Showing papers in "International Psychogeriatrics in 2007"

Development and validation of the Geriatric Anxiety Inventory.

Abstract: Background: Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people. Methods:We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale. Results: Cronbach's alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%. Conclusions: The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

A systematic review of the prevalence and covariates of anxiety in caregivers of people with dementia

Abstract: Background: Caregiving for people with dementia has consistently been linked with psychological problems, usually in terms of caregiver burden, general psychological distress and depressive symptomatology, while morbidity due to anxiety has been relatively neglected in this group.Methods: We conducted a systematic review of the literature, searching electronic databases, reference lists, relevant systematic reviews and contacting experts in the field. We used Centre for Evidence Based Medicine (CEBM) criteria for inclusion and rating the validity of all studies that reported (1) the prevalence, predictors and covariates of anxiety disorders or anxiety caseness, and (2) covariates and predictors of the level of anxiety symptoms.Results: Thirty-three studies met our inclusion criteria. Clinically, significant anxiety affects about a quarter of caregivers for people with dementia and was more common than in matched controls. Such caregivers have higher anxiety levels than controls, and that confrontative and escape avoidance coping, caregiver burden and poorer caregiver physical health are factors associated with higher anxiety levels from cross-sectional studies.Conclusions: Coping style may be more associated with anxiety than depression while other covariates (burden and poor physical health) are similar to those for caregiver depression. We found no conclusive evidence about factors associated with anxiety disorders or predicting anxiety from longitudinal studies. Neither care recipient cognition nor ADL impairment; nor caregiver age nor duration of caring are associated with caregiver anxiety levels. Good quality cohort studies are needed to determine whether these factors also predict anxiety disorders.

The incidence of delirium associated with orthopedic surgery: a meta-analytic review.

Abstract: Background: The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery.Methods: Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias.Results: 26 publications reported an incidence of postoperative delirium of 4–53.3% in hip fracture samples and 3.6–28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6–28.8] vs. 12.1% [95% CI = 9.6–14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7–34.7] vs. 8.8% [95% CI = 4.1–13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%.Conclusions: Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

Suffering from dementia - the patient's perspective: a review of the literature.

Abstract: Background: Among the general public there is a deep fear of developing dementia, which has led to an increasing number of people "at risk" seeking ways (such as advance directives) to avoid undergoing progressive mental decline. The views of people with dementia are vital in obtaining a real answer to the question of how the disease affects people's lives and whether it actually involves the suffering that so many fear. Method: A review of the international literature is provided on what is known about living through dementia from the patient's perspective. Results: A total of 50 papers met the inclusion criteria. The findings of these reviewed papers give insight into the impact of dementia and the ways that those who have it deal with its effects by using different coping strategies. The literature on the perspective of the patient gives no solid support to the widespread assumption that dementia is necessarily a state of dreadful suffering. Although the impact of dementia and the experiences of loss resulting in multiple "negative" emotions cannot be denied, our findings also indicate that people do not undergo the disease passively and use both emotion-oriented and problem-oriented coping strategies to deal with its challenges. The experiences of living through dementia as told by the sufferers appear to yield a more subtle picture than the assumptions made by the general public. Conclusion: The overview provides a good starting point for improving the adjustment of care to the experience and wishes of people with dementia.

Loneliness in older persons: a theoretical model and empirical findings.

Abstract: Background: This study examines predictors of loneliness among low-income older adults through a framework named MODEL (Model of Depression and Loneliness), which we developed to address the need for a comprehensive and intervention-oriented theory of loneliness in old age. The framework is rooted in a cognitive-behavioral theory that conceptualizes behaviors as resulting from an interaction of cognitive processes and environmental events.Methods: 161 residents of five independent-living buildings for low-income older adults in Maryland were interviewed individually. The assessments were based on the theoretical framework, MODEL, which describes the influences that environmental resources, health, and psychological factors have on loneliness and depression.Results: MODEL explained a large percentage of the variance of both loneliness and depressed affect. Of all the barriers examined in the present study, our findings suggest that psychosocial factors/barriers have the strongest influence in the etiology of loneliness.Conclusion: In this population of low-income older persons, the importance of new contacts, mobility, and financial resources in predicting loneliness suggests that preventive social services should target these factors in developing opportunities for socialization.

Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderly community residents.

Abstract: Objective: The aim of this study is to evaluate the validity and the utility of the Japanese version of the WHO-Five Well-Being Index (WHO-5-J) in the context of detecting suicidal ideation in elderly community residents.Methods: A sample of 696 subjects aged 70 years or over who completed a set of questionnaires was examined.Results: Cronbach's α was 0.87 and Loevinger's coefficient was 0.64. The total score was significantly correlated with the number of cohabitants, the number of physical illnesses, physical functioning, instrumental activities of daily living, and depressive symptoms. Subjects with suicidal ideation had significantly lower scores on the WHO-5-J. The receiver-operating characteristic curve analysis indicated that the scale significantly discriminated the subjects with suicidal ideation. When combined with the assessment of a lack of perceived social support (PSS), a standard cut-off criterion of “a total score ≤ 12 or answering 0 or 1 to any of the five items” more appropriately identified elderly subjects with suicidal ideation: sensitivity = 87%, specificity = 75%, negative predictive value = 99%, and positive predictive value = 10%.Conclusions: In combination with PSS, the scale has predictive utility to detect suicidal ideation in elderly community residents.

The relationship between suicide rates and age: an analysis of multinational data from the World Health Organization.

Abstract: Background: Suicide rates generally increase with age. With the emergence of studies from several countries without an increase in suicides rates with aging, a cross-national study examining the relationship between suicide rates and age was undertaken.Methods: The relationship between suicide rates and age was examined by ascertaining suicide rates in both sexes in seven age-bands 16–24 years, 25–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years and 75+ years, from the World Health Organization website for all the listed countries (N = 62).Results: The main findings were: (i) there was a significant increase in suicide rates with increasing age in males and females in 25 and 27 countries respectively; (ii) there was no significant increase in suicide rates with increasing age in males and females in 31 and 29 countries respectively; (iii) suicide rates were the highest in the younger age-bands in countries without a significant increase in male suicides rates with increasing age; (iv) countries without a significant increase in the suicide rate with increasing age in both sexes, females only and males only demonstrated regional clustering; and, (v) in a small number of countries suicide rates declined with increasing age.Conclusions: Potential explanations for regional and cross-national variations in the relationship between suicide rates and age require further study.

Subjective needs of people with dementia: a review of the literature.

Abstract: Objective: Insight into the individual care needs of the growing number of people with dementia is necessary to deliver more customized care. Our study aims to provide an overview of the literature on the subjective needs of people with dementia. Method: Electronic databases were searched for publications on subjective needs between January 1985 and July 2005, and reference lists were cross-referenced. Extracts of needs were classified within problem areas of the (Dutch) National Dementia Program and quality of life domains, and the extracts were classified as a "need" (an implicitly communicated felt state of deprivation), "want" (expression of a need) or "demand" (suitable solution to fulfill a need). Results: Subjective needs were found in 34 studies with various research aims, such as awareness and coping. Few studies aimed to measure needs of people with dementia. The most frequently reported needs of people with dementia were the need to be accepted and respected as they are, the need to find adequate strategies to cope with disabilities, and the need to come to terms with their situation. Explicit wants or demands were reported less frequently than needs. Conclusion: The high number of reported needs and the limited number of wants and demands show that people with dementia do not frequently mention how they want their needs to be met. Most reported needs are not instrumental, but are related to well-being and coping. Further research to inventory these needs could help achieve more demand-directed and better attuned care in the future.

Nursing home staff training in dementia care: a systematic review of evaluated programs.

Abstract: Background: We reviewed studies of in-service interventions for caregivers of personswithdementiainnursinghomespublishedbetween1990and2004. The aim was to obtain an overview of the evaluated interventions and to characterize their methodological quality. Methods: A thorough literature search was conducted, including searching electronic databases for selected intervention studies and previous reviews. Selected studies were summarized and compared along certain categories, and methodological quality was assessed. Results: A total of 21 studies were identified, mostly published in the United States. Most were of poor methodological quality. Although nearly all reported positive effects, their results must be interpreted cautiously due to methodological weaknesses. Extensive interventions with ongoing support successfully demonstrated sustained implementation of new knowledge. Owing to methodological weaknesses and a lack of follow-up evaluations, little or no evidence existed for the efficacy or, particularly, the transfer of knowledge in simpler interventions when reinforcing and enabling factors were not present. Conclusion: On an international and, particularly, on a national level a lack of evaluated in-service training programs for caregivers in homes for people with dementia is apparent. Methodological weakness is common. This study highlights the need for well-defined methodologically improved studies, providing conclusive evidence of the effects of intervention types to help improve the quality of dementia care.

