The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents.

A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores.

During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks.

The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

Given growing numbers of older adults with mental and substance use disorders (MSUDs), this study examined the association between ten types of adverse childhood experiences (ACEs) and lifetime MSUDs among those aged 50+.

Data (N = 14,738 for the 50+ age group) came from the 2012 to 2013 National Epidemiologic Survey on Alcohol and Related Conditions. Using multivariable binary logistic regression analyses, we examined relationships between ten ACEs and six lifetime MSUDs (major depressive disorder (MDD) and anxiety, post-traumatic stress, alcohol use, drug use, and nicotine use disorders). Gender differences were examined using tests of interaction effects and gender-separate logistic regression models.

Of the sample, 53.2% of women and 50.0% of men reported at least one ACE. For both genders, parental/other adult's substance abuse was the most prevalent (22.6%), followed by physical abuse, and emotional neglect. Child abuse and neglect and parental/other adult's mental illness and substance abuse had small but consistently significant associations with MSUDs (e.g., odds ratio = 1.28, 95% CI = 1.12–1.46 for parental/other adult's substance misuse and MDD). Although the relationship between total number of ACEs and MSUDs was cumulative for both men and women, the associations of physical abuse, sexual abuse, emotional neglect, and parental separation/divorce with MSUDs were stronger among men.

This study underscores the significant yet modest association between ACEs and lifetime MSUDs in late life. More research is needed to investigate why ACEs seem to have greater effects on older men and to discern the sources of gender differences in ACEs’ effects.

Subjective cognitive decline (SCD), the potentially earliest notable manifestation of preclinical Alzheimer's disease and other dementias, was consistently associated with lower quality of life in cross-sectional studies. The aim of this study was to investigate whether such an association persists longitudinally – particularly with health-related quality of life (HRQoL) in older individuals without cognitive impairment.

Data were derived from follow-up 2–6 of the prospective Germany Study on Ageing, Cognition and Dementia in Primary Care (AgeCoDe) covering a total six-year observation period. We used linear mixed effects models to estimate the effect of SCD on HRQoL measured by the EQ-5D visual analogue scale (EQ VAS).

Of 1,387 cognitively unimpaired individuals aged 82.2 years (SD = 3.2) on average, 702 (50.6%) reported SCD and 230 (16.6%) with SCD-related concerns. Effect estimates of the linear mixed effects models revealed lower HRQoL in individuals with SCD (unadjusted: –3.7 points on the EQ VAS, 95%CI = –5.3 to –2.1; SE = 0.8; p < 0.001; adjusted: –2.9 points, 95%CI = –3.9 to –1.9; SE = 0.5; p < 0.001) than in individuals without SCD. The effect was most pronounced in SCD with related concerns (unadjusted: –5.4, 95%CI = –7.6 to –3.2; SE = 1.1; p < 0.001; adjusted: –4.3, 95%CI = –5.8 to –2.9, SE = 0.7; p < 0.001).

SCD constitutes a serious issue to older cognitively unimpaired individuals that is depicted in persisting lower levels of HRQoL beyond depressive symptoms and functional impairment. Therefore, SCD should be taken seriously in clinical practice.

Previous studies have thoroughly investigated the prevalence and risk factors for completed suicide. In marked contrast is the lack of a better understanding of attempted suicide in the elderly. The aim of this study was to estimate the prevalence of attempted suicide in the elderly and examine the associated factors.

Using a multi-stage cluster sampling approach, a cross-sectional survey of 8,399 elderly house-dwelling residents was conducted in Shanghai, China.

The two-week prevalence of attempted suicide in the elderly was 0.75%. In the bivariate analysis, having no caregivers, depressive, anxiety, sad, fear, obsessive-compulsive and anger symptom, and lower scores on the Barthel Index of Activities of Daily Living and the Lawton Instrumental Activities of Daily Living Scale were significantly associated with an increased risk of attempted suicide in the elderly. In the multivariate analysis, sad and fear symptoms were significantly and independently associated with a higher risk of attempted suicide in the elderly.

