The current therapeutic agents advocated for the treatment of delirium (Meagher, 2001) have not been developed from an understanding of the underlying pathophysiology of this condition. Rather, they have emerged from “off label” clinical practice which has sought to reduce the distress experienced by both patients and clinicians. Accordingly, their use has not developed from a strong, specific evidence base, and nor is it now supported by large, well-designed clinical trials. It is also the case that these drug treatments will address the management (usually by sedation) of patients with florid, psychotic or “positive” delirium whilst quiet or “negative” delirium remains under-diagnosed and is poorly managed despite the distress it causes patients.

Applicants are sought for the position of Editor-in-Chief of International Psychogeriatrics, the prestigious academic journal (2007 impact factor – 2.207) owned by the International Psychogeriatric Association (IPA) and currently published six times per year by Cambridge University Press (CUP). The appointment will be for four years (January 2011 to January 2015) and the successful applicant will be eligible for re-appointment for a second four-year term (2015–2019) as determined by the IPA Board of Directors. Applicants are sought now, so that the successful candidate can be appointed as Editor-in-Chief elect at IPA's September 2009 Board of Directors (BOD) meeting. The intent is to ensure a smooth transition and enable the editor-elect to work closely with the current editor, Professor David Ames, to master the duties prior to assuming the position.

Psychogeriatric research has explored many factors likely to influence our mental health in later life, but one which has received surprisingly little attention given the current interest in genetic determinants has been paternal age. We now know that both delayed motherhood and delayed fatherhood may have a significant detrimental effect on the mental health of the offspring, but by different mechanisms. While delayed motherhood has been associated with higher rates of obstetric and perinatal problems, delayed fatherhood has been associated with higher risk of new inheritable-mutation disorders. Tarin et al. (1998) have postulated that this is because aging leads to a reduction in the activities of antioxidant enzymes within the seminal plasma and spermatozoa making them more vulnerable to mutational changes. In most syndromes the mutation rate increases with paternal age at an exponential rate. This rate is much higher than in elderly women, perhaps due to the greater number of cell divisions in the male germ line (Crow, 1997).

At the present time, there is increasing recognition and understanding of the mild cognitive impairment (MCI) entity as a stage which is a frequent precursor and harbinger of subsequently manifest Alzheimer's disease (AD) and, perhaps, other related conditions, such as vascular dementia (Gauthier et al., 2006). MCI has been defined in two disparate but generally compatible ways in the current literature (see Reisberg et al., 2008 (this issue), for a more complete historical overview of MCI). These two definitional approaches might be termed: (a) the clinical approach to MCI, and (b) the clinical plus psychometric approach to MCI.

Alzheimer's disease (AD) has become the model disease for the whole dementia syndrome with predominant memory deficits (World Health Organization, 1994). Other forms of neurodegenerative dementias – dementia with Lewy bodies (DLB) and frontotemporal degeneration (FTD) – are characterized by different patterns of neuropsychological performance and behavioral disturbances (Neary et al., 1998; McKeith et al., 2004). AD, DLB and FTD affect specific neuronal systems underlying different memory functions (Gabrieli et al., 1994; Moscovitch et al., 2005). Such differential effects on memory are associated with distinct effects on the perception of time. Concepts of time and their pathological change have not been considered as central issues in dementia research and care. This paper suggests that the altered perception of time in patients with different forms of dementia is largely neglected, and that clinical observations in dementia may improve our understanding of how the past, the present and the future are psychologically connected, a problem which philosophers have addressed repeatedly.

Traditionally, the prevalence of illicit and problematic drug use in the elderly was thought to be very low (Abrams and Alexopoulos, 1988; Rosenberg, 1995; Crome and Day, 1999; Simoni-Wastila and Yang, 2006). Indeed, in the most recent British Crime Survey respondents over the age of 59 years were not asked about illicit drug use because previous surveys indicated that less than 1% of those aged 60 years and over had taken illicit drugs in their lifetime (personal communication, Home Office Direct Communications Unit, 2007). The vast majority of epidemiological studies of illicit drug use and problematic use in the elderly are from the U.S.A., although studies from other countries are emerging. These epidemiological studies have either been population-based or of convenience samples.

