Background: The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high, and it has been shown previously that people with such symptoms have poorer health outcomes. This study was designed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth, Western Australia. We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls.

Methods: The study was designed as a randomized, single-blinded, controlled trial. All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated randomly to the intervention or usual care group. Demographic and clinical information (including medications and use of physical restraint) was gathered systematically from all participants at baseline, and at 6 and 12 months. At each assessment, the Geriatric Depression Scale (GDS), the Health of the Nation Outcome Scales for older adults (HoNOS 65+), the Mini-mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered. Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were reviewed within a 2-week period by the Inner City Mental Health Service of Older Adults (ICMHSOA). If clinically appropriate, mental health services were introduced without the involvement of the research team.

Results: One hundred and six subjects and their next of kin consented to participate in the study (53 in each group). Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts, self-rated health, use of psychotropic or PRN medication, use of physical restraint, 12-month mortality, or mental health outcomes, as measured by the GDS-15, HoNOS 65+ and NPI (p>0.05 for all relevant outcomes).

Conclusion: Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes. More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed.

Background: Mounting evidence implicates diets high in fats and processed sugars with increased generation of free radicals in animals. It is still not clearly established whether such a diet alters antioxidant balance in dementia patients, where an oxidative stress status may already exist. The disruption to lipid metabolism by oxidative stress has been recently linked to neurodegeneration and clinical disease. The aim of this study is to assess the relationship between fat, sugar, carbohydrate and caloric intake levels, and antioxidant status in patients with mild to moderate dementia.

Methods: The levels of 3 essential endogenous antioxidants (superoxide dismutase, catalase, glutathione peroxidase) were measured in the blood of 26 dementia subjects and 26 cognitively unimpaired controls. Concurrently, the intake levels of relevant nutrients and dietary antioxidants were assessed in all subjects.

Results: A statistically significant positive association was observed in the dementia group between glutathione peroxidase activity and the intake of fats (r=0.44; p=0.023), carbohydrates (r=0.46; p=0.018), total sugars (r=0.51; p=0.007) and calories (r=0.47; p=0.14). The only significant association in the control group was observed between glutathione peroxidase and fat (r=0.47; p=0.015).

Conclusion: The higher glutathione peroxidase activity among subjects with greater intake of fats, carbohydrates and sugars may represent a compensatory response to the additional increase in oxidative stress in dementia. Our data shed light on the influence of dietary intake on the oxidant-antioxidant system in mild to moderate dementia patients.

Several genetic disorders, though rare, are associated or present with dementia. Developments in the field of genetics are contributing to clarify and expand our knowledge of the complex physiopathological mechanisms leading to neurodegeneration and cognitive decline. Disorders associated with misfolded and aggregated proteins and lipid, metal or energy metabolism are examples of the multifarious disease processes converging in the clinical features of dementia, either as its predominant feature, as in cases of Alzheimer's disease (AD) or frontotemporal dementia (FTD), or as part of a cohort of accompanying or late-developing symptoms, as in Parkinson's disease (PD) or amyotrophic lateral sclerosis with dementia (ALS-D). Awareness of these disorders, allied with recent advances in genetic, biochemical and neuroimaging techniques, may lead to early diagnosis, successful treatment and better prognosis.

Background: This study was carried out to determine why women caring for men report more burden than other caregivers, and to further examine the role of care-recipient problem behaviors as determinants of burden.

Method: A sample of 557 primary caregivers of community-dwelling individuals referred to a memory clinic was used. All care-recipients had a diagnosis of Alzheimer's disease (NINCDS-ADRDA). Data on care-recipient function, caregiver attributes, external supports and caregiver burden were obtained on the first visit. Hierarchical regression models were used to determine the contribution of gender, after controlling for care-recipient status, caregiver attributes, and external supports.

Results: This model explained 46% of the variability in caregiver “role burden”, with care-recipient problem behaviors and dependence in instrumental activities of daily living. The caregiver/care-recipient gender interaction explained an additional 4% of the variance (p=0.001); women caring for men scored 5.61 higher on the burden scale than other caregivers. Specific problem behaviors (e.g., anger) were more problematic for women caregivers than men.

Conclusion: These results indicate that the experience of men and women caregivers may be different despite seemingly identical circumstances, and highlight the need for interventions geared to the specific needs of women caregivers.

Background: Alzheimer's disease (AD) is characterized by multiple cognitive deficits and affects functional competency to perform daily activities (ADL). As this may contribute to the patient's overall disability, it is important to identify factors that compromise competency.

