Two-thirds of individuals with Alzheimer's disease (AD) are women, owing largely to the fact that women outlive men (https://www.alz.org/downloads/facts_figures_2012.pdf). Women's increased longevity, however, is not sufficient to explain the fact that women are 1.5 times more likely than men to develop the disease (Gao et al., 1998). After age 80, the incidence of AD is much higher in women than in men, such that the proportion of women with AD is almost twice the proportion of men with the disease (e.g., Zandi et al., 2002; Plassman et al., 2007). Moreover, once diagnosed with AD, women decline more rapidly, both cognitively and functionally, compared to men (Ito et al., 2011; Tschanz et al., 2011).

Most trainees, whether social workers, physicians, psychologists or nurses, are attracted to their career choice by the desire and hope that they will “cure” people and restore them to full health. Cures do occur in all of these fields, of course, but it is a surprise to most people to learn that cures are the exception and that chronicity is the basis of the care needs for a majority of individuals in most settings.

Since the original 1984 criteria for Alzheimer's disease (AD), put forth by a work group jointly established by the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer's Disease and Related Disorders Association (ADRDA) (McKhann et al., 1984), important advances have occurred in our ability to detect AD pathophysiology, with the incorporation of biomarkers – defined as anatomic, biochemical, or physiologic parameters that provide in vivo evidence of AD neuropathology (Cummings, 2011) – that can improve the certainty of AD diagnosis. Use of imaging biomarkers such as positron emission tomography (PET) with amyloid ligands, particularly in asymptomatic and pre-dementia stages of AD, however, has been the subject of debate (Dubois et al., 2013), with arguments both for and against the biomarker driven diagnosis of AD.

It is this time again to celebrate another milestone which International Psychogeriatrics has reached. In 2014 the theme is silver, since it is a quarter of a century since the International Psychogeriatric Association (IPA), founded in 1982, and International Psychogeriatrics joined forces in the quest to improve the mental health of older people around the globe. Our journal has matured since coming to life in 1989, growing up under the watchful eyes of a series of dedicated editors to come of age in 2009 (Ames, 2009), and now experiencing maturity, enjoying the 25th wedding anniversary with the IPA. International Psychogeriatrics is proud to be the scientific journal of IPA and strives to publish high quality scientific work in the field of psychogeriatrics with the aim to reflect the global vision and mission of IPA. International Psychogeriatrics will commemorate this happy occasion with exciting content in the 12 issues of 2014 as well as a silver ribbon on the cover.

Motivated by a vision for a “new gerontology” that focuses on optimal functioning rather than losses and declines, Rowe and Kahn (1987) argued that many of the age-related declines that define usual aging are due to modifiable factors such as diet, exercise, personal habits such as smoking, and psychosocial factors. Thus, individuals may engage in lifestyle modifications to avoid diseases and, consequently, enhance their chance of aging well. Three domains of outcomes were said to jointly define successful aging: (a) low probability of disease and disease-related disability, (b) high cognitive and physical functioning, and (c) engagement with life (namely in the form of social connectedness and productive activities; Rowe and Kahn, 1997). All three criteria are meant to be relative (i.e. without absolute thresholds), although subsequent studies tend to adopt a threshold approach (see Depp and Jeste, 2006). The three criteria are somewhat hierarchical, in that avoiding diseases (and associated risk factors) makes high physical and cognitive functioning possible, which in turn enables the individual to engage in social and productive activities (Rowe and Kahn, 1997). However, remaining free of disease/disability and maintaining high physical and cognitive functioning are less likely as one ages, whereas participation in social and even productive activities may not be affected until significant physical and cognitive declines have occurred (McLaughlin et al., 2010; Yaffe et al., 2010; Hsu and Jones, 2012).

Terms to describe the behavioral and psychological symptoms commonly seen in dementia, including “Behavioral and Psychological Symptoms of Dementia” (BPSD), “non-cognitive symptoms,” and “neuropsychiatric symptoms,” were introduced in the 1980s and 1990s to draw attention to the heterogeneous group of symptoms that, distinct from cognitive deficits, are commonly seen in dementia and cause significant distress to patients and carers (Reisberg et al., 1987; Cummings et al., 1994; Allen and Burns, 1995; Finkel et al., 1996). BPSD include a wide range of affective, psychotic, and hyperactivity symptoms, and studies include different combinations of symptoms. These symptoms are also often studied individually outside the context of BPSD in the older population with or without cognitive impairment. Depression is most frequently studied, particularly in the older population without dementia. The relationship between dementia and depression in older people and the courses of the two disorders have been an important research topic for around 70 years (Roth, 1955).

