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Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson’s disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson’s disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.

The dementia syndrome encompasses not only cognitive but also functional impairments. This is acknowledged in canonical definitions of dementia (DSM-IV) and major neurocognitive disorder (DSM-5).1 2 However, functional (executive) deficits are not addressed in standard cognitive screening instruments, although they may be more significant for both patients and their carers in terms of their impact on activities of daily living. Traditionally, separate scales have been used to assess cognition and executive function. Free-Cog was developed to assess both cognitive and executive function in a single instrument, hence, a ‘hybrid’ test which combines questions in both domains (accessed at https://www.gmmh.nhs.uk/free-cog).3 The former component assesses traditional measures such as orientation in time and place, memory, calculation, attention, visuospatial function, language and fluency. The latter items are assessed on the basis of responses to a series of themed questions related to activities of daily living, including social functioning, travel, self-care and safety at home. Maximum scores for ‘cognitive function’ and ‘executive function’ are 25 and 5, respectively, giving an overall composite score of 30. Higher scores indicate better function. In this way, it is similar to most other cognitive screening tests such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and the Mini-Addenbrooke’s Cognitive Examination (MACE). Free-Cog was initially validated in a proof-of-concept test accuracy study.3 In this index study, a cohort of 960 patients and controls was recruited from multiple memory clinics in the UK, mostly based within psychogeriatric services. The total Free-Cog score and its …

Objective To compare the occurrence of spontaneous cerebral emboli and venous to arterial circulation shunts in patients with Alzheimer9s disease or vascular dementia and controls without dementia. Design Cross sectional case-control study. Setting Secondary care old age psychiatry services, Manchester. Participants 170 patients with dementia (85 with Alzheimer9s disease, 85 with vascular dementia) and 150 age and sex matched controls. Patients on anticoagulant treatment, patients with severe dementia, and controls with marked cognitive impairment were excluded. Main outcome measures Frequencies of detection of spontaneous cerebral emboli during one hour monitoring of the middle cerebral arteries with transcranial Doppler and venous to arterial circulation shunts by a transcranial Doppler technique using intravenous microbubbles as an ultrasound contrast. Results Spontaneous cerebral emboli were detected in 32 (40%) of patients with Alzheimer9s disease and 31 (37%) of those with vascular dementia compared with just 12 each (15% and 14%) of their controls, giving significant odds ratios adjusted for vascular risk factors of 2.70 (95% confidence interval 1.18 to 6.21) for Alzheimer9s disease and 5.36 (1.24 to 23.18) for vascular dementia. These spontaneous cerebral emboli were not caused by carotid disease, which was equally frequent in dementia patients and their controls. A venous to arterial circulation shunt indicative of patent foramen ovale was found in 27 (32%) Alzheimer9s disease patients and 25 (29%) vascular dementia patients compared with 19 (22%) and 17 (20%) controls, giving non-significant odds ratios of 1.57 (0.80 to 3.07) and 1.67 (0.81 to 3.41). Conclusion Spontaneous cerebral emboli were significantly associated with both Alzheimer9s disease and vascular dementia. They may represent a potentially preventable or treatable cause of dementia.

Objective The objective assessment of socially inappropriate behaviour in patients with frontotemporal lobar degeneration (FTLD) is difficult and hampered by its elusive cognitive basis. Neuropsychological tests of social cognition such as complex theory- of-mind tasks are unlikely to be helpful for early differential diagnosis in the future, because patients with non-neurological disorders show impairments on these tasks and they are confounded with general executive abilities. Here, we used a newly developed test of the knowledge of the consequences of social behaviour to investigate whether this can be impaired in patients with FTLD relative to a previously developed test of social conceptual knowledge. Method We included 19 consecutive patients with features of bvFTD or SD. Based on their background neuropsychological tests and neuroimaging features, we classified patients into those with primary neurodegeneration of the anterior temporal lobes (ATL group, n=12), those with primary neurodegeneration outside the ATL (non-ATL group, n=5) and those with global impairment or atrophy (n=2). Results As predicted, we found conceptual knowledge of social behaviour to be impaired in the primary ATL group whilst knowledge of its long-term consequences was relatively preserved compared with the non-ATL group. In contrast, the non-ATL group showed impaired performance on the task probing knowledge of long-term consequences with relatively better conceptual social knowledge compared with the ATL group. Conclusions This shows that conceptual and sequential knowledge of social behaviour are dissociable and are likely to independently contribute to socially inappropriate behaviour. Short versions of these social conceptual and sequential knowledge tests are therefore promising tools for improvement of differential diagnosis when added to standard test batteries.

