The Geriatric Anxiety Inventory (GAI) is a newly developed instrument specifically designed to measure common symptoms of anxiety in older adults Pachana et al., 2006). It contains 20 items with a dichotomous response format “agree/disagree”. The GAI can be self-rating or administered by a trained health professional. Pachana et al. reported the GAI to have sound psychometric properties in both normal older people and in a sample of geriatric psychiatry patients. The geriatric psychiatry patients consisted of 46 older people attending a community geriatric psychiatric service and were free of clinically significant cognitive impairment. In this sample, a cut-off point of 8/9 (out of 20) has a sensitivity of 73% and a specificity of 80% in identifying patients with an anxiety disorder. The GAI, however, was not designed to diagnose specific anxiety disorders but to assess the severity of anxiety symptoms across a range of presentations in older adults.

Background: Research with nondepressed adults suggests that social networks and social support are stable over the life course until very late age. This may not hold true for older adults with depression. We examined baseline status and trajectories of social networks and social support at the group and individual levels over five years.

Methods: The sample consisted of 339 initially depressed adults aged 59 or older (M = 69 years) enrolled in a naturalistic study of depression. Measures of social ties, including social network size, frequency of interaction, instrumental support, and subjective support, were administered at baseline and yearly for five years.

Results: Latent growth curve models were estimated for each aspect of social ties. On average, social network size and frequency of interaction were low at baseline and remained stable over time, whereas subjective and instrumental support were high at baseline yet increased over time. There was significant variation in the direction and rate of change over time, which was not predicted by demographic or clinical factors.

Conclusions: Because increasing social networks may be ineffective and may not be possible for a portion of people who already receive maximal support, interventions to increase social support may only work for a portion of older depressed adults.

The growing interest in analyzing the cost-effectiveness of interventions presents a challenge to anyone involved in dementia research. Although not yet often expressed as a formal requirement, drug authorities and budget holders also wish to have information on cost effectiveness. Clinical outcomes must therefore be combined with outcomes suitable for cost effectiveness analysis. However, issues about cost effectiveness are seldom included in empirical clinical trials, but are more often analyzed using modeling approaches. Clinical researchers and economists need to bridge these areas of potential conflict when long-term cost effectiveness is being considered. Randomized clinical trials (RCTs), observational studies, register data and economic models all have their advant-ages and drawbacks, and in making statements about cost effectiveness it is necessary to make a comprehensive judgment based on several methodological approaches. RCTs with a duration of at least 12 months should include assess-ments of resource utilization, and outcomes should offer a link to population-based cohort studies to discuss generalizability (e.g. a cognitive measure avail-able both in trials and cohort studies, such as the Mini-mental State Examination (MMSE), staging instruments, quality of life instruments) of the costs, while also serving as one source of modeling. Both dementia-specific and generic quality of life instruments are required. Models are necessary but must be transparent so that the assumptions on which the models are built can be critically analyzed.

Background: The aim of this survey is to investigate professional attitudes to the presence and value of spiritual care from Old Age Psychiatrists.

Method: All registered members of the Faculty of the Psychiatry of Old Age in the United Kingdom were asked to complete a 21-question semi-structured questionnaire. The first mail shot took place in 2002 and the second mail shot to non-respondents in 2003. Quantitative and qualitative analyses were carried out on the answers received.

Results: The response rate was 46%. The majority of respondents (92%) recognize the importance of spiritual dimensions of care for older people with mental health needs and about a quarter of respondents appear to consider referring patients to the chaplaincy service. In contrast, integration of spiritual advisors within the assessment and management of individual cases is rare.

Conclusions: Opinions vary as to whether provision of spiritual care should become widely available to older people with mental health needs who are admitted to hospital. Old age psychiatrists recognize that awareness of spiritual dimensions may be important for their patients. They seem less clear about the role of spiritual advisors and how NHS multidisciplinary clinical teams and spiritual and pastoral care services can be best integrated. Much work needs to be done on developing effective training and operational policies in this area.

Objectives: The aim of this study was to investigate factors associated with depression among men and women aged 85 and over.

Method: A population-based study was undertaken in northern Sweden. Out of 527 eligible participants, aged 85, 90 or ≥95, 363 were evaluated for depression. Data were collected from structured interviews, assessments and medical charts and from relatives and caregivers. Depression was screened for using the Geriatric Depression Scale-15 and further assessed using the Montgomerysberg Depression Rating Scale (MADRS).

Results A higher proportion of women were diagnosed with depression (33% vs. 18.6%, p = 0.006). In both men and women experienced loneliness (OR 3.4 vs. 7.0) and not going outside independently (OR 2.6 vs. 26.0) were associated with depression in the final regression model. Depression among men was also independently associated with loss of a child/children during the preceeding ten years (OR 30.0).

