the day after IGF-1 measurement (p = 0.97), at which time 65% of the assessable patients were delirious. No significant association was found between IGF-1 levels and duration of normal mental state (p = 0.23).

Conclusions: This pilot study, the first to investigate IGF-1 and delirium in critically ill patients, found no association between IGF-1 and delirium. Future studies including serial measurements of IGF-1 and IGF-1 binding proteins are needed to determine whether this hormone has a role in delirium during critical illness.

Background: Many countries have adopted new mental health legislation, with the detention of adults for treatment of mental disorders remaining an integral part of such policies. However, there are relatively few publications on the use of mental health legislation in the detention of older adults. This paper examines the civil detention of older adults in one Scottish region under successive mental health legislation.

Method: This prospective study collected data primarily by clinician-based interviews on all emergency detentions under the Mental Health (Scotland) Act 1984 of older adults in 1994 and compared these with all emergency and initial short-term detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 of older adults during 2008 in the same Scottish region.

Results: There were a total of 124 detentions, with an initial rate of 68 increasing to 141 detentions per 100,000 of the respective over-65 year age populations, a two-fold increase. Compared to the 1994 patient cohort, the 2008 cohort had higher rates of over 85-year-olds (18.4% v 5.4%) and organic mental disorders (74.7% v 56.8%) and were significantly more likely to be detained by consultant psychiatrists (73.6% v 18.9%) during working hours (87.4% v 48.6%) and proceed to six-month detention orders (31% v 10.8%).

Conclusion: The observed higher rates and longer periods of detention in the 2008 cohort may reflect changes in clinical attitudes and legal requirements from a previous reliance on the common law doctrine of necessity to the requirements of a more legalistic framework, and may signal future clinical requirements, given the aging population, pointing towards the need for earlier recognition and management of clinical issues in an attempt to minimize the “necessity” of clinico-legal intervention.

This case describes the differential diagnosis and treatment of a 70-year-old man with an avoidant personality disorder. It illustrates that diagnostic assessment and treatment of personality problems in the elderly are possible in mental health care. It demonstrates that multiple stand-alone treatment modules can form part of a single course of adaptation-focused treatment of personality disorders. An interpersonal approach forms an important basis for tackling the typical interpersonal difficulties that occur in axis-II disorders.

Background: This study aimed to explore changes in patterns of use of psychotropic medication in Sydney nursing homes over recent years, and to compare current usage rates with those reported from other countries.

Methods: Data were obtained from 44 of the 48 nursing homes in a central Sydney health area. Researchers noted details from medication cards concerning residents’ age, gender and all currently prescribed drugs, checking whether medication had been given as prescribed. Frequency of administration of “as required” drugs in the previous four weeks was noted.

Results: The pattern of use of psychotropic medication changed considerably between 1993 and 2009. The number of residents taking regularly administered antipsychotics increased by 24% during 1998–2009, though mean dosages decreased. In 2009, fewer residents took hypnotic and/or anxiolytic medications than in the 1990s, and fewer than in countries from which equivalent data have been reported. Antidepressant use increased over the 16 years but only to 25.6%. Only 3% of residents in Sydney nursing homes in 2009 took cognition-enhancing drugs.

Conclusions: Compared to other countries, rates of use of hypnotic, anxiolytic and antidepressant medication in Sydney nursing homes are low. Benefits and disadvantages of these differences merit analysis. Antipsychotic medications were administered to similar percentages of survey residents in 1993 and 2009, but at lower mean dosages in 2009 compared to previous surveys, and with a change to using mainly atypical antipsychotic drugs. Compared to various other countries, cognition-enhancing and antidepressant medications are administered to proportionally fewer residents in Sydney nursing homes. Outcome analysis regarding the use and benefits of such drugs in nursing homes is desirable.

Patients with moderate to severe dementia commonly exhibit agitation and aggression in response to personal care. Incident pain is a common factor underlying response agitation that in turn can obstruct the delivery of essential nursing care. Medications commonly used to manage response agitation have specific risks in patients with dementia. This report details the case of a patient suffering from severe dementia with incident pain and response agitation that remitted with the use of sublingual sufentanil, a rapid-onset and ultra-brief acting opioid analgesic.

Background: The aim of the study was to investigate whether urinary tract infection (UTI) in a representative sample of 85-, 90- and ≥95-year-old women is associated with delirium.