The two-week prevalence of attempted suicide in the elderly is relatively high when compared with the annualized or lifetime prevalence reported in China and foreign settings. Elderly individuals with certain mental symptoms should be targeted for suicide prevention and provided with timely mental health support.

Comprehensive neurocognitive assessment may not be performed in clinical practice, as it takes too much time and requires special training. Development of easily applicable, time-saving, and cost effective screening methods has allowed identifying the individuals that require further evaluation. The aim of present study was to assess the diagnostic value of the Attended With (AW) and Head-Turning Sign (HTS) for screening cognitive impairment (CI).

Comprehensive geriatric assessment was performed in 529 elderly outpatients, and the presence or absence of AW and HTS was investigated in them all.

Of the 529 patients, of whom the mean age was 75.67 ± 8.29 years, 126 patients were considered as CI (102 dementia, 24 mild CI). The patients with positive AW had significantly lower scores on Mini-Mental State Examination, Cognitive State Test, and Montreal Cognitive Assessment, and activities of daily living compared to AW (−) patients (p < 0.001). Similar significant findings were obtained in the patients with positive and negative HTS (p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of AW in detecting CI were 92%, 37%, 31.4%, and 93.7%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of HTS were 80%, 64%, 41.8%, and 91.5%, respectively. The area under the receiver-operating characteristics curve was 0.90 for AW and 0.82 for HTS.

AW and HTS are fast, simple, effective, and sensitive methods for detecting CI. Therefore, they can be used for older adults attending the primary care settings with memory loss. Those with positive AW or HTS can be referred to the relevant centers for detailed cognitive assessment.

Detecting delirium superimposed on dementia (DSD) can be challenging because assessment partly relies on cognitive tests that may be abnormal in both conditions. We hypothesized that a combined arousal and attention testing procedure would accurately detect DSD.

Patients aged ≥70 years were recruited from five hospitals across Europe. Delirium was diagnosed by physicians using DSM-5 criteria using information from nurses, carers, and medical records. Dementia was ascertained by the Informant Questionnaire on Cognitive Decline in the Elderly. Arousal was measured using the Observational Scale of Level of Arousal (OSLA), which assesses eye opening, eye contact, posture, movement, and communication. Attention was measured by participants signaling each time an “A” was heard when “S-A-V-E-A-H-A-A-R-T” was read out.

The sample included 114 persons (mean age 82 years (SD 7); 54% women). Dementia alone was present in 25% (n = 28), delirium alone in 18% (n = 21), DSD in 27% (n = 31), and neither in 30% (n = 34). Arousal and attention was assessed in n = 109 (96%). Using OSLA, 83% participants were correctly identified as having delirium (sensitivity 85%, specificity 82%, AUROC 0.92). The attention task correctly classified 76% of participants with delirium (sensitivity 90%, specificity 64%, AUROC 0.80). Combining scores correctly classified 91% of participants with delirium (sensitivity 84%, specificity 92%, AUROC 0.94). Diagnostic accuracy remained high in the subgroup with dementia (93% correctly classified, sensitivity 94%, specificity 92%, AUROC 0.98).

This combined arousal–attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD.

Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment.

Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs’ attitude of “trying to establish a diagnosis of dementia on their own.”

Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28–5.23).

Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

The onset of Alzheimer's disease (AD) affects couples’ relationship. We investigated the perception of change and sexual satisfaction in spouse-caregivers and their partners diagnosed with AD.

We compared 74 dyads of people with Alzheimer's disease (PwAD)/spouse-caregivers and 21 elderly dyads control. We assessed sexual satisfaction with Questionnaire on Sexual Experience and Satisfaction (QSES), cognition using a Mini-Mental State Examination (MMSE), disease severity using a Clinical Dementia Rating scale (CDR), awareness of disease with Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD), functionality with Pfeffer Functional Activities Questionnaire (FAQ), depressive symptoms with Cornell Scale for Depression in Dementia (CSDD), quality of life using a Quality of Life in Alzheimer's Disease Scale (QoL-AD), and burden using a Zarit Burden Interview (ZBI).