Objective: The relationship between different cognitive domains and functional activities in AD was studied.

Methods: The functional competency of 73 Japanese AD patients, most with mild dementia, was assessed using a 27-item relative/carer-rating scale covering 7 ADL: managing finances, using transportation, taking precautions, self-care, housekeeping, communication and taking medicine. Cognitive assessment used 16 neuropsychological tests from the Japanese version of the WAIS-R and COGNISTAT, covering 9 cognitive domains: orientation, attention, episodic memory, semantic memory, language, visuoperceptual and construction abilities, computational ability, abstract thinking, and psychomotor speed.

Results: Multiple regression analysis by the stepwise method indicated that functional competency could, for the most part, be predicted from test scores for orientation, abstract thinking and psychomotor speed.

Discussion: The results of this study suggest that impairment of these three cognitive domains plays an important role in the functional deterioration of AD.

Background: Cerebrovascular disease may cause “vascular depression” (VaD). Calcium-channel blockers are presumed treatments for cerebrovascular disease and might be expected to improve depression and prevent recurrence.

Objective: To examine the efficacy and tolerability of the use of nimodipine as an augmentation of fluoxetine in the treatment of VaD.

Design: A double-blind, randomized clinical trial in which 101 patients with VaD (Alexopoulos criteria) were treated with fluoxetine at standard doses. Patients were randomized to placebo (n=51) or nimodipine (n=50). Treatment outcomes were assessed using the Hamilton Depression Rating Scale (HDRS) regularly up to 8 months after treatment initiation.

Results: Depression was reduced in 63% of patients, but those whose treatment was enhanced with nimodipine had greater improvements overall by repeated measures analysis of covariance (ANCOVA) (F(1.80)=9.76, p=0.001). In addition, a greater proportion of patients treated with fluoxetine–nimodipine (54% vs. 27%) exhibited full remission (χ2(d.f. 1)=7.3, p=0.006), with the number needed to treat (NNT) equal to 4 (95% CI 2–12). Of those experiencing full remission in the first 61 days, fewer patients on fluoxetine–nimodipine (3.7%) developed recurrence of major depression as compared to those on fluoxetine alone (35.7%) (χ2(d.f. 1)=7.56, p=0.006), NNT 3 (95% CI 2–9). Side-effects were noted in 33.3% of patients in the control group and 48% of the experimental group (χ2(d.f. 1)=2.25, p=0.133).

Conclusions: In treating VaD, augmentation of fluoxetine with nimodipine led to better treatment results and lower rates of recurrence. These findings support the argument that augmentation of antidepressant therapy might be helpful in the treatment of cerebrovascular disease, which is involved in the pathogenesis of this type of depression.

Background: Platelet hyper-aggregability is an important risk factor for leukoaraiosis. In this study we investigated whether aggravation of leukoaraiosis can be controlled by means of long-term correction of platelet hyper-aggregability.

Methods:Twenty-one patients with leukoaraiosis and uncorrected platelet hyper-aggregability were compared with 21 controls matched for age, grade of leukoaraiosis and observation period whose platelet hyper-aggregability was corrected. Platelet aggregability was estimated by an optical analytical method with a nine-stage display using two different concentrations each of adenosine diphosphate (ADP) and collagen (the double ADP method).

Results:The mean observation period between two magnetic resonance imaging (MRI) scans for both groups was 4.1 years. In the non-corrected group, moderate to severe aggravation of leukoaraiosis was observed in a large number of patients. In the corrected group, only a small number of patients showed generally mild aggravation of leukoaraiosis. The number of patients showing aggravation of periventricular hyperintensity (PVH) was 7 in 21 in the non-corrected group versus 1 in 21 (p=0.022) in the corrected group, and for aggravation of deep white-matter hyperintensity, these values were 9 in 21 versus 4 in 21, respectively. Thus, the difference was more significant if the degree of aggravation was taken into account.

Conclusion:The progress of leukoaraiosis is greatly inhibited by long-term correction of platelet hyper-aggregability.

Objective: The aim of this study was to retrospectively differentiate the cognitive profile of subjects with geriatric depression who will later be diagnosed with Alzheimer's disease (AD) from those who will be diagnosed with other dementias, and subjects who will remain with no dementia.

