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Affecting 3% of the old-age population and 10-20% of elderly patients with chronic medical illness or dementia, depression is an important health problem in late life. Depression with first onset in late life differs from early-onset depression clinically as well as by more organic cerebral involvement. If untreated, depression in the elderly leads to severe disability and to excess mortality by suicide and by adverse outcome of medical illness. The response to antidepressant drugs in old age is on the same level as in younger age-groups, and as less than 1 in 5 elderly people with depression is diagnosed and treated, there is substantial room for improving the prognosis of old-age depression.

Introduction: Although delirium is a reversible cerebral syndrome, the effect of treatment of the elderly is unsatisfactory, involving prolonged hospitalizations and increased risk of relapse and mortality. The purpose of this study was to evaluate whether hospitalization for delirium (severe delirium) diagnosed by ICD-10 criteria predicts increased morbidity, utilization of health services and mortality., Materials and Methods: Delirious inpatients (n = 26) discharged after treatment in an old-age psychiatric university clinic were studied for nine years. In a register-based design, the above-mentioned parameters of the delirium cohort were compared with a group of controls (n = 116)., Results: There was a trend to increased mortality in the delirium cohort. Compared with the controls, the delirium cohort had a significantly increased incidence of disorders of vital organs, serious psychiatric disorders, particularly depression, increased use of hospital psychiatry and general practitioner's out-of-hours service, but less use of office-hour services. The incidence of delirium in the cohorts was low. In the delirium cohort, there was no significantly increased use of services or the number of diagnoses in somatic hospitals., Conclusion: Increased somatic and psychiatric morbidity and a trend to increased mortality indicate a serious prognosis after severe delirium in the elderly. It is noteworthy that the delirium cohort had increased use of GPs' out-of-hours services but less use of office-hour services.

Behavioural and psychological symptoms of dementia (BPSD) are common and can dominate disease presentation. Antidepressions are commonly prescribed for depressive symptoms, but the evidence to support this practice is weak. The atypical antipsychotics risperidone and olanzepine have significant efficacy for the treatment of aggression and risperidone is also efficacious in the treatment of psychosis, but both with substantially increased risk of stroke. There are no newer studies of benzodiazepines in the treatment of anxiety and in old studies the efficacy are doubtful.

Unlabelled: The prevalence of depressive disorders (D) in 70 years of age or older frail elderly was studied. Two hundred and eleven (81%) recipients of Municipal Home Help Service (frail elderly) in a rural area of Jutland were included and screened by the Geriatric Depression Scale-15 (GDS). If participants had: a) a GDS-score > or = 5 points or/and b) a history of depression, further evaluation was given by: 1) general practitioners (GPs) (implicit criteria), 2) a psycho-geriatrician (ICD-10 criteria), and 3) a geriatrician with the Hamilton Test for Depression. Prevalence rates for D among the evaluators: 15-18%. The diagnostic agreement was only fair., In Conclusion: 18% of the studied population fulfilled the ICD-10 research criteria for depression. The GDS may help GPs in diagnosing depression among frail elderly. False GDS negatives, found among GDS negatives with a history of depression, should be evaluated thoroughly when identifying depression in the target group.

The purpose of the study was to describe a Danish nursing home population. The study consists of 288 nursing home residents (median age 84.6 years, 68% females). The psychiatric morbidity of the residents was diagnosed with the GMS-AGECAT. The staff was interviewed about the residents' ADL, disturbing behaviour and therapeutic measures. Seventy-one percent had a psychiatric disorder, with organic disorder as the most frequent (61%). Demented residents received significantly less hypnotics, were more often physically restrained and had lower ADL levels compared to other residents. The situation in Denmark can be seen as a paradox. While substantial effort has been made to increase the possibility of choice and to "deinstitutionalize" nursing homes, the majority of the residents are demented and thus not capable of making valid choices.

