Background: Paratonia is one of the associated movement disorders characteristic of dementia. The aim of this study was to develop an assessment tool (the Paratonia Assessment Instrument, PAI), based on the new consensus definition of paratonia. An additional aim was to investigate the reliability and validity of the PAI.

Methods: A three-phase cross-sectional survey was conducted. In the first two phases, the PAI was developed and validated. In the third phase, the inter-observer reliability and feasibility of the instrument was tested.

Results: The original PAI consisted of five criteria that all needed to be met in order to make the diagnosis. On the basis of a qualitative analysis, one criterion was reformulated and another was removed. Following this, inter-observer reliability between the two assessors resulted in an improvement of Cohen's κ from 0.532 in the initial phase to 0.677 in the second phase. This improvement was substantiated in the third phase by two independent assessors with Cohen's κ ranging from 0.625 to 1.

Conclusion: The PAI is a reliable and valid assessment tool for diagnosing paratonia in elderly people with dementia that can be applied easily in daily practice.

Background: This study aims to develop and validate a Chinese translation of the 6-item De Jong Gierveld Loneliness Scale – a widely used instrument to measure loneliness – specifically determining its psychometric properties in community-dwelling Chinese elders in Hong Kong. The relationships between loneliness and several clinical variables are also assessed.

Method: The English version was translated into Chinese. Content validity was established by group discussion and Delphi panel. The questionnaire was administered to 103 Hong Kong Chinese community-dwelling elders. Statistical analysis was performed to test the reliability and validity of the scale.

Results: The content validity was high as shown by the results of the Delphi panel. Cronbach's α of the 6-item scale was 0.76. For the inter-rater reliability of the six items, the intra-class correlation coefficients ranged from 0.98 to 1.00. The emotional loneliness subscale significantly correlated with the social loneliness subscale (ρ = 0.37; p < 0.001). In using a direct question to measure loneliness, 21 participants (20%) reported that they were lonely. The overall loneliness scale score significantly correlated with the answers on the direct question of loneliness (rpb = 0.71; p < 0.001). The overall loneliness score showed significant correlation with Cornell Scale for Depression in Dementia (ρ = 0.29; p = 0.003), current smoking status (rpb = 0.24; p = 0.014), and some objective social characteristics.

Conclusion: The Chinese version of the 6-item De Jong Gierveld Loneliness Scale is a reliable and valid measure of loneliness in Chinese elders.

Background: Tailor-made care in dementia requires an individual needs assessment. The Camberwell Assessment of Need for the Elderly (CANE) was developed to assess needs of older people with mental disorders. In this study the validity and reliability of the Dutch version of the CANE were studied among community-dwelling persons with dementia and their informal carers.

Method: Interviews were carried out with 236 people with mild to severe dementia and 322 informal carers; 69 informal carers were interviewed twice. Construct and criterion validity and test-retest reliability of the CANE were studied using data for informal carers. Construct validity was also studied for CANE ratings of people with dementia.

Results: The construct validity of the CANE was good among people with dementia and informal carers. Criterion validity could be studied for 76.9% of the CANE items, and all significant correlations were convergent. Test-retest reliability of the CANE varied from poor to very good and was best on domains where needs were explicit and problems well defined.

Conclusions: Use of the Dutch version of the CANE among community-dwelling people with dementia and their carers is supported by the study results, with the study showing acceptable construct and criterion validity and test-retest reliability of the CANE.

We recently completed an audit on cognitive testing used in routine practice within our Older People Community Mental Health Team in East Dorset, U.K. We measured the frequency of use of the Addenbrooke's Cognitive Examination (ACE) following its introduction as the baseline test for cognition, comparing it to the Mini-mental State Examination (MMSE) (Folstein et al., 1975).

Objective: This cross-sectional study examined the clinical significance and impact of subsyndromal depression in a sample of elderly people living in the community in Singapore.

Method: Data were analyzed from a population survey (the Singapore National Mental Health Survey of the Elderly). A total of 1092 respondents from a nationally representative multi-ethnic (Chinese, Malay and Indian) stratified random sample of older adults aged 60 and above were examined for depression using the Geriatric Mental State Examination (GMS). Diagnostic confidence levels of 3–5 indicated a DSM-IV diagnosis of syndromal depression, and 1–2 indicated subsyndromal depression. Other variables included sociodemographic characteristics, psychiatric and medical comorbidities, MMSE, health awareness, health and functional status.

Results: Subjects with subsyndromal depression were more likely to have poor socioeconomic status, cognitive impairment, anxiety, and measures of poor mental, physical and functional status compared with non-depressed subjects, and were similar to or worse than syndromal cases. In multivariate analyses that controlled for age, gender, ethnicity, education and several other sociodemographic factors, both subsyndromal and syndromal depression were significantly associated with higher numbers of medical comorbidities, diagnoses of comorbid dementia and anxiety, lower MMSE scores, self-reported mental health problem, functional disability and poor health status.

Conclusion: In this Asian population, subsydromal depression had the same clinical significance and health impact as syndromal depression, similar to findings in the West.

Background: Behavioral symptoms and caregivers' responses may differ among various ethnic and cultural groups. Therefore it is important to have a reliable instrument to assess behavioral disturbances of dementia in various cultures. The Neuropsychiatric Inventory (NPI) has been widely used in many countries. To date there has been no reliability study of this instrument in Brazil.

Methods: The psychometric properties of the Brazilian Portuguese version of the NPI were studied in a sample of 36 Alzheimer's disease (AD) outpatients from southern Brazil. Test-retest, inter-rater reliability and internal consistency were estimated. The profile of neuropsychiatric symptoms and caregiver distress were also evaluated. The NPI was translated into Portuguese and then back translated to English.