Methods: Forty-four depressed patients admitted to a day hospital program for depression who participated in a historical cohort study were assessed after 7.5 years of follow-up. Fourteen of these subjects subsequently developed dementia: seven met the criteria for probable AD and seven met the criteria for dementias other than AD (Dementia-No-AD; D-NAD, such as dementia with Lewy bodies (DLB), vascular and mixed dementia). Thirty subjects remained without dementia (No Dementia, ND) at follow-up. The three groups were thus compared on their baseline cognitive performances on the six sections of the Mini-mental State Examination (MMSE) and on the five subscales of the Dementia Rating Scale (DRS).

Results: An analysis of variance (ANOVA) and post-hoc Student–Newman–Keuls analyses with an alpha of p<0.05 revealed that the subjects who received a diagnosis of dementia at follow-up had previously had more impairment on tasks measuring attention and memory (DRS-MMSE) than those who did not develop dementia (AD=D-NAD<ND). Moreover, the future AD subjects could be differentiated on the basis of their difficulties on the MMSE-orientation subtest (AD<ND=D-NAD), whereas the future D-NAD subjects initially had more problems with executive functions (DRS) and MMSE-visuospatial abilities (D-NAD<AD=ND).

Conclusion: The identification of early neuropsychological markers in elderly depressed patients highlights the need to evaluate this population broadly as soon as possible in the depression/dementia process in order to improve the prognosis.

Background: In recent years, it has been claimed that learning potential (also called cognitive plasticity or rehabilitation potential) may be a good predictor of the course of cognitive impairment and the process of dementia. The basic objective of this research program is to test the extent to which the “Battery of Learning Potential for Assessing Dementia” (BEPAD) discriminates healthy people from those diagnosed with Mild Cognitive Impairment (MCI) and with Alzheimer's Disease (AD).

Methods: Two hundred people: 100 healthy elders (51 women, 49 men, mean age: 73.13), 50 diagnosed with MCI (30 women, 20 men, mean age: 74.89), and 50 diagnosed with mild AD (36 women, 14 men, mean age: 75.07). Learning potential was assessed through dynamic assessment (or testing-the-limits), using experimental test-training-post-test, a form of evaluation closely related to functional or stress testing in medicine. In several previous studies the BEPAD was developed, with four tasks: visuo-spatial, verbal recall (including delayed verbal recall), executive control and verbal fluency. For all of these tasks, training procedures were developed, converting them into learning potential tests.

Results and Conclusions: All “dynamic” or learning scores (post-test) discriminate better healthy, MCI and AD subjects than all static or pre-test scores. A total of 89% of cases are correctly classified by the BEPAD: 95.7% of the healthy subjects, 90.6% of AD patients, and 71.1% of the MCI individuals were correctly classified.

Background: Australia has a growing aging migrant population and rates of dementia in residential care are high. The communication of persons with dementia and limited English language proficiency in residential care is an area that has received little attention in the research literature.

Method: Thirty-nine Italian-background older persons with severe dementia residing in either mainstream (n = 20) or Italian-specific (n = 19) aged care facilities were observed and language use was recorded. Medication regime and language proficiency information was obtained.

Results: Participants in mainstream facilities engaged in less communication with co-residents and were prescribed daytime benzodiazepines at a higher rate than those in Italian-specific facilities.

Conclusions: Older persons in mainstream facilities with dementia and lower levels of English proficiency may benefit from additional language-relevant resources. The finding of higher prescription rate of daytime benzodiazepines requires further investigation.

In this review, we explore the relationship between epilepsy and cognition and between epilepsy and dementia. Chronic epilepsy, particularly mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis, may be associated with impaired cognition, which can be secondary to uncontrolled seizures, to adverse effects of antiepileptic drugs (AEDs) or to the underlying biological abnormality. The choice of an adequate AED with an appropriate dose regimen may lead to a favorable outcome. This feature is especially relevant in elderly patients with dementia and associated epilepsy, a vulnerable population in which the diagnosis of seizures can be difficult and for whom treatment guidelines are not yet available. Based on available information and on data derived from studies with other populations, recommendations for the management of these patients are presented.

Background: Subjective cognitive complaints have been included in diagnostic concepts such as Aging-Associated Cognitive Decline (AACD) aiming to identify older adults with cognitive impairments at high risk of developing dementia. Although several studies in normal aging have found that subjective cognitive complaints are related to depressive affect and personality factors, little is known as to whether this is also true for older adults with AACD.