The purposes of the study were to account for aetiology, treatment concept, outcome of treatment, and discharge destination of delirious elderly inpatients. During one year all patients in a psychogeriatric university department were assessed on admission and at discharge with a selection of assessments measuring psychopathology, behavioural disorders, depressive symptoms, intellectual functioning, activities of daily living, and gait. Diagnoses were made according to the ICD-10 criteria for research. All patients with a principal diagnosis of delirium (n = 26) are accounted for. Delirious patients improved their health status significantly in all the assessments, and 86% of patients admitted from independent living were discharged to independent living. It is concluded that elderly inpatients with severe or prolonged delirium profit significantly from the treatment concept in all of the rated health aspects.

Unlabelled: The objectives were to study clinical symptoms of major depression in later life by using relevant assessment scales of psychopathology, behavioural disorders, and physical functioning. The evaluations on admission and at discharge were based on interdisciplinary observations and interview of patients. The study was carried out during twelve months in a psychogeriatric university department and encompassed 202 patients. All (N = 80) (40%) patients who had a principal diagnosis of major depression are accounted for. Mean age was 79.5 years. Results of the assessments all showed significant improvements (p = 0.0000-0.0024). The overall results of the assessments show that the key symptom of sadness is often missing, muted, or overshadowed by other symptoms, and that behavioural disturbancies and functional disability may be important symptoms in geriatric depression., In Conclusion: adequate treatment of major depression in the elderly significantly improves psychopathology, behavioural disorders and physical functioning. When dealing with mental disorders in this age group, awareness of the five clinical presentations in major geriatric depression, i.e. dementoform, somatoform neurotiform, eretic and classic geriatric depression, may target the diagnostic procedure.

Case reports of 110 patients referred to a neurological dementia clinic were reviewed to evaluate a standardized diagnostic program. The patients were evaluated by a neurologist, a gerontopsychiatrist, and a neuropsychologist. ICD-10 criteria were used. Fifty-two patients had dementia while 58 had not; of these, 27 suffered from other non-dementia diseases and 31 were without dementia or other psychiatric or neurological disease. Thirteen patients with Alzheimer's disease were treated with tacrine. Four patients underwent cobalamin substitution treatment and seven started antidepressant medication. Ten patients received acetylsalicylic acid (150 mg Q.D.) and two a levo-dopa-type drug. Twenty-six patients were followed by gerontopsychiatric district care. Because only 47% of the patients suspected of dementia actually fulfilled dementia criteria, the evaluation suggests that patients suspected of dementia benefit from a standardized diagnostic program in a specialist setting.

During one year all patients with a diagnosis of depression in accordance with ICD-10, referred to a psychogeriatric department, were assessed at admission and discharge with a number of rating scales: The Brief Geriatric Depression Scale, Katz' ADL-index, the Multidimensional Dementia Assessment Scale, the Mini-Mental State Examination and the Functional Ambulation Classification. The department has an active stepwise treatment strategy: SSRI (selective serotonin reuptake inhibitor), potentiation with mianserin, lithium potentiation, ECT. The 87 depressive patients had a median age of 79 and most had one or more severe somatic conditions. Fifty-nine were severely depressed at admission, 19 at discharge; the number of functionally disabled dropped from 22 to seven and the number of cognitively impaired from 35 to 19. In conclusion, a nihilistic approach to treatment in the very old is unfounded.

Behavioral-disturbed elderly patients with dementia are often treated with psychotropic drugs, frequently by doctors who only have sporadic contact with such cases. Knowledge concerning psychotic symptoms and behavioural disturbances in dementia has increased over the past years, as to a certain extent has the number of investigations of psychopharmacological therapy in demented patients. Based on results of controlled drug trials and empiric consensus among psychogeriatricians, recommendations and guidelines regarding indications for drug therapy and type of psychotropic drug suitable for the treatment of psychiatric problems in dementia are given.