Alcohol problems in older adults aged 65 years or over, in the United Kingdom and internationally, have risen steadily over the past decade. These are a common but underdiagnosed and under-recognized problem. A UK survey in 2008 found that 21% of men and 10% of women aged 65 years and over reported drinking more than four and three units of alcohol respectively on at least one day per week (National Health Service Information Centre, 2010). A recent Royal College of Psychiatrists Report (2011) cited research that showed there has been a rise in the number drinking over weekly recommended limits by 60% in men and 100% in women between 1990 and 2006 with the number of people aged over 65 years requiring treatment for a substance misuse problem, set to more than double between 2001 and 2020, all of which points to a significant public health problem both now and in the future (National Health Service Information Centre, 2009).

I think it is fair to say that the UK was one of the first countries to develop dedicated old age psychiatry services. The first such documented service was set up in the Crichton Royal Hospital in Dumfries in 1958 (Robinson, 1965). This arose after decades of recognition that older people with mental illness get a raw deal if they are managed in adult services (Hilton, 2012). Following a slow start, specific old age services began to burgeon. The discipline got recognition as a separate faculty in the Royal College of Psychiatrists in 1988, and throughout the eighties and nineties, virtually all areas of the UK developed their own specialist old age psychiatry services; multi-disciplinary teams working with people over the age of 65 generally providing community-based services with input to people's homes as the norm.

In this editorial, we hope to reflect the image of current care, often labeled as good care, in nursing homes. The data are anecdotal, based on our visits to several clinical team meetings in nursing homes, but they raise issues which are common and need to receive higher priority.

The first patient described by Alzheimer in 1907 had both progressive cognitive deterioration and prominent comorbid signs and symptoms of psychosis and agitation (Alzheimer, 1907, 1987). In this editorial, we use “psychosis” to denote delusions and hallucinations and “agitation” to denote irritability, aggression, pressured motor activity, and active resistance to necessary care. Although advances have been made in the treatment of these non-cognitive symptoms, these psychosis and agitation symptoms continued to be burdensome and costly for dementia patients, caregivers, and society. Among the pharmacologic treatments available for psychosis and agitation, antipsychotic drugs are the drug class most consistently demonstrated effective for psychosis and agitation in dementia (Lyketsos et al., 2006; APA Work Group on Alzheimer's Disease and Other Dementias et al., 2007). These are widely prescribed for these behavioral problems, but their use remains controversial and their mechanism of action unclear.

As psychiatrists, we assess, diagnose, and manage psychiatric problems in older adults. We also have an important role as their advocates and in promoting positive attitudes toward this group. Only in the 1950s was there increasing recognition that older age did not necessarily equate to senility, that treatment of psychiatric disorders in this group was possible, and could have good outcomes (Roth, 1955). There is, however, still an undercurrent of pervasive negative attitudes toward the elderly, and their psychiatric needs continue to be marginalized, with less attention from the media, funding bodies, and even from our medical and surgical colleagues (Penson et al., 2004).

The title of this Editorial, with apologies to Milan Kundera (Kundera, 1985) implies no lack of gravitas in the concept of Mild Cognitive Impairment (MCI). Rather, it refers to the current definitions of MCI being somewhat free-floating, loosely anchored to diagnostic frameworks, and more conceptual than operational. In their defense, we cannot completely obliterate the flexibility clinicians need in order to exercise expert judgment and take individual patients’ circumstances into account when making clinical diagnoses. Further, it would be imprudent to prematurely codify diagnostic criteria for MCI; after all, we are still gathering basic information about the wide range of mildly impaired states that we encounter in different clinical settings and in the population at large.