We found differences between the perception and no perception of change in sexual activity of PwAD (p < 0.001), spouse-caregivers (p < 0.01), and controls (p < 0.05). Moderate to severe sexual dissatisfaction was observed in 36.5% of PwAD, 65% of spouse-caregivers, and 31% of controls. PwAD sexual satisfaction was related to cognitive impairment (p < 0.05). Spouse-caregivers sexual satisfaction was related to gender (p < 0.05) and the presence of sexual activity (p < 0.001).

The perception of change with higher sexual dissatisfaction, were significant in PwAD and their spouse-caregivers, in comparison with couples of elderly without dementia.

Family members are often called upon to make decisions for an incapacitated relative. Yet they have difficulty predicting a loved one's desire to receive treatments in hypothetical situations. We tested the hypothesis that this difficulty could in part be explained by discrepant quality-of-life assessments.

The data come from 235 community-dwelling adults aged 70 years and over who rated their quality of life and desire for specified interventions in four health states (current state, mild to moderate stroke, incurable brain cancer, and severe dementia). All ratings were made on Likert-type scales. Using identical rating scales, a surrogate chosen by the older adult was asked to predict the latter's responses. Linear mixed models were fitted to determine whether differences in quality-of-life ratings between the older adult and surrogate were associated with surrogates’ inaccuracy in predicting desire for treatment.

The difference in quality-of-life ratings was a significant predictor of prediction inaccuracy for the three hypothetical health states (p < 0.01) and nearly significant for the current health state (p = 0.077). All regression coefficients were negative, implying that the more the surrogate overestimated quality of life compared to the older adult, the more he or she overestimated the older adult's desire to be treated.

Discrepant quality-of-life ratings are associated with surrogates’ difficulty in predicting desire for life-sustaining interventions in hypothetical situations. This finding underscores the importance of discussing anticipated quality of life in states of cognitive decline, to better prepare family members for making difficult decisions for their loved ones.

ISRCTN89993391

A past history of self-harm is a significant risk factor for suicide in older people. The aims of this study are to (i) characterize older people who present with self-harm to emergency departments (EDs); and (ii) determine the predictors for repeat self-harm and suicide.

Demographic and clinical data were retrospectively collected on older people (age 65+ years), who presented to seven EDs in New Zealand following an episode of self-harm between 1st July 2010 and 30th June 2013. In addition, 12-month follow-up information on repeat self-harm and suicide was collected.

The sample included 339 older people (55.2% female) with an age range of 65–96 years (mean age = 75.0; SD = 7.6). Overdose (68.7%) was the most common method of self-harm. 76.4% of the self-harm cases were classified as suicide attempts. Perceived physical illness (47.8%) and family discord (34.5%) were the most common stressors. 12.7% of older people repeated self-harm and 2.1% died by suicide within 12 months. Older people who had a positive blood alcohol reading (OR = 3.87, 95% Cl = 1.35–11.12, p = 0.012) and were already with mental health services at the index self-harm (OR = 2.73, 95% Cl = 1.20–6.25, p = 0.047) were more likely to repeat self-harm/suicide within 12 months.

Older people who self-harm are at very high risk of repeat self-harm and suicide. Screening and assessment for alcohol use disorders should be routinely performed following a self-harm presentation, along with providing structured psychological treatment as an adjunct to pharmacological treatment for depression and interventions to improve the person's resilience resources.

Both physical frailty and cognitive impairment predict death, but the joint effect of these two factors is uncertain. The objectives are to determine if the Mini-mental state examination (MMSE) and the Frailty Index (FI) predict death over a five-year interval after accounting for the effect of the other; and if there is an interaction in this effect.

An analysis of an existing prospective cohort study of 1,751 community living older adults followed over a five-year time frame. Age, gender, and education were self-reported. The predictor variables were the FI – a measure of frailty based on the “Accumulation of Deficits” model of frailty; and the MMSE. Cox proportional hazards models were constructed for the outcome of time to death.