Persistent mild cognitive impairment in geriatric depression.

Abstract: Background: Cognitive impairment often occurs with geriatric depression and impairments may persist despite remission of depression. Although clinical definitions of mild cognitive impairment (MCI) have typically excluded depression, a neuropsychological model of MCI in depression has utility for identifying individuals whose cognitive impairments may persist or progress to dementia.Methods: At baseline and 1-year follow-up, 67 geriatric patients with depression had a comprehensive clinical examination that included depression assessment and neuropsychological testing. We defined MCI by a neuropsychological algorithm and examined the odds of MCI classification at Year 1 for remitted depressed individuals with baseline MCI, and examined clinical, functional and genetic factors associated with MCI.Results: Fifty-four percent of the sample had MCI at baseline. Odds of MCI classification at Year 1 were four times greater among patients with baseline MCI than those without. Instrumental activities of daily living were associated with MCI at Year 1, while age and APOE genotype was not.Conclusions: These results confirm previous observations that MCI is highly prevalent among older depressed adults and that cognitive impairment occurring during acute depression may persist after depression remits. Self-reported decline in functional activities may be a marker for persistent cognitive impairment, which suggests that assessments of both neuropsychological and functional status are important prognostic factors in the evaluation of geriatric depression.

Mini-mental State Examination performance in mild cognitive impairment subtypes

Abstract: Background: Diagnosis of mild cognitive impairment (MCI) and its subtypes requires a detailed diagnostic assessment and so may be missed at routine primary-care appointments, since the ordinary dementia screening tests lack sensitivity owing to ceiling effects, especially in highly educated subjects.Methods: The study was undertaken using a cross-sectional assessment of 112 elderly subjects (mean age 67.96 ± 5.77 years, and mean education level of 12.8 ± 5.7 years) with a semi-structured interview and a neuropsychological battery.Results: MCI patients did not differ from controls on total MMSE scores (p = 0.212). Nevertheless, MCI patients showed worse performance than controls on the verbal memory task (p = 0.012), and “drawing a pentagon” (p = 0.03). Amnestic MCI patients performed worse only on the “three-word recall” task (p = 0.013); non-amnestic MCI patients performed worse on the “three-stage command” task (p = 0.001); and multiple-domain MCI patients performed worse on the “drawing a pentagon” task (p = 0.001) and had a trend toward performing poorly on the ‘three word recall’ task (p = 0.06).Conclusion: The analysis of MMSE subtest scores, in addition to MMSE total scores, may increase the sensitivity of the MMSE test in screening for MCI and its subtypes.

Global measures: utility in defining and measuring treatment response in dementia.

Abstract: Global measures used in treatment trials in dementia encompass two distinct categories: (1) clinician's interview-based global severity scales, and (2) clinician's interview-based global change scales. The global severity scales that have been used include: the Clinical Dementia Rating (CDR) and the related CDR-sum of boxes (CDR-SB), the Global Deterioration Scale (GDS), and the Functional Assessment Staging (FAST) procedure. The global severity scales are clearly useful in subject categorization in treatment trials, in part because they are relatively free of many of the sociocultural biases inherent in mental status and psychometric descriptors. Global severity scales can also be used to demonstrate therapeutic efficacy in terms of the general progression of the dementia process. These measures have also proven to be useful in sensitively assessing pharmacotherapeutic effects in Alzheimer's disease (AD) treatment trials. For example, in pivotal trials: (1) in Mild to Moderate AD, the GDS has shown significant change in response to medication, whereas the results on the Mini-mental State Examination (MMSE) were not significant, and (2) in Moderate to Severe AD, the FAST has shown significant pharmacotherapeutic efficacy, whereas the results using the MMSE were not significant. The global change scales employed in dementia trials differ widely in assessment methodology. Clinical Global Impressions of Change (CGIC) scales do not have defined methodologies, whereas Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus) scales are much more elaborate. The CIBIC-Plus procedures require an independent clinician assessment and can provide independent, comprehensive evidence of therapeutic efficacy. The CIBIC-Plus procedure may also be useful in sensitively assessing efficacy in future prevention trials, for example in subjects with Subjective Cognitive Impairment. For Mild Cognitive Impairment (MCI), global severity scales already appear to be one modality for the sensitive assessment of change. The CIBIC-Plus procedures might also productively be applied in future MCI therapeutic trials.