In this issue of International Psychogeriatrics, our research group published a paper on alcohol use disorders (AUD) in elderly adults (Kist et al., 2014). According to different authors, age of onset is an important characteristic to distinguish subgroups of patients with AUD, similar to, for example, late-onset depression (LOD) and late-onset schizophrenia (LOS). The cut off age to discriminate between early and late-onset AUD varies but is often 25 years, which is substantially younger than the cutoffs to discriminate LOD or LOS. However, in AUD, many patients started having alcohol problems much later in life, for example, after 45, 50, or even after 60 years. These very late onset patients are almost completely ignored in research. In a group of older inpatients with AUD, we found that those who started drinking heavily after 25 and after 45 years of age have similar cognitive impairments compared with their peers who started drinking before 25 years of age. Our results are counter-intuitive at first instance, but some other authors have found the same results. However, several potential limitations may also account for this result, and replication is needed before conclusions that are more definite can be drawn. In the preparation of this editorial, we found a lack of research in patients who started drinking excessive amounts of alcohol very late in life. This is in contrast with, for example, a fair amount of research in LOD and at least some research in LOS.

Many countries face policy challenges related to the well-being of their aging populations, and China, with the world's largest aging population, is no different. Over the past 40 years, China has experienced demographic transition toward an “aging society.” According to the National Bureau of Statistics in China (NBSC), the number of people aged 60 years and older in China has risen to 185 million, with rural areas aging more rapidly during China's demographic transition (National Bureau of Statistics of China, 2013). In 1982, the proportion of population aged 60 years and older was 7.8% in rural China and 7.1% in urban China. However, by 2011 these proportions had risen to 12.6% and 15.4%, respectively, with a national average of 13.26% (National Bureau of Statistics of China, 2013). Difference between rural and urban areas in the proportion of the population aged 65 years and older in China has shown a similar trend over time. Rapid economic reforms since the 1980s, associated with increased rural-to-urban migration, especially the outflow of rural young population, have resulted in a larger proportion of elderly adults in rural areas (Cai et al., 2012; National Bureau of Statistics of China, 2013). These same social forces have resulted in relatively fewer people available to take care of the growing population of older adults as well. The “elderly dependency ratio” (the ratio of older adults in China to those in the population of working age) has increased from 8.0% in 1982 to 12.7% in 2012 (National Bureau of Statistics of China, 2013). The economic and social impact on caregiving will be profound.

Although exact figures are lacking, many studies show that mental–physical multimorbidity is common in older people (van den Brink et al., 2013). Particularly, older patients with a chronic disease often have psychiatric disorders (Verdurmen et al., 2006). Conversely, medical comorbidity is common in psychiatric patients, especially cardiovascular, pulmonary, and neurological disorders and diabetes (Lyketsos et al., 2002).

For more than 2,000 years cognitive decline and dementia were considered a part of aging, like graying of hair, wrinkling of skin, or (more recently) reduction of pulmonary capacity or glomerular filtration rate. Thus, our recent predecessors considered “senile dementia” a normal consequence of the aging process. Their confidence increased after Martin Roth and colleagues added specificity to the concept by differentiating it within the broader category of “senile psychosis” (which, consequently, became obsolete). A diagnosis of “Alzheimer's pre-senile dementia,” by contrast, was reserved for people with earlier onset of dementia.

The question I wish to consider is: how do we approach people with dementia? I want to suggest that the approach we take should be the aesthetic one. I shall need to say what this is. My question is not an empirical one. I am not asking how we actually approach people with dementia. My question has an ethical bent to it: how ought we to approach people with dementia? In asking this question, however, I am not after an explanation suggesting we should act with kindness, compassion, honesty, integrity and so forth. We ought to do all these things, of course, and I hope such virtues will flow from the account I shall give. But I am really after something somewhat deeper, a philosophical understanding of what it is to be a person with dementia and, consequently, how we ought to stand as human beings in relation to this person.

The image used to illustrate this editorial comes from a late medieval Book of Hours and shows some of the rituals related to death and burial at the time (Figure 1). For the Christian people of medieval Western Europe death was not only a common occurrence, but also one that was illustrated in many places in their lives. In their churches they would see sculptures of the Last Judgment above the front doors, a Dance of Death inside the back door, and along the walls funerary monuments. Above them were stained glass windows as well as altarpieces that might show the Death of the Virgin or other saints. At home there would be more panel paintings, as well as the illuminations of death-related rituals in the Office of the Dead in their books of hours, and the woodcuts of the Good Death in their Ars Moriendi books.