The unadjusted Hazard Ratio (HR) (95% CI) for mortality was 2.17 (1.69, 2.80) for those who were only cognitively impaired, 2.02 (1.53, 2.68) for those who were only frail, and 3.57 (2.75, 4.62) for those who were both frail and cognitively impaired with the reference group of those who were neither frail nor cognitively impaired. Adjusted for age, gender, and education, the HR (95% CI) was 1.49 (1.13. 1.95) for those who were only cognitively impaired, 1.81 (1.35, 2.41) for those who were only frail, and 2.28 (1.69, 3.09) for those who were both frail and cognitively impaired.

Both frailty and cognitive impairment are predictors of mortality and the effect is cumulative. There was no interaction in this effect.

Most of the previous studies attempted to disentangle the relationship between disability and depressive symptoms were limited to observation periods of only few years. Moreover, evidence is missing regarding the complex co-occurrence of disability and depressive symptoms in old age in Germany. In order to close the research gap, we aimed at disentangling the complex co-occurrence of disability and depressive symptoms in old age in Germany over a longer time frame.

Based on data from a representative survey of the German general population aged 75 years and older, the course of disability as well as depressive symptoms was observed every 1.5 years over six waves. While disability was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale, the Geriatric Depression Scale was used to measure depressive symptoms. Taking into account the complex co-occurrence of depressive symptoms and disability, a panel vector autoregressive model was used. By taking the first differences, unobserved heterogeneity was taken into account.

In the total sample and in both sexes, we revealed a robust positive association between an initial change in depressive symptoms and subsequent changes in disability. No robust association between an initial change in disability and a subsequent change in depressive symptoms was detected.

Our findings highlight the importance of changes in depressive symptoms for future changes in disability in old age.

Volumetric atrophy and microstructural alterations in diffusion tensor imaging (DTI) measures of the hippocampus have been reported in people with Alzheimer's disease (AD) and mild cognitive impairment (MCI). However, no study to date has jointly investigated concomitant microstructural and volumetric changes of the hippocampus in dementia with Lewy bodies (DLB).

A total of 84 subjects (23 MCI, 17 DLB, 14 AD, and 30 healthy controls) were recruited for a multi-modal imaging (3T MRI and DTI) study that included neuropsychological evaluation. Freesurfer was used to segment the total hippocampus and delineate its subfields. The hippocampal segmentations were co-registered to the mean diffusivity (MD) and fractional anisotropy (FA) maps obtained from the DTI images.

Both AD and MCI groups showed significantly smaller hippocampal volumes compared to DLB and controls, predominantly in the CA1 and subiculum subfields. Compared to controls, hippocampal MD was elevated in AD, but not in MCI. DLB was characterized by both volumetric and microstructural preservation of the hippocampus. In MCI, higher hippocampal MD was associated with greater atrophy of the hippocampus and CA1 region. Hippocampal volume was a stronger predictor of memory scores compared to MD within the MCI group.

Through a multi-modal integration, we report novel evidence that the hippocampus in DLB is characterized by both macrostructural and microstructural preservation. Contrary to recent suggestions, our findings do not support the view that DTI measurements of the hippocampus are superior to volumetric changes in characterizing group differences, particularly between MCI and controls.

Schematherapy (ST) is an effective therapy for personality disorders (PD's) in adults, however, empirical research into ST in older adults is limited. The manifestation of schemas over the life course is unclear. Besides, long-term patterns of schemas in old age and whether schemas change during the aging process remain unknown.

We performed a Delphi study involving a group meeting of nine experts in the field of ST in older adults.

Full consensus was achieved that schemas vary later in life, and that this is due to biopsychosocial factors. The concepts of schema triggering (the chance that a maladaptive schema is activated) and schema coping (the psychological and behavioral effort a person makes to minimize the stress that comes with the schema) in the past are important in clinical practice. Understanding how schemas are triggered during the life course and how patients deal with their schemas throughout life will help the therapist to complete the diagnostic puzzle in older individuals and to choose appropriate interventions.

Schemas are flexible and dynamic constructs that can fade or intensify due to multiple factors. This study is a first step toward advancing the state of knowledge regarding schema theory in an aging population. The results will contribute to improvements in ST in older adults by developing an understanding of the plasticity of schemas during the life course.

The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use.

A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed.

Forty-five eligible studies were quality assessed. A significant proportion utilized a case–control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853.

Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.