Measuring quality of life in dementia: purposes, goals, challenges and progress.

Abstract: The choice of outcomes in clinical research should be influenced by a linkage between the targeted symptom or disorder and the outcome being measured, the clinical meaningfulness of the outcome, and the ability to measure the outcome accurately. Dementia, defined as a syndrome consisting of disorders that impair two or more distinct cognitive capacities, occur in clear consciousness, and begin in adulthood, presents unique challenges in the choice of appropriate outcomes for treatment trials.

White matter microstructural abnormalities in late-life depression.

Abstract: Objective: To evaluate the location and the degree of white matter damage in late-life depression using diffusion tensor imaging (DTI). Methods: Thirty-one patients with late-life depression and 15 healthy volunteers matched for age, gender and years of education received conventional MRI (magnetic resonance imaging) and MR-diffusion tensor scanning. The fractional anisotropy (FA) values of white matter were measured respectively in frontal and temporal regions and the corpus callosum. Results: FA values were significantly decreased in the frontal (superior and middle frontal gyrus), and temporal (right parahippocampal gyrus) regions of elderly patients with depression compared with healthy controls. Conclusion: Microstructural changes in the frontal (superior and middle frontal gyrus) and temporal (right parahippocampal gyrus) areas are associated with late-life depression.

Economic impact of dementia in developing countries: an evaluation of costs of Alzheimer-type dementia in Argentina

Abstract: Background: There is no previous information about economic costs of Alzheimer's disease (AD) in South America. The objective of this study was to evaluate the costs of AD in Argentina. Methods: Eighty community-dwelling patients, 20 institutionalized AD patients and their respective primary caregivers, and 25 healthy elderly subjects participated in this study. The cognitive and neuropsychiatric impairments and severity of dementia were assessed with the Mini-mental State Examination, Neuropsychiatric Inventory and Clinical Dementia Rating, respectively. A structured interview about health and health-care resources used during the past 3 months was administered to family caregivers. The time devoted by carers to looking after the patients and the caregiver burden (Zarit's Burden Interview) were recorded. Results: The annual direct costs of the disease increased with cognitive deterioration from US$3420.4 in mild to US$9657.6 in severe AD, and with institutionalization (US$3189.2 outpatient vs. US$14 447.68 institutionalized). Most direct costs were paid for by the family. Conclusions: With the projected increase in the number of persons at risk for developing AD in emerging countries, the economic familial cost of the disease will be significant. Dementia costs should be a matter of analysis when health policies are being designed in developing countries.

Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians.

Abstract: Background: The object of this study was to develop an Iranian version of the General Health Questionnaire-28 (GHQ-28) for use with elderly subjects.Methods: The GHQ-28 Farsi version was evaluated for face validity among 204 elderly subjects aged 59 years or older, chosen randomly from residents of Tehran. The Composite International Diagnostic Interview (CIDI) was used to establish a gold standard diagnosis of mental disorders.Results: The GHQ-28 was an internally consistent measure. Cronbach's α, split-half coefficients and test-retest reliability were 0.9, 0.89 and 0.58 respectively. Four factors were extracted using factor analysis: “depression,” “psychosocial activity,” “anxiety,” and “somatic.” Using receiver operating curve (ROC) analysis, the optimum cutoff score for the GHQ-28 in this group was 19/20 (sensitivity 0.83, specificity 0.76). Using a loading of 0.6 or greater, a short form of the instrument (GHQ-15) (α = 0.9) was derived and correlated well with the longer form of the scale (r = 0.97). Using ROC analysis, the optimum cutoff score was 10/11 (sensitivity 0.83, specificity 0.69).Conclusions: The short and long forms of the GHQ-28 are suitable screening instruments for elderly Iranian residents, particularly those living in urban areas.

Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments

Abstract: Neuropsychiatric symptoms (NPS) are central features of dementia and an important treatment target. They should be assessed in future studies of emerging dementia therapies, using appropriate measures matched to the purpose of each study. Several significant issues remain regarding (1) the classification of these symptoms into syndromes, and (2) the development of better clinical measures for their quantification. In particular, effort should be directed at assessing their evolution over shorter time periods, and at using more objective methods in their measurement, such as actigraphy. These issues can be solved with nosologic study and other advances that could be brought about quickly, if appropriate time and effort are allocated. Empirical characterization of clinically meaningful change in NPS--by examining their relationship with dementia care burden, disability, quality of life, caregiver distress, and resource utilization--would be an important advance.

International Psychogeriatric Association consensus statement on defining and measuring treatment benefits in dementia.

Abstract: Current symptomatic treatments for dementia have only modest efficacy. Assessing meaningful benefits in this variably progressive syndrome is complex and difficult. This consensus statement was generated by an international group representing caregivers, organizations and professionals with expertise in dementia. We recommend the statement of clear, pre-defined diagnostic and severity criteria and outcome measures, which include functional and executive capacity, in treatment trials. Outcomes can include effects on people with dementia (PWD) with regard to cognition, behavioral and psychological symptoms, quality of life, global assessments, and activities of daily living, and must be tailored to the education and culture of the participants. Outcomes can also appropriately encompass effects on caregivers. New instruments may be needed, as validation of many existing measures has been in relatively homogenous populations. Treatment goals can be to prevent dementia emerging, or in those with established dementia to slow deterioration, and to postpone, stabilize or improve symptoms. Comparisons between treatment groups should be on the basis of clinically relevant measures with both risk and benefit reported for all participants regardless of whether or not they continue to receive treatment throughout the trial. Characterization of any groups that respond well to treatment has been unsuccessful to date, but may be facilitated in the future by measurement of putative biomarkers. Despite considerable recent progress and several 'candidate' biomarkers, none is yet satisfactory for determining diagnosis, severity, progression or prediction of response. To provide meaningful data, economic analyses should use up-to-date, country-specific data. Health economic measures should be incorporated as secondary outcomes in all Phase 3 trials since health systems are concerned with cost-effectiveness as well as clinical outcome. Health utility measures are not, however, validated satisfactorily in dementia, thus calling into question previous health economic analyses. While current drugs appear to reduce the amount of family caregiver time required by PWD, these costs fall in the main on older individuals who often exert little political leverage, rather than on society at large. Traditionally, elderly people have been marginalized in the political process. The growth in the older population across the world, and their potential for increasing political empowerment may lead to a radical re-evaluation of the economics of treatment in dementia.

Severe domestic squalor: a review.

Abstract: Background: Referrals to clinical services of people living in severe domestic squalor are not uncommon. It is timely to review literature concerning and discussing such cases. Method: Using Medline, Psychinfo, Embase, CINAHL and reference lists from relevant publications, literature referring to over 1100 cases was identified and then reviewed. Results: Half of those described as living in severe squalor are elderly. Outcomes of intervention are often poor. People living in severe squalor are most commonly diagnosed as having dementia, alcoholism or schizophrenia, though personality problems are evident in a high proportion. There is evidence to suggest that neglect of hygiene and of attention to cleanliness of accommodation may be largely attributable to frontal lobe changes. The review also revealed a second body of literature, not often cited in papers focussed on unclean living conditions and published in psychiatric or medical journals, that concludes that hoarding is most commonly due to obsessive-compulsive disorder (OCD). Accumulation of rubbish is described in over half of the case reports on severe domestic squalor, but it is suggested that this should only be called hoarding if it results from purposeful collection of items. Lack of impulse control may contribute to collecting behavior, resulting in reduction in living space if there is also a failure to discard. Conclusions: There is a need for further studies, using standardized ratings of living conditions, investigating and trying to understand the complex interplay of triggers and vulnerabilities, exploring how best to intervene and examining outcomes of interventions.

Assessment of the psychometric performance of the WHOQOL-BREF instrument in a sample of Brazilian older adults.