Background: The objective of this study was to review available dementia screening instruments that could be recommended for self-administration, particularly in electronic format. Owing to the gradual loss of insight associated with the progression of dementia, a broad definition of self-administration including self-administration by concerned informants (family, friends, carers) was used.

Method: A systematic search of PubMed, PsychINFO, and the Cochrane Library Database was conducted. Only available full-text articles about dementia screening instruments written in English were included. Articles reporting on instruments used in a non-English context were excluded unless a validated English version of the instrument was available. Included instruments were assessed against the precise criteria and characteristics of the Mini-mental State Examination (MMSE), the most widely used screening instrument.

Results: The Concord Informant Dementia Scale (CIDS) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were the only instruments meeting all selection criteria. The Memory Impairment Screen (MIS) also met the criteria, although it lacks validation for self-administration. No instrument has been validated for self-administration in electronic format.

Conclusions: It is recommended that the MIS, the CIDS and the IQCODE be validated for self-administration in electronic format.

This synthetic review presents an approach to the use of biomarkers for the development of new treatments for Alzheimer's disease (AD). After reviewing the process of translation as applied to AD, the paper provides a general update on what is known about the biology of the disease, and highlights currently available treatments. This is followed by a discussion of future drug development for AD emphasizing the roles that biomarkers are likely to play in this process: (1) define patients who are going to progress rapidly for the purpose of trial enrichment; (2) differentiate disease and therapeutically relevant AD subtypes; (3) assess the potential activity of specific therapies in vivo or ex vivo; and (4) measure the underlying disease state, so as to (a) detect disease and assess drug response in asymptomatic patients, (b) serve as a secondary outcome measure in clinical trials of symptomatic patients, and (c) decide if further development of a treatment should be stopped if not likely to be effective. Several examples are used to illustrate each biomarker utility in the AD context.

Background: Vocally disruptive behavior (VDB) in the elderly is a common condition, especially in people with dementia, but difficult to treat. It may occur in as many as 40% of nursing home residents. This study is a review of the existing literature on this condition.

Method: The literature review was conducted using PubMed (particularly Medline and the Cochrane database) and reference lists from relevant publications in English, French, and German.

Results: Most studies are small and no conclusive prevalence data are available. Many biological and psychosocial treatments have been advocated, but most studies are little more than anecdotal case reports. It is evident that VDB can have deleterious consequences on others and the patients themselves, although no studies specifically examine the range or the pervasiveness of VDB. Etiopathogenic research on VDB is still in its infancy.

Conclusions: Most aspects surrounding VDB are insufficiently understood. The heterogeneity and multiple contributive factors regarding VDB suggest quite convincingly that a panoply of different interventions tailored to the individual's needs will be required to overcome VDB and the suffering related to it.

Background: Studies examining trends in elderly suicide rates over time reported a decline, an increase and no change. A cross-national study was undertaken to examine the current status of trends over time in elderly suicide rates because previous cross-national studies were well over a decade old.

Methods: Trends in suicide rates for males and females in the age-bands 65–74 years and 75+ years over a 10-year period were examined using data from the World Health Organization website for all the listed countries.

Results: The main findings were: (1) elderly suicide rates either declined or remained unchanged over the 10-year period in most countries; and, (2) suicide rates in both sexes in both the age-bands, over the 10-year period, declined in several European countries, and remained unchanged in several Central and South American countries, Eastern European countries and countries of the former Soviet Union.

Conclusions: Potential explanations for regional and cross-national variations in trends over time in elderly suicide rates include cross-national differences in trends over time in the prevalence of mental illness in the elderly, socioeconomic factors, cultural factors, the availability of appropriate healthcare services, and public health initiatives to improve the detection and treatment of mental illness, mental health and suicide prevention.

Background: Falls are a major health problem among the elderly, particularly in nursing homes. Abnormalities of balance and gait, psychoactive drug use, and dementia have been shown to contribute to fall risk.

Methods: We conducted a systematic review of the literature to investigate which psychoactive drugs increase fall risk and what is known about the influence of these drugs on gait in nursing home residents with dementia. We included studies with a prospective cohort design on psychoactive drug use in nursing homes with dementia residents and with falls as an outcome measure.