Methods: In 504 out of 643 women (78.4%) it was possible to evaluate UTI and delirium. Assessments such as the Organic Brain Syndrome (OBS) Scale, the Geriatric Depression Scale-15 (GDS-15) and the Mini-mental State Examination (MMSE) were performed during home visits. Delirium, dementia and depression were diagnosed according to the DSM-IV criteria. A diagnosed, symptomatic UTI with or without ongoing treatment, documented in medical records or detected in association with the assessments, was registered.

Results: Eighty-seven of 504 women (17.2%), were diagnosed as having a UTI with or without ongoing treatment when they were assessed, and almost half of them (44.8%) were diagnosed to be delirious or having had episodes of delirium during the past month. One hundred and thirty-seven of the 504 women (27.2%) were delirious or had had episodes of delirium during the past month and 39 (28.5%) of them were diagnosed to have a UTI. In a multivariate logistic regression model, delirium was significantly associated with Alzheimer's disease (OR = 5.8), multi-infarct dementia (OR = 5.4), depression (OR = 3.1), heart failure (OR = 2.3) and urinary tract infection (OR = 1.9).

Conclusions: A large proportion of very old women with UTI suffered from delirium which might indicate that UTI is a common cause of delirium. There should be more focus on detecting, preventing and treating UTI to avoid unnecessary suffering among old women.

Background: Inappropriate sexual behavior (ISB) is an important topic in geriatrics; etiologies remain unclear and evidence for the efficacy of treatment strategies is limited. The aims of this study were to provide a description of the phenomenology of ISB in the geriatric population, to identify potential contributing factors, and to review the efficacy of interventions aimed at reducing ISB.

Methods: A retrospective chart review was conducted of ten patients admitted to an academic inpatient geriatric psychiatry ward because of their ISB (study group) and ten patients matched in age and gender (control group). A comprehensive chart review inventory was done to determine variables that may contribute to ISB. For the study group, effectiveness, adverse effects, and discontinuation due to adverse effects of interventions aimed at reducing ISB were reviewed.

Results: A significant finding was the association of a history of right frontal lobe stroke with ISB (Fisher's Exact Probability Test p < 0.05). Also significant was performance on cognitive testing and the presence of dementia (Fisher's Exact Probability Test p < 0.05) in the study group. Citalopram was well tolerated but with minimal reduction of ISB. Atypical antipsychotics olanzapine and risperidone were effective in some cases but also had adverse effects. Medroxyprogesterone acetate was well tolerated and effective in all cases in which it was utilized (n = 5).

Conclusions: This study suggests that ISB in the geriatric population is associated with a history of right frontal lobe stroke and with severity of dementia. Case examples of pharmacologic interventions are reviewed.

It is predicted that there will be a significant growth in the population aged over 65 years in the U.K., from 15.9% in 2000 to 23.3% in 2050, with the fastest growth rate being among the oldest old (United Nations, 2005). In line with such growth, there will be a commensurate increase in the population of older people suffering from psychiatric conditions. This will lead to a demand for increased health care services and the need for reorganization and prioritization of resources channeled into health care for this group.

Background: Male sexual dysfunction is a significant international public health issue affecting both middle-aged and older adults. To date, however, no studies have compared age differences in psychiatric issues, frequency of sexual activity and treatment recommendations between older and middle-aged male military Veterans seeking treatment for erectile dysfunction (ED) in the U.S.A.

Methods: Data were collected between 1982 and 2003 at the Palo Alto Veterans Affairs Andrology Clinic. The 1,250 participants, aged 22 to 87 years (median = 63), completed a semi-structured interview. Using multiple linear regressions, we examined age differences in five domains: medical and endocrine risk factors; psychiatric and psychosocial risk factors; frequency of sexual behaviors; self-reported and objectively measured erectile function; and treatment recommendations.

Results: Compared with middle-aged adults, older adults were more likely to present for ED treatment with medical risk factors and were more often recommended a vacuum pump treatment. Middle-aged male Veterans were more likely to experience psychiatric risk factors for ED and were more sexually active than older Veterans. Despite greater objective erectile ability in middle-aged adults, there were no age differences in maximum self-reported erectile functioning.

Conclusions: These results provide some evidence of age-related characteristics and treatment needs of male patients seeking treatment for sexual dysfunction. We encourage health care professionals working with adults across the lifespan to consider ways to individualize psychoeducation and brief psychotherapy for the treatment of ED to the specific needs of the patient, which may vary between middle-aged and older cohorts of patients.