Abstract: Background: There has been increasing interest in the measurement of quality of life in cross-sectional investigations and in the assessment of intervention outcomes in elderly adults. Several instruments used in this measurement have not yet been adequately tested.Objective: To describe the psychometric properties of the World Health Organization's Quality of Life Instrument–Short Version (WHOQOL-BREF) in a sample of Brazilian elderly.Method: A total of 424 elderly adults selected through convenience sampling completed the instruments WHOQOL-BREF, the Beck Depression Inventory (BDI), the Beck Hopelessness Scale (BHS) and a sociodemographic data form. Discriminant validity, concurrent validity, criterion validity and internal consistency were analyzed.Results: The sample comprised predominantly women (64.2%), community-dwelling subjects (84.4%) and subjects who consider themselves healthy (67.5%). All domains in the instrument showed the ability to discriminate levels of depressive symptoms and hopelessness, as well as different perceptions of health status. The correlation coefficients among the domains and the BDI and BHS scores were statistically significant. The reliability coefficients present scores ranging from 0.614 to 0.925.Conclusion: The WHOQOL-BREF instrument shows suitable psychometric performance in a sample of Brazilian older adults, becoming a useful alternative in the measurement of quality of life in this population.

Sixty years later: post-traumatic stress symptoms and current psychopathology in former German children of World War II

Abstract: Background: The aim of the study was to determine the amount of trauma impact, post-traumatic stress symptoms and current psychopathological distress in a sample of former German children of World War II.Methods: 93 participants were recruited through the local press, and assessed using the modified Post-traumatic Diagnostic Scale (PDS) and the Symptom Checklist (SCL-90-R).Results: Subjects reported a high qualitative and quantitative degree of trauma exposure. 13.8% reported PTSD-related symptoms after the war, and 10.8% reported current symptoms. PTSD symptoms after World War II were significantly correlated with current psychopathological distress.Conclusions: In line with other studies, our data document a high degree of trauma exposure during warchildhood. In comparison with other studies on PTSD in warchildren, there is a persisting high prevalence of war-associated PTSD symptoms in this sample. Despite some methodological limitations, our data underline the urgent need for further studies on the ageing group of former children of World War II.

A controlled trial of a predominantly psychosocial approach to BPSD: treating causality.

Abstract: Background: The adverse effects of behavioral and psychological symptoms of dementia (BPSD) are well described but treatment remains problematical, including overuse of psychotropic medication. This study aims to compare the outcome of two approaches to BPSD, one focusing on causality and using predominantly psychosocial interventions, the other relying predominantly on psychotropic medication.Methods: Thirty-three residential care clients manifesting BPSD who had been referred to a community psychogeriatric service (intervention group) were assessed and treated, with the focus placed on the causes of the behavior and why it was perceived as a problem by nursing staff. Cases were managed primarily by psychosocial means with psychopharmacology as an adjunct. A control group was made up of 22 referrals to an adjacent service, which used primarily psychopharmacology with psychosocial methods as an occasional adjunct.Results: Measures of behavior and staff response showed significant improvement in both groups at two- and five-months' follow-up. Antipsychotic use in the intervention group decreased over time while in the control group it increased. Service measures showed both groups required approximately the same number of clinical visits but the intervention group experienced fewer medication changes, fewer drug side effects, and all but one case could be treated in situ. Five control group participants spent extended periods as inpatients in a psychogeriatric unit. Minor sampling differences did not affect the results, and neither they nor the nature of the behavior explained the difference in clinical approach.Conclusion: The causality-focused approach appears to be as effective as the more common predominantly pharmacological approach, and appears to involve lower human and financial costs.

Increased risk of dementia following mild head injury for carriers but not for non-carriers of the APOE ε4 allele

Abstract: Background: The e4 allele of apolipoprotein E (APOE) and head injury are risk factors for dementia diseases, and may act synergistically to further increase the risk. The aim of this study was to e ...

Potential ethnic modifiers in the assessment and treatment of Alzheimer's disease: challenges for the future.