Conclusion: Depression was more common among women than among men. Experienced loneliness and not going outside independently seem to be closely related to depression in both men and women. Loss of a child seems to be the most important factor among men.

Based on efficacy and safety data, several drugs have been approved for symptomatic improvement of dementia of the Alzheimer type and one for the symptomatic improvement of dementia associated with Parkinson's disease. However, established treatment effects must be considered as modest. Randomized clinical trials in other subtypes of dementia (e.g. vascular dementia) have not been able to demonstrate clinically relevant symptomatic improvement, nor has it yet been possible to establish disease-modifying effects in any dementia syndrome or its subtypes. Recent progress in basic science and molecular biology of the dementias has now fostered new interest for more efficacious symptomatic treatments as well as for disease-modifying approaches in the degenerative dementias.

For regulatory purposes this requires better standardization and refinement of diagnostic criteria, which allow the study of homogeneous disease populations in specialized academic centers as well as in the general community setting. Depending on the disease stages (early versus late, mild to moderate to severe impairment) and disease entities, distinct assessment tools for cognitive, functional and global endpoints should be used or newly developed. The typical design to show symptomatic improvement is a randomized, double-blind, placebo-controlled, parallel group study comparing change in two primary endpoints, one of them reflecting the cognitive domain and the second preferably reflecting the functional domain of impairment. The changes must be robust and clinically meaningful in favor of active treatment versus placebo.

If a treatment claim for prevention of the emergence, slowing or stabilizing deterioration is strived for, it has to be shown that the treatment has an impact on the underlying neurobiology and pathophysiology of the process of dementia. Establishing such an effect in a highly variable progressing syndrome is complex and difficult; however, a variety of trial designs has been provided, including baseline designs, survival designs, randomized start or randomized withdrawal designs, with or without incorporation of biomarkers as surrogate endpoints (e.g. magnetic resonance tomography, emission tomography, cerebrospinal fluid markers). To be accepted as a surrogate endpoint such a biomarker ideally should respond to treatment, predict clinical response and be compellingly related to the pathophysiological process of the dementia. However, careful and sufficient validation of proposed biomarkers as a potential surrogate endpoint is a prerequisite for acceptance by regulatory bodies.

This review outlines the regulatory requirements for approval of a new medicinal product for symptomatic improvement or disease-modifying effects in patients with dementia, with special emphasis on the importance of validation of the assessment tools and potential surrogate endpoints based on recent experience and discussion regarding anti-dementia drugs in the European framework.

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.

Background: The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce.

Objectives: To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies.

Method: Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded.

Results: Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns – the “workhorse” and the “dabbler” – were observed, as was a culture of postponed retirement due to a sense of obligation and working “until you drop.” Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.

Conclusion: To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer “the four Ds”: dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

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.

The “for debate” series in International Psychogeriatrics offers an opportunity for different points of view to be put forward regarding a particular topic or controversial area of practice in our field. The contributions here are related to the use of neuroimaging in the investigation of those with suspected dementia. Advocates of neuroimaging suggest that it is a vital component in the workup of all those with suspected cognitive impairment, and this view has largely been reflected in guidelines such as those of the American Academy of Neurology (Knopman et al., 2001), the Royal College of Psychiatrists, the National Institute for Health and Clinical Excellence (NICE) in the U.K. (www.nice.ac.uk), and other eminent international groups including the European Federation of Neurology (Waldemar et al., 2000; Waldemar et al., in press). However, critics of this approach argue that neuroimaging represents an intensive resource which could be better used elsewhere, that the “added value” of improving diagnostic accuracy over and above that possible without neuroimaging remains to be proven (and, even more so, the cost effectiveness of such), and that use of neuroimaging should be selective and directed only to where it is likely to make a substantial impact on patient management.

Dr. Lim's practice audit of maintenance electroconvulsive therapy (M-ECT) in the elderly (Lim, 2006) describes a group of older people treated with M-ECT in Australia but does not describe the views of Australian psychiatrists regarding the use of this form of treatment. We explored the views of psychiatrists in northwest England regarding the use of M-ECT in the 1990s: our study group was a subset of the cohort reported in Benbow et al. (1998), namely those respondents to a first-stage questionnaire who stated that they had used M-ECT (25%) or were prepared to consider its use (67%). A second-stage questionnaire inquired specifically about practice in relation to M-ECT, defined as the regular administration of ECT in order to minimize the likelihood of further episodes of illness, and was sent to 85 individuals of whom 77 responded, giving a response rate of 87.5%. Of these respondents, 49% stated that they had not prescribed maintenance treatment within the past 10 years; 42% estimated that they had prescribed one or two courses; 8% three to four courses and 1% five to six courses. None had prescribed more than six courses, so the experience of any one individual was relatively limited.