Results: The Brazilian Portuguese version of the NPI showed good inter-rater and test-retest reliability with the coefficients of all scales > 0.85. Internal consistency was also good (Cronbach's α 0.70 for total severity and distress). Apathy provided higher NPI scores of total severity and distress.

Conclusions: This NPI version was found to be a reliable instrument for the evaluation of neuropsychiatric symptoms and caregiver distress due to dementia in AD. The profile of behavioral disturbances was similar to that observed in other countries. Severity of dementia may have biased some caregivers' answers.

We note with interest the recently proposed new diagnostic framework published in Lancet Neurology entitled “Research criteria for the diagnosis of Alzheimer's disease: revising the NINCDS-ADRDA criteria” by Dubois et al. (2007).

Suicide rates have traditionally been thought to increase with age (Shah and De, 1998). A recent cross-national study of 62 developing and developed countries has reported an increase in suicide rates with aging in males and females in only 25 and 27 countries respectively (Shah, 2007a). Public health initiatives are being developed in many countries to facilitate reduction in suicide rates including those in the elderly (e.g. Chiu et al., 2003; Shah, 2007b). Such initiatives in the U.K. included legislation requiring general practitioners to offer annual physical and mental examinations to those over the age of 75 years, the Defeat Depression Campaign organized by the Royal College of Psychiatrists and the Royal College of General Practitioners, the governmental “Our Healthier Nation” suicide reduction targets, the National Confidential Enquiry into Suicides and Homicides, the National Service Frameworks for Mental Health and for Older People, and the National Suicide Prevention Strategy (Shah, 2007b).

Mukadam et al. (2008) report cholinesterase inhibitors to be effective in treating delirium. This suggests that cholinesterase inhibitors have a broader spectrum of effect than the treatment of dementia alone. Acetylcholine itself interacts with various other neurotransmitters. Cancelli et al. (2004) report that a fall in acetylcholine levels, as occurs in dementia, could increase sensitivity to serotonin agonists. Increased sensitivity to serotonin agonists and cholinergic hypoactivity seems to trigger complex visual hallucinations. It has been reported that selective serotonin reuptake inhibitors (SSRIs) may provoke suicidality, especially in young patients. SSRIs may decrease sensitivity of serotonin agonists and raise acetylcholine levels.

We recently cared for a patient with hypertension who presented with severe amnesia. Magnetic resonance imaging of the brain revealed localized intracerebral hemorrhage in the left medial temporal lobe. There have been only a few case reports of severe amnesia caused by a restricted hemorrhagic lesion in the unilateral medial temporal lobe (Arai et al., 2006). Here, we present an elderly woman who developed severe amnesia due to left hippocampal hemorrhage. The authors obtained informed consent to the publication of this letter from the patient's son, who was her legal guardian.

Concepts of personal autonomy and freedom have featured prominently in British social and political history. They are widely regarded as a very positive aspect of British culture. However, the presumption of mental capacity and the privileged status of autonomy over the promotion of well-being may on some occasions result in unnecessary suffering and neglect. Currently, individuals are presumed able to make autonomous decisions about their treatment. Their autonomy can only be challenged through a proactive process, in which the health professional must provide valid arguments for overriding it.

There has been growing concern about the levels of violence on psychiatric wards in recent years, which has led to increased emphasis on the safe management of such behavior. Physical intervention (PI) is a form of “hands on restraint” to manage the aggressive patient. PI was originally introduced as control and restraint in high security special hospitals in the mid-1980s to enable nursing staff to manage aggressive behavior in a systematic manner. The use of PI is highly emotive and controversial, yet staff are trained in the techniques across all mental health services in the U.K. (Wright et al., 2005). To be legally and ethically justifiable, the form of PI employed must be an appropriate, proportionate and reasonable response to the risk posed and be terminated at the earliest possible opportunity (National Institute of Clinical Excellence, 2005).

Background: The aim of this study was to determine the prevalence of dementia in a socioeconomically disadvantaged population of older adults living in the city of São Paulo, Brazil.

Methods: A cross-sectional one-phase population-based study was carried out among all residents aged ≥ 65 in defined census sectors of an economically disadvantaged area of São Paulo. Identification of cases of dementia followed the protocol developed by the 10/66 Dementia Research Group.

Results: Of 2072 individuals in the study, 105 met the criteria for a diagnosis of dementia, yielding a prevalence of 5.1%. Prevalence increased with age for both men and women after age 75 years, but was stable from 65 to 74 years. Low education and income were associated with increased risk of dementia.

Conclusions: The prevalence of dementia among older adults from low socioeconomic backgrounds is high. This may be partly due to adverse socioeconomic conditions and consequent failure to compress morbidity into the latter stages of life. The increasing survival of poorer older adults with dementia living in developing countries may lead to a rapid increase in the prevalence of dementia worldwide.

The number of studies aimed at analyzing caregiving distress among carers of people with dementia has grown exponentially in recent years. The study of variables that may help reduce the impact of caregiving demands on the health of caregivers is an issue of special interest for researchers. Self-efficacy is one of these variables. Perceived self-efficacy has been described as the subjective belief that one can organize and execute courses of action to manage given situations. Higher self-efficacy expectations regarding the caregiver's own ability to handle caregiving challenges have been significantly related to lower scores on burden, anger, anxiety and depression, even after controlling for objective stressors.

Background: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.

Methods: The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery).

Results: Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a ‘do not hospitalize’ order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity.

Conclusions: Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.