Abstract: Objective: Despite numerous clinical trials, it is unknown whether ethnicity affects treatment response to cognitive enhancers in Alzheimer's disease (AD). There is convincing evidence of ethnic and genetic variability in drug metabolism. This article reviews the available data on ethnicity in clinical trials for AD to answer two questions: (1) what are the challenges to diagnose and treat AD across different ethnic groups, and (2) are there differences in response to pharmacologic interventions for AD across these different ethnic groups?Method: Available data from Alzheimer's Disease Cooperative Study (ADCS) randomized controlled clinical trials and from randomized controlled industry-sponsored trials for four cognitive enhancers (donepezil, galantamine, rivastigmine and sabeluzole) were pooled to assess the numbers of non-Caucasian participants.Results: The participation of ethnic minority subjects in clinical trials for AD was dependent on the funding source, although Caucasian participants were over-represented and non-Caucasian participants were under-represented in the clinical trials. Because of the low participation rate of ethnic minorities, there were insufficient data to assess any differences in treatment outcome among different ethnic groups. Strategies to improve diversity in clinical trials are discussed.Conclusion: Greater participation of ethnically diverse participants in clinical trials for AD would generate additional information on possible differences in metabolism, treatment response, adverse events to therapeutic agents, and could foster the investigation of genetic variability among ethnic groups.

Meaning and measurement of caregiver outcomes.

Abstract: The focus of dementia intervention research has broadened from a focus purely on the person with dementia to include the caregiver as well. Psychological, physical, social and health care utilization costs are well documented and effective caregiver interventions reported. Caregivers are crucial to many aspects of the path of dementia traveled by affected persons. They influence outcome and they are a secondary target in drug trials. Measurement of caregiver outcomes should be targeted to likely outcome, and key mediating variables should be measured too. A list of potential instruments and recommendations is provided.

Gender differences in depression among the very old.

Abstract: Emotional suffering in old age is largely caused by various psychiatric conditions, of which depression is the most common Depression is associated with a decline in both well-being and daily functioning and reduces both morale and social capacity among the very old, which may produce high health and social costs for society The overall aim of the thesis was to study the prevalence of depression among the very old, to identify factors associated with depression and to evaluate the prognosis of depression among the very old In total, 363 people were evaluated for depression, 242 from an urban municipality in the year 2000 and 121 from five rural municipalities in 2002 In 2005, those still alive in the urban municipality were asked to participate again, and were therefore re-evaluated The prevalence of depression was 27% in the urban municipality, 34% in the rural municipalities and 29% in the total sample Of those depressed, about 67% were receiving antidepressive treatment, and of those, approximately 50% had responded to treatment In the rural municipality, the depressed were less often treated with Selective Serotonin Re-uptake Inhibitor medications, receiving instead Tri-Cyclic Antidepressants In the rural municipalities, only 38% of the depressed had responded to treatment A higher proportion of women were diagnosed as depressed, 33% vs 19%, p=0006, although the response rate was the same for men and women Depression was twice as common among those with dementia, 44% vs 23% There were discrepancies concerning associated factors between the depressed participants with dementia and those without Experiencing the death of a child during the preceding ten years was associated with depression and independently associated with depression among men and participants with dementia In all the studies, the depressed were less often able to go outside independently and to visit others They also received fewer visits from others and often experienced loneliness The great majority of those who were depressed in 2000 died during the subsequent five years, only 13 out of 65, 22%, were still alive in 2005, compared to 41% of those who were not depressed, p=0003 Of 13 who survived, only two had recovered Twenty-four out of 70 non-depressed people, 34%, had developed depression during the five years (2000-2005), and the total prevalence in year 2005 was 42% (35 out of 83 participants) Ten out of the 24 who had developed depression were prescribed antidepressants Of those ten, four were regarded as responders In the group with persistent depression, nine out of eleven were receiving antidepressants and 67% were responders In conclusion, a large proportion of the very old suffer from under-diagnosed and undertreated depression The response rate to treatment seems to be low, and the quality of treatment and follow-up also seems to be poor The mortality rate among the depressed was high The spectrum of factors associated with depression in people with dementia is different from that associated with depression among non-demented Depression among the very old clearly emerges as a common and serious public health problem, with probably the most serious impact on quality of life More efforts have to be made to improve the quality of assessments, treatment and research regarding depression among the very old

A psychometric evaluation of a Swedish version of the Quality of Life in Late-Stage Dementia (QUALID) scale.