The psychogeriatric department in the county of Arhus is in a unique position to collect cases of old people treated with psychotropics in various inappropriate ways in hospital wards or by general practitioners. In 1991 the department was in contact with 768 elderly people mostly on an outpatient basis among whom 40 patients exhibited accumulated errors of psychopharmacologic treatment. The treatment episodes were analysed. The patients were very old (mean 80.8 years) with severe somatic morbidity. A majority were demented or delirious. 75% were living in nursing homes. The treatment episodes exhibited polypharmacy and large doses of neuroleptics (mean 0.7 DDD/day) or benzodiazepines (mean 1.41 DDD/day). Psychotropics not suitable for elderly patients were used in 34 patients. Indications for treatment were mostly unspecified behavioural disturbances, sometimes reflecting inappropriate social support. The majority of patients had side effects, sometimes rendering the patient more acceptable to staff and other residents.

Psychotropics are to a great extent used in nursing homes to sedate and incapacitate the residents for social reasons. The very high prescription rate also reflects gerontophobic and dementophobic myths placing the old and disturbing patient beyond general accepted ethical rules. The problem is highlighted by the new Danish law concerning the uncurable ill patient. Under certain conditions it is now legal not to treat demented people for a life threatening but treatable physical illness. The boundaries between active and passive euthanasia seem more and more blurred concerning old demented patients.

In 32 nursing homes selected at random in the 16 counties in Denmark, the use of psychotropic medication was studied in all residents aged over 65 years (1454 persons) by interview of nursing staff and review of treatment records regarding drug group, dose, duration of treatment and target symptoms. Psychotropic prescriptions were recorded in 56% of the elderly. The frequency of residents receiving daily treatment with neuroleptics was 20% and for anxiolytics, hypnotics and antidepressants 13%, 33% and 11%, respectively. The duration of treatment was two to three years. The indications were mostly unspecified behavioural disturbances. The use reflects the high psychiatric morbidity in nursing home residents, especially regarding dementia. From what is known of therapeutic efficacy and side-effects, it is concluded that the prescription rate is too high, duration of treatment much longer than necessary and that drugs inappropriate for elderly are often used.

This paper describes the admission and discharge pattern in a psychiatric hospital for 315 senile and arteriosclerotic demented patients (290.09, 293.09 ICD-8) aged 65 years and over and admitted for the first time. 47% (149) of the patients were admitted from other hospitals and temporary stays in nursing homes. A total of 203 (65%) of the patients experienced one or more changes of residence during the three months prior to admission to the psychiatric hospital. A Kaplan-Meier analysis showed that 25% of the patients were still hospitalized 48 weeks after admission. A total of 62 patients died in the psychiatric hospital, one patient was still hospitalized when the investigation ceased. Of those discharged alive 201, (80%) were discharged to nursing homes 26 (10%) to their own homes and 25 (10%) to hospitals. Of those who had their own home at the time of admission and were discharged alive only 16% were discharged to their own homes, the remainder were discharged to nursing homes and hospitals. On account of the many changes of environment the demented patients experience prior to admission to the psychiatric hospital, they risk developing confusional psychoses which may be disastrous to their physical and mental health.

Case records of 404 elderly patients (aged 65 years or more) who were admitted for the first time to the Psychiatric Hospital in Aarhus were investigated retrospectively. In 315 patients the diagnoses were senile dementia (290.09) and arteriosclerotic dementia (293.09) according to ICD-8. Information about use of psychotropic drugs before admission and on discharge alive was obtained from the patient case records. In the present study, the use of drugs was not found to be correlated with age, sex and degree of dementia. Significantly fewer committed patients were treated with psychoactive drugs and significantly fewer lived independently in their own homes. Only 42 (13%) patients had a crude psychiatric disorder while 251 (80%) were admitted on account of unacceptable behaviour. 90% of the latter group of patients had been treated with one or more psychoactive drugs on admission. The risks involved in the use of psychoactive drugs are discussed. On account of demographic changes in the Danish population and the recent decrease in psychiatric hospital beds and nursing home beds, it is recommended that the patterns of committed admissions of demented patients to psychiatric hospitals should be followed closely.