Brunet thinks that current interest in dementia will lead to harm and overdiagnosis.1 This current awareness is a triumph for a concerted approach from patients, carers, the public, professionals, charities, policy makers, and politicians. There is great dissatisfaction with existing services, especially regarding delays in diagnosis and support immediately after diagnosis and throughout the illness. People involved in dementia practice and policy want to improve this situation so that patients with dementia, families, and carers feel supported at every stage of …

Mental health problems are distressingly prevalent in the general population. Primary care clinicians have learned the full impact of this fact as US federal and state agencies have cut funding for mental health services, sending patients with both complex and severe psychiatric problems to seek care in generalist practices. Just to give you an idea of the prevalence of DSM-IV mental disorders in the general population, a study of 9,282 adult individuals revealed a 12-month prevalence of the following disorders: anxiety, 18.1 %; mood, 9.5 %; impulse control, 8.9 %; substance abuse, 3.8 %; and any mental health disorder, 26.2 %. Of the cases described, 22.3 % were considered serious; and 23 % of patients had three or more DSM-IV diagnoses [2].

Brunet questions the validity of the dementia diagnosis rate, which is expressed as a simple percentage.1 2 The numerator is the annual return made as part of the primary care Quality and Outcomes Framework process and the denominator is the estimated number of people with the diagnosis (estimated prevalence). This figure is based on the best evidence of prevalence, which comes from the latest epidemiological information. The Cognitive Function and Ageing Study3 and …

In their article, “Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis,”1 Le Couteur and colleagues contribute to the BMJ ’s “Too Much Medicine” campaign and attempt to repudiate three decades of dementia research and clinical practice. It completely misses the main aims of the current political approach and is in danger of affronting the millions of people with dementia and their families affected by this devastating illness, and of undoing much of the good done over recent years. The impact of dementia is unique. It affects an estimated 36 million people worldwide, costs $600bn (£376bn; €444bn),2 and attracts profound stigma, which demotivates people to come forward for assessment and contributes to less than half of people with …

Objectives Chronic low dose pesticide exposure, especially to organophosphates (OPs) has been associated with ill-health particularly in sheep farmers but in the absence of overt acute toxicity the epidemiological evidence linking chronic ill-health to such exposures is weak. Our aim was to determine whether neuropsychiatric disease was associated with pesticide exposure in sheep farmers. Methods 18 958 British farmers from the 1970s were identified using contemporaneous records held by the National Farmers9 Union, Sheep and Cattle Associations and through Shepherd9s Guides. Each farmer was sent a health and occupational questionnaire. The prevalence of screen identified depression, dementia, Parkinsonism and neuropathy was determined using previously published algorithms. Associations between work activities, handling the pesticide concentrate, and screen identified ill-health were determined after adjustment for demographic variables. Results Screen-identified ill-health was associated with the somatic symptom severity score and ever seeking advice for pesticide poisoning. Handling the pesticide concentrate was associated with screen-identified Parkinsonism (OR adj 1.76, 95% CI 1.06 to 2.92) and to a lesser extent with neuropathy (OR adj 1.58, 95% CI 0.96 to 2.60) but not depression or dementia. After excluding those participants who had sought advice for pesticide poisoning, risks for Parkinsonism and neuropathy remained elevated but were no longer significant. After stratification by somatic symptom severity score, associations were found only in farmers with low scores. Conclusions Results are consistent with the a priori hypothesis linking chronic low dose exposure to ill-health but require confirmation using more precise measures of exposure and outcome. Somatisation does not appear to play an important role in this population.

Editorial by Marshall Residential and nursing homes provide an essential contribution towards the care of people with dementia. It is a challenge to provide good care within tight budgets and often with a workforce that has little formal training. Most people are cared for within the private sector, although a limited number of NHS beds provide continuing care for people with severe dementia and intractable behaviour problems. Dementia care mapping1 is a direct, standardised assessment with good interrater reliability.2 Activities are coded according to category of behaviour, and they are recorded every five minutes. Wellbeing is measured using the dementia care index, which indicates the overall quality of care within a particular environment extrapolated from dementia care mapping evaluations of half of the residents.1 We used dementia care mapping to evaluate the quality of care in 10 private sector and seven NHS …

Aims Cognitive impairment in Parkinson9s disease (PD) has been associated with both pathological gambling and apathy. The aim of this study is to investigate, by means of a direct comparison, the neuropsychological associations of three behavioural groups of PD sufferers: impulse control disorder (ICD), apathy and controls. Methods Non-demented (n=96) PD sufferers were compared on clinical (motor and psychiatric) and cognitive variables. The PD sufferers were divided into three behavioural groups: impulse control disorder (ICD) (n=33); apathy (n=26); and controls (n=37). Correlations between variables were sought. Results The three behavioural groups differed significantly in set shifting (errors on the Trail Making task part B; p Conclusions Cognitive functioning differs according to behavioural phenotype, with apathy PD patients experiencing more difficulties.