Abstract: Background: The aim of the present study was to evaluate the validity, reliability and responsiveness of a Swedish translation of the Quality of Life in Late-Stage Dementia (QUALID) Scale.Method: A total of 169 elderly residents at 19 dementia special care units in eight long-term care facilities in the Gothenburg city region participated in the study. Assessments were made by 107 proxy informants.Results: Results showed satisfactory levels of internal consistency reliability (Cronbach's α coefficients 0.74), acceptable inter-rater reliability between informants (0.69), and high test-retest reliability (0.86). As hypothesized, QUALID scores were also associated with those from other quality-of-life (QoL) indices (criterion validity), as well as with use of psychoactive drugs, and with tests of cognitive impairment (clinical validity). The responsiveness of the questionnaire was also acceptable.Conclusions: As important clinical decisions may derive from perceived QoL effects, it is vital that the QoL data be reliable, valid and sensitive to change. Our evaluations of the psychometric properties of the Swedish QUALID indicate that it satisfactorily meets the need for an instrument to assess QoL in late-stage dementia in Sweden, in a wide range of settings and applications.

Behavioral correlates of GABAergic disruption in Alzheimer's disease.

Abstract: Background: Losses of γ-aminobutyric acid (GABA) have been variably demonstrated in Alzheimer's disease (AD) and may be related to the presence of behavioral and psychological symptoms of dementia (BPSD) in AD. Our objective was to assess the relationship between plasma GABA (pGABA) levels and specific BPSD in patients with severe AD.Methods: pGABA levels and BPSD were measured in 14 institutionalized AD patients (8M/6F, mean age ± S.D. = 85.6 ± 4.5 years) with severe cognitive impairment (Mini-mental State Examination score = 4.5 ± 4.6) and prominent behavioral disturbances (Neuropsychiatric Inventory (NPI) score = 33.4 ± 23.6).Results: pGABA was positively correlated with depression and apathy scores on the NPI and negatively correlated with age. Apathy and age were independent predictors of pGABA levels.Conclusions: The final stages of AD are associated with GABAergic changes, which may contribute to depression and apathy in AD.

Depressive symptoms in newly admitted nursing home residents

Abstract: To study the relationship between the prevalence of depressive symptoms in newly admitted nursing home residents and their previous place of residence.

Alternate forms of logical memory and verbal fluency tasks for repeated testing in early cognitive changes.

Abstract: Background: Repeat cognitive testing is an essential diagnostic strategy to measure changes in cognition over time when following people with memory problems. Alternate forms may avert practice effects that can mimic improvements in cognition. We evaluated alternate forms of verbal fluency and logical memory (paragraph recall) tasks to evaluate their equivalence for clinical use. Methods: Participants with mild cognitive impairment (MCI) and dementia were recruited from five outpatient memory clinics and one nursing home. Participants with normal cognition (NC) were recruited from family members or friends. Verbal fluency categories of animals, cities & towns, fruits & vegetables and first names were used. Scores were recorded for 0–30 seconds, 31–60 seconds and errors. For the logical memory task, participants were read one of three different paragraphs and then were asked to recall the story. Immediate recall and delayed recall scores were recorded. The Standardized Mini-mental State Examination, the AB Cognitive Screen and the 15-point Geriatric Depression Scale were administered as part of the assessment. Analyses were performed using means, frequency distributions, t -tests, receiver-operating characteristic curves and effect sizes. Results: There were 46 NC participants, 45 with MCI and 55 with dementia. For verbal fluency, the mean number of animals, cities & towns, names or fruits & vegetables named in 60 seconds did not differ significantly within each cognitive group. First names was an easier category than the others: NC named 16.9–22.3 items, MCI named 11.6–14.4 items and dementia named 8.1–11.4 items. The mean number of items immediately recalled in logical memory was not significantly different for the three paragraphs. The verbal fluency task (in 60 seconds) and logical memory immediate recall were highly sensitive and specific to differences between NC and MCI (areas under the curves 0.87 and 0.76, respectively). Conclusions: Alternate forms allow serial testing without learning bias. Verbal fluency and logical memory tasks are sensitive to early cognitive changes.