Results: Seventeen studies were included in the review. Pooled risk estimates were not calculated because there was no homogeneity across studies. We assessed the strength of evidence for psychoactive drugs as a prognostic factor for falls by defining four levels of evidence: strong, moderate, limited or inconclusive. Strong evidence was defined as consistent findings (≥80%) in at least two high quality cohorts. We found strong evidence that the use of multiple drugs (3/3 cohorts, effect sizes 1.30–1xs0.30), antidepressants (10/12 cohorts, effect sizes 1.10–7.60), and anti-anxiety drugs (2/2 cohorts, effect sizes 1.22–1.32) is associated with increased fall risk. The evidence for the association of other psychoactive drug classes with fall risk was limited or inconclusive.

Conclusions: Research on the contribution of psychoactive drugs to fall risk in nursing home residents with dementia is limited. The scarce evidence shows, however, that multiple drugs, antidepressants and anti-anxiety drugs increase fall risk in nursing home populations with residents with dementia.

Background: Clock-drawing tests are popular components of dementia screens but no single scoring system has been universally accepted. We sought to identify an optimal subset of clock errors for dementia screening and compare them with three other systems representative of the existing wide variations in approach (Shulman, Mendez, Wolf-Klein), as well as with the CDT system used in the Mini-Cog, which combines clock drawing with delayed recall.

Methods: The clock drawings of an ethnolinguistically and educationally diverse sample (N = 536) were analyzed for the association of 24 different errors with the presence and severity of dementia defined by independent research criteria. The final sample included 364 subjects with ≥5 years of education, as preliminary examination suggested different error patterns in subjects with 0–4 years of education and inadequate numbers of normal controls for reliable analysis.

Results: Eleven of 24 errors were significantly associated with dementia in subjects with ≥5 years of education, and six were combined to identify dementia with 88% specificity and 71% sensitivity: inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, or refusal to attempt clock drawing. Time setting was the most prevalent error at all dementia stages, refusal occurred only in moderate and severe dementia; and ethnicity and language of administration had no effect. All critical errors increased in frequency with dementia stage. This simplified scoring system had much better specificity than two other systems (88% vs 39% for Mendez's system – 63% for Shulman's) and much better sensitivity than Wolf-Klein's (71% vs 51%). Stepwise logistic regression found the simplified system to be more strongly predictive of dementia than the three other CDT systems of dementia. Substituting the new CDT algorithm for that used in the original CDT Mini-Cog improved the Mini-Cog's specificity from 89 to 93% with minimal change in sensitivity.

Conclusions: Only six errors need be assessed to capture most of the power of clock drawing to discriminate between people with dementia and normal subjects, and improves specificity over older systems in subjects with ≥5 years of education. These errors require minimal conceptual classification and are easily detected and scored by non-specialists.

Descriptions of dementia can be traced to antiquity. Prichard (1837) described four dementia stages and Kral (1962) described a “benign senescent forgetfulness” condition. The American Psychiatric Association's DSM-III (1980) identified an early dementia stage.

In 1982, the Clinical Dementia Rating (CDR) and the Global Deterioration Scale (GDS) were published, which identified dementia antecedents. The CDR 0.5 “questionable dementia” stage encompasses both mild dementia and earlier antecedents. GDS stage 3 described a predementia condition termed “mild cognitive decline” or, alternatively, beginning in 1988, “mild cognitive impairment” (MCI). This GDS stage 3 MCI condition is differentiated from both a preceding GDS stage 2, “subjective cognitive impairment” (SCI) stage and a subsequent GDS 4 stage of mild dementia.

GDS stage 3 MCI has been well characterized. For example, specific clinical concomitants, mental status and psychological assessment score ranges, behavioral and emotional changes, neuroimaging concomitants, neurological reflex changes, electrophysiological changes, motor and coordination changes, and changes in activities, accompanying GDS stage 3 MCI have been described.

Petersen and associates proposed a definition of MCI in 2001 which has been widely used (hereafter referred to as “Petersen's MCI”). Important differences between GDS stage 3 MCI and Petersen's MCI are that, because of denial, GDS stage 3 MCI does not require memory complaints. Also, GDS stage 3 MCI recognizes the occurrence of executive level functional deficits, which Petersen's MCI did not. Nevertheless, longitudinal and other studies indicate essential compatibility between GDS stage 3 MCI and Petersen's MCI duration and outcomes.