Aims Behavioural manifestations in Parkinson9s disease (PD), such as impulsivity or apathy, are most likely driven by differing patterns of predisposing risk factors, including premorbid and current personality traits. This study explores associations of premorbid and current personality traits in PD sufferers with different behavioural syndromes, from the sufferer and carer perspectives. Methods This is a cross-sectional descriptive study of 94 non-demented PD sufferers with clinically significant apathy, impulse control disorder, or neither. Each participant was administered the 60-item NEOFFI, a measure of premorbid and current personality functioning, for self- and carer-rated scores. Relationships with other clinical variables were explored. Analysis included comparisons of mean NEO-FFI scores using ANOVA/Kruskall-Wallis. Correlations between personality scores from the carer and the PD sufferer were sought. Results The PD sufferers with impulse control disorder scored higher on neuroticism, extraversion and openness but lower on agreeableness compared to apathy and control-PD group. Carer ratings of personality correlated on all but one personality trait for the apathy group, but correlations between rater-type in the other two groups were not found. Premorbid and current personality ratings across the entire group correlated on all but two of the personality traits. Conclusions Differences in personality style in the PD sufferers with impulse control disorder compared to other PD sufferers exist. Some changes in personality from the pre-motor to the clinical stage exist in PD.

Aims Carer distress in Parkinson9s disease (PD) has been associated with psychiatric symptoms and levels of disability and disease severity in the PD sufferer. The specific contribution of behavioural phenotype in PD (impulsive vs apathetic) to carer burden has not yet been fully explored. Methods Non-demented (n=71) PD sufferer-carer dyads (spouse or child) were examined on various measures. The PD sufferers were divided into three behavioural groups: impulse control disorder (ICD) (n=21); apathy (n=22); and controls (n=28). Carer burden was rated using the Zarit Burden Scale and carer distress was determined from the Neuropsychiatric Inventory. PD sufferers were assessed for levels of disability, quality of life, clinical (motor and psychiatric), demographic variables and cognitive function. Correlations between variables were sought. Results The three behavioural groups differed significantly on measures of carer burden, with the ICD and apathy group carers’ having a greater burden of care. The PD groups differed significantly in levels of disability, psychiatric morbidity, cognitive functioning and clinical variables. Strong correlations were found between measures of psychiatric morbidity and carer burden (UPDRS Mental dysfunction score: n=0.453, p Conclusions Carer burden and distress differ according to behavioural phenotype, which appears to be driven by differences across several clinical factors.

Professor of child and adolescent psychiatry University of Manchester (b 1956; q Birmingham 1980), died from postoperative complications on 22 May 2004.​2004. Figure 1 Richard Harrington studied psychiatry at the Maudsley Hospital, London, before taking a research post at the Institute of Psychiatry, where he began his studies of children and adolescents with depressive illness. After two years as senior lecturer in Birmingham he was appointed professor of child and adolescent psychiatry at Manchester University. He became chairman of the British Child Psychiatry Research Society and vice president of the European Society of Child and Adolescent Psychiatry. In 1998 the American Academy of Child and Adolescent Psychiatry presented him with an award for best original research in the field of depression in young people. He leaves a wife, Lesley, and three children.

The three expressions of the clinical syndrome of dementia have been well documented: cognitive deficits —amnesia, aphasia, apraxia, and agnosia; neuropsychiatric features —a heterogeneous array of psychiatric symptoms and behavioural disturbances such as depression, delusions, hallucinations, misidentifications, aggression, agitation, wandering, collectively described as neuropsychiatric features, behavioural and psychological symptoms of dementia (BPSD),1 or non-cognitive features2; and problems with activities of daily living . The history of interest in the neuropsychiatry of dementia is relatively short by comparison with research into cognitive dysfunction. Psychiatric symptomatology …

A diagnosis of Alzheimer’s disease (AD) is a diagnosis of exclusion. A consideration of current and past medical and psychiatric conditions, surgeries, metabolic abnormalities, and pharmacotherapy is vital to making a diagnosis. Numerous factors can affect cognitive and functional abilities, and it is not unusual for other medical comorbidities to be present in addition to an underlying neurodegenerative process. Although these are rarely solely responsible for cognitive impairment, they may influence cognition adversely. This chapter will discuss recommended practices for the initial assessment of AD, including laboratory, imaging, and other types of diagnostic tests.

Twenty patients satisfying standard clinical criteria for Alzheimer's disease (AD) and six age-matched normal controls were studied using 99mTc hexamethyl-propyleneamine oxime and single photon emission tomography. The AD patients had lower regional cerebral blood flow (rCBF) in the temporal and posterior parietal lobes compared to controls. AD patients with apraxia and aphasia had lower rCBF in the lateral temporal and posterior parietal lobes than AD patients without these features. Within the AD group, correlations were found between neuropsychological tests and rCBF: praxis correlated with posterior parietal activity, memory with left temporal lobe activity and language with activity throughout the left hemisphere.