Methods: In 123 older adults diagnosed with AACD and 291 controls, the role of actual cognitive performance, depressive affect, neuroticism and conscientiousness in predicting subjective cognitive complaints was investigated. In separate ordinary least squares regression analyses for both groups with gender, age, years of schooling, cognitive performance, depressive affect, neuroticism and conscientiousness as predicting variables, in the control participants, gender, age, depressive affect and neuroticism were related to subjective cognitive complaints, whereas in the AACD participants only gender and neuroticism accounted for variance in subjective cognitive complaints. Testing for group differences in predictive power, revealed differential effects for gender, depressive affect and neuroticism.

Conclusions: As subjective cognitive complaints in the AACD group were related to neuroticism and gender rather than to cognitive performance, their inclusion in diagnostic concepts such as AACD should be revaluated. However, the nature of subjective cognitive complaints might be qualitatively different in persons diagnosed with AACD compared to those stated by normal older adults.

Functional psychiatric disorders are associated with a variety of cognitive deficits and, in some instances, severe cognitive impairment. This paper reviews the cognitive profile of patients with schizophrenia, depression, bipolar and anxiety disorders, as well as the longitudinal course and clinical outcome of the cognitive impairment associated with these conditions. The paper also discusses some of the mechanisms that may contribute to the expression of the cognitive deficits in these disorders and their potential relationship with common causes of dementia.

Old age psychiatrists are often called upon to give expert evidence in challenges of testamentary capacity. The nineteenth-century English case, Banks v. Goodfellow (1870) remains the hallmark case for defining the criteria for testamentary capacity in Australia and other Common Law countries. However, a need to go beyond the traditional Banks and Goodfellow criteria for defining testamentary capacity (i.e. (i) understanding of the nature of a will; (ii) knowledge of the nature and extent of one's assets; (iii) being able to recall and understand the claims of potential heirs; (iv) being free of delusions or hallucinations that influence one's testamentary decisions) has been identified recently in the international literature (Shulman et al., 2005). Recent court rulings in Australia which have acknowledged the differences between the nineteenth-century context and today are therefore of international interest, as are recently adapted guidelines for clinicians asked to assess capacity.

Objective: Depression, one of the most prevalent psychiatric disorders, causes disability and reduces quality of life. Rates of clinical depression in community samples of older adults range between 1–16%. Most studies of old age depression have been conducted in developed countries. The present study was conducted to determine the prevalence of depressive disorders among Turkish elderly in an urban community.

Method: This study was carried out in the Kadiköy district of Istanbul. The sample for the cross-sectional part of the study was 1067 individuals age 70 or older, randomly selected from population registries. Geriatric Depression Scale (GDS), Mini-mental State Examination (MMSE) scores and demographic data were obtained by face-to-face home interviews. The data were analyzed using regression analysis for each variable.

Results: The study group consisted of 623 (61%) females and 395 (39%) males. The mean age was 74.8 years, with 63% of subjects aged 70–74, 29% between 75–84 years old and 8% aged 85 and above. Sixteen percent (n=163) of the total group scored 14 or higher on the GDS. Only 9% of the depressed group were on antidepressant medication. Logistic regression analysis indicated that significant predictors for higher scores GDS scores were: illiteracy, aged 75–79 yrs, female sex and having 4 or more children.

Conclusion: Depression is a common but unrecognized and thus untreated problem among the elderly population in Turkey. While gender and age are unmodifiable, education level and multiparity can be altered. Education of caregivers and medical staff about old age depression may increase its rate of detection and facilitate improved treatment.

No medication has received regulatory approval in the U.S.A. for the distressing agitation and aggressive behaviors that often complicate dementia. Although studies suggest that several psychotropic medications are sometimes useful for these behavioral problems, response is variable and adverse effects often limit treatment. Theoretical considerations suggest that increasing estrogenic activity or reducing androgenic activity could reduce agitation and aggression in dementia. Estrogen has been reported helpful for these symptoms, but adverse effects are problematic. Chronic administration of the synthetic gonadotropin (luteinising hormone) releasing hormone analogue, goserelin, reduces testosterone activity. Here we describe the apparently sustained elimination of previously treatment-resistant agitation and aggression with goserelin treatment in a 78-year-old male nursing-home resident with Alzheimer's disease.

There is much caregiving literature describing factors that affect carer burden, and interventions that may be useful for carers of those with common dementias such as Alzheimer's disease (AD). By contrast, relatively little information and few data are available on potentially diverse issues facing carers of those with uncommon dementias, such as frontotemporal dementia (FTD), Huntington's disease (HD) and human immunodeficiency virus (HIV) dementia. This paper highlights particular characteristics of caregiving for those with uncommon dementias, and the unique needs that may arise for this group of carers who often “fall between the net” of services and supports available. Further research into this area is required.