Background: Alcohol problems in the elderly are common and frequently undetected, and therefore a potential target for a screening program.

Method: Using Medline, Psychinfo and reference lists from relevant publications, articles were identified testing pen-and-paper screens in the primary care population aged over 60 years.

Results: Using standard definitions of alcohol problems, conventional screens adapted for use in the elderly have performances similar to screens in the younger primary care population. However, it can be argued that special screens perform better for the elderly.

Conclusions: The Alcohol Use Disorders Identification Test is a useful screen for detecting harmful and hazardous drinking in the elderly while the CAGE is valuable when screening for dependence. In the future, the Alcohol-Related Problems Survey, a computer-based screen, may prove to be superior if practical implementation problems can be overcome.

Introduction: The aim of this study is to understand the long-term course and outcomes of depressive symptoms among older adults in the community by examining trajectories of depressive symptoms over time and identifying profiles of depressive symptoms predicting different trajectories.

Method: We measured depressive symptoms biennially for up to 12 years, using the modified Center for Epidemiological Studies-Depression (mCES-D) scale, in 1260 community-based adults aged 65+ years. We determined latent trajectories of total mCES-D scores over time. We identified symptom profiles based on subgroups of baseline depressive symptoms derived from factor analysis, and examined their associations with the different trajectories.

Results: Six trajectories were identified. Two had one or no depressive symptoms at baseline and flat trajectories during follow-up. Two began with low baseline symptom scores and then diverged; female sex and functional disability were associated with future increases in depressive symptoms. Two trajectories began with high baseline scores but had different slopes: the higher trajectory was associated with medical burden, higher overall baseline score, and higher baseline scores on symptom profiles including low self-esteem, interpersonal difficulties, neurovegetative symptoms, and anhedonia. Mortality was higher among those in the higher trajectories.

Conclusions: In the community at large, those with minimal depressive symptoms are more likely to experience future increases in symptoms if they are women and have functional disability. Among those with higher current symptom levels, depression is more likely to persist over time in individuals who have greater medical burden and specific depressive symptoms.

Background: We evaluated the combined and differential effects of physical, social and productive activities on cognitive decline and whether they were modified by the presence of the APOE-ε4 allele.

Methods: In a prospective cohort study of 1635 community-dwelling Chinese older adults aged 55 or older participating in the ongoing Singapore Longitudinal Aging Study, physical, social and productive leisure activities were assessed at baseline, and cognitive decline (at least one point drop) in MMSE scores between baseline and follow-up after one year.

Results: Cognitive decline was observed in 30% of the respondents. Controlling for age, gender, education and other risk factors, odds ratios (ORs) were significantly reduced in those with medium (OR: 0.60, 95% CI: 0.45–0.79) and high activity levels (OR: 0.62, 95% CI: 0.46–0.84). A stronger association was shown for productive activity (OR = 0.36), than for physical (OR = 0.78) and social activities (OR = 0.85). These associations showed statistically significant interactions with APOE genotype, being more pronounced in those with the APOE-ε4 allele.

Conclusion: Increased leisure activity, especially productive activities more than physical or social activities, was associated with a lowered risk of cognitive decline. APOE-ε4 genotype individuals appeared to be more vulnerable to the effects of low and high levels of leisure activities.

Background: Neurocognitive impairment is known to occur in euthymic bipolar patients, but language alterations have not been thoroughly investigated. The aim of this study is to examine the performance in language tests of a sample of elderly patients with bipolar disorder.

Methods: We studied 33 euthymic elderly patients with bipolar disorder but no dementia and 33 healthy individuals, matched for age and education, who were compared in terms of their CAMCOG global score and its subitems.

Results: The scores obtained in language-related abilities for patients and controls, respectively, were: language (total): 27.3 (1) and 28.5 (1), p < 0.0001; comprehension: 8.6 (0.5) and 8.9 (0.3), p = 0.006; production: 18.7 (1) and 19.6 (0.9), p = <0.0001; abstraction: 6.8 (1.1) and 7.3 (0.7), p = 0.016; verbal fluency: 16.3 (4.3) and 19.6 (4.1), p = 0.003.

Conclusion: A mild but significant impairment in language-related ability scores was detected when comparing patients and controls.