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.

Background: Memory enhancement programs that can significantly improve actual memory performance and subjective perceptions of everyday memory in elderly people are rare. This study was designed to evaluate a new memory enhancement program incorporating principles of successful aging, designed to enhance subjective and objective everyday memory in community-dwelling old people.

Methods: Two matched groups of 20 healthy community-dwelling elderly adults were assessed on measures of objective and subjective memory performance before and after participating in a memory enhancement or active control condition.

Results: Planned multivariate analysis of variance (MANOVA) on change scores showed that participants in the memory enhancement program improved significantly on both objective and subjective measures. Specifically, greater improvement was demonstrated on a verbal paired associates task, story recall, face recognition, contentment with memory, and use of memory strategies.

Conclusions: Although a fully randomized design was not used, the results are promising, suggesting that memory training incorporating principles of successful aging can enhance memory performance in healthy old people, objectively and subjectively.

Background: The aim of this study is to compare the results of magnetic resonance (MR) imaging, particularly the decline in hippocampal volume, of patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI) with healthy age-matched controls, to examine the reliability of hippocampal volumetry in the early diagnosis of AD and the correlation of the severity of hippocampal atrophy with the severity of cognitive decline.

Methods: Twenty-six AD, 22 MCI and 15 normal cognitive status (NCS) patients were scanned with a 3 Tesla MR scanner. Hippocampus volumes were detected manually by Osiris 4.18.

Results: Multivariate regression analysis, which was performed to adjust the covariate effects of education, age, gender, hypertension and diabetes mellitus, showed that hippocampal atrophy was correlated with AD and MCI for right hippocampus; AD, MCI and age for left hippocampus independent of other parameters. A second regression analysis revealed that MMSE was correlated with hippocampal volume.

Conclusions: Hippocampal volumetry can be used in early diagnosis of cognitive impairment, as well as grading cognitive decline.

Papers submitted to International Psychogeriatrics undergo peer review, with each manuscript read by two or more reviewers possessing expertise relevant to the paper's topic. The advice of reviewers is often highly valuable to authors working to strengthen papers through revision, and their recommendations are central to the process of determining what is published in International Psychogeriatrics.

We report the case of an Italian family in which three sisters experienced transient global amnesia (TGA). Since its early description, this transitory pure memory deficit has attracted increasing interest, especially within the neurological community. In 1964 the term “TGA” was coined to identify the abrupt onset of anterograde amnesia, accompanied by repetitive queries lasting for hours and then gradually recovering, leaving an amnesic gap for the duration of the attack. Afterwards, many studies focused on TGA, and in 1990 clinical criteria were defined by Hodges and Warlow (1990). Further studies showed that meeting diagnostic criteria was a significant predictor for a better outcome than in other forms of transient amnesia, while amnesic patients who did not fulfil the TGA criteria had different outcomes. Precipitating and trigger events for TGA were identified and divided into physical and psychological factors (Inzitari et al., 1997; Quinette et al., 2006). Physical precipitants were found to be gardening, housework and sawing wood, contact with water and changes in body temperature occurring during hot baths or showers, or a cold swim at the swimming pool. Emotional trigger events included a major life or death event, emotional stress triggered by a gastric endoscopy, an exhausting work session, and anxiety resulting from conflicts at home or at work, health problems and money worries. Several hypotheses have been proposed for its pathogenesis such as psychogenic, venous dysfunction due to jugular venous valve incompetence, or ischemic aetiology, but the enigma of TGA still needs to be unravelled (Lewis, 1998; Akkawi et al., 2001).

Harm avoidance is one of the four temperament dimensions in Cloninger's psychobiological model of personality (Cloninger et al., 1993). In this model, personality is conceptualized as having four temperament dimensions (novelty seeking, harm avoidance, reward dependence, persistence) and three character dimensions (self-directedness, cooperativeness, self-transcendence). Individuals high in harm avoidance (HA) tend to be described as “worrying and pessimistic; fearful and doubtful; shy; and fatigable.” Those with low HA scores are “relaxed and optimistic; bold and confident; outgoing; and vigorous.” HA was initially proposed as a personality trait that is independent of the state of depression. However, other reports have found HA to be positively correlated with the severity of depression (Hansenne et al., 1999; Hirano et al., 2002). Repeated within-subject measures have been used to explore the stability of HA in major depression. However, conflicting results are reported in the literature and research in HA is largely with adults (Chien and Dunner, 1996; Marijnissen et al., 2002). The aim of this study is to investigate whether the personality trait of HA is stable over a 12-month period in a group of older people with a history of depression. This is a first report on the stability of HA in an exclusive elderly sample.

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.