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Introduction Although cardiovascular risk factors (CVRFs) have been identified as important risk factors for both major depression and cognitive decline in later life, their association with neuropsychiatric symptoms (NPS) has not been fully elucidated. Furthermore, CVRFs, particularly hypertension, hypercholesterolemia, and diabetes, may ultimately lead to physical conditions such as small vessel disease known to disrupt cognition, thereby leading to the onset of NPS. Thus, a better understanding of the association between CVRFs and NPS could improve the development of treatments and preventative measures for NPS. Methods Using baseline data from the Prevention of Alzheimer's Dementia with Cognitive Remediation plus Transcranial Direct Current Stimulation (PACt-MD) study, a multi-site intervention study targeting older patients with depression and cognitive decline, we analysed the distribution of CVRFs (Framingham risk scores; Hachinski ischemic score; presence of hypertension, hypercholesterolemia, hyperlipidemia, diabetes, and smoking) in patients with and without NPS as determined by a score of 1 and above or 0 on the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Participants fell into one of the following three diagnosis groups: Mild Cognitive Impairment (MCI) with a lifetime history of major depression (MDD); MCI without MDD; and MDD without MCI. Comparisons of distributions of CVRFs between NPI positive and negative groups were conducted using the non-parametric Mann-Whitney U test at a significance level of Results In a combined sample of 140 participants, there were no significant differences in any CVRF between positive and negative total NPI groups. However, some NPI subscale scores, notably agitation/aggression, anxiety, disinhibition, irritability, and night-time behaviour were significantly associated with increased CVRFs (p Conclusions None of the CVRFs were associated with overall total NPI-Q scores, however, these preliminary analyses suggest that some specific CVRFs were associated with certain NPI-Q subdomains. This suggests that CVRFs contribute to specific NPS domains rather than overall NPS burden. This research was funded by This project has been made possible by Brain Canada through the Canada Brain Research Fund, with the financial support of Health Canada and the Chagnon Family.

Introduction Cardiovascular risk factors are associated with both cognitive impairment and depression. However, the extent to which these factors are associated with cognitive impairment in patients with mild neurocognitive disorder with and without a history of lifetime depression needs to be clarified. Methods We looked at the distribution of Framingham Risk Scores (FRS) for cardiovascular disease in three groups of participants age 60 years and older in the Prevention of Alzheimer's Dementia with Cognitive Remediation plus Transcranial Direct Current Stimulation (PACt-MD) study: those with mild cognitive impairment (MCI; n = 42), remitted major depressive disorder (MDD, n =29), or MCI plus remitted MDD (n = 21). We also examined the association between cardiovascular risk factors and cognitive scores on the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MOCA), and the Montgomery–Asberg Depression Rating Scale (MADRS) using the non-parametric Spearman's rank order correlation test. Results There were no differences in the severity of FRS across the three diagnostic groups (p=0.281). Comparison of age, gender, education, and cognitive scores across FRS severity groups showed a significant correlation of increased FRS severity with higher age (p=0.016) and lower MOCA (p=0.023). When we assessed the correlation between specific cardiovascular risk factors (i.e hypertension, hypercholesterolemia, smoking, diabetes, hyperlipidemia) and MMSE, MOCA, and MADRS, the only significant correlation was found to be between a history of hypertension and lower MOCA scores (p=0.001). Conclusions The similar FRS distribution across MDD and MCI provides further support for the association of cardiovascular burden with both MDD and cognitive impairment. Hypertension was the only cardiovascular risk factor that was correlated with cognitive impairment. Future research is needed to clarify the mechanism behind this association. This research was funded by This Project has been made possible by Brain Canada through the Canada Brain Research Fund, with the financial support of Health Canada and the Chagnon Family.

Objectives Dementia draws on a variety of public and private resources. There is increasing pressure to define the cost components in this area to improve resource allocation and accountability. The aim of this study was to characterize frailty in a group of cognitively impaired community-dwelling elders and evaluate its relationship with cost and resource utilization. Methods We assessed a cross-sectional, convenient sample of 115 cognitively impaired patients of age >55 years who attended the National Memory Clinic in St James' University Hospital, a Trinity College-affiliated hospital in Dublin, Ireland. Participants had a clinical diagnosis of possible Alzheimer's disease or mild cognitive impairment. Frailty was measured using the biological syndrome model. Formal health and social care costs and daily informal caregiving costs were collected and the total costs of care estimated by applying the appropriate unit cost estimate for each resource activity. Stepwise regression models were constructed to establish the factors associated with increased care costs. Results Patient dependence, frailty and number of co-morbid illnesses explained 43.3% of the variance in observed daily informal care costs in dementia and cognitively impaired patients. Dependence was the sole factor retained in an optimal model explaining 19% of the variance in formal health and social care costs. Conclusion Frailty retained a strong association with daily informal care costs even in the context of other known risk factors for increasing care costs. Interventions that reduce frailty as well as patient dependence on others may be associated with cost savings. Copyright © 2015 John Wiley & Sons, Ltd.

OBJECTIVES: The older population are at a high risk for suicide. This study sought to learn more about the characteristics of suicide in the oldest-old and to use a cluster analysis to determine if oldest-old suicide victims assort into clinically meaningful subgroups. METHODS: Data were collected from a coroner's chart review of suicide victims in Toronto from 1998 to 2011. We compared two age groups (65-79 year olds, n = 335, and 80+ year olds, n = 191) and then conducted a hierarchical agglomerative cluster analysis using Ward's method to identify distinct clusters in the 80+ group. RESULTS: The younger and older age groups differed according to marital status, living circumstances and pattern of stressors. The cluster analysis identified three distinct clusters in the 80+ group. Cluster 1 was the largest (n = 124) and included people who were either married or widowed who had significantly more depression and somewhat more medical health stressors. In contrast, cluster 2 (n = 50) comprised people who were almost all single and living alone with significantly less identified depression and slightly fewer medical health stressors. All members of cluster 3 (n = 17) lived in a retirement residence or nursing home, and this group had the highest rates of depression, dementia, other mental illness and past suicide attempts. CONCLUSIONS: This is the first study to use the cluster analysis technique to identify meaningful subgroups among suicide victims in the oldest-old. The results reveal different patterns of suicide in the older population that may be relevant for clinical care. Copyright © 2015 John Wiley & Sons, Ltd. Language: en

SUMMARY Agitation and aggression are prevalent in Alzheimer's disease and have significant consequences for the patient, caregiver and care system more generally. We briefly discuss the epidemiology and etiology of agitation and aggression in Alzheimer's disease and provide an overview of assessment and approaches to care. We then review the evidence for and against a number of pharmacological and psychosocial approaches to care. There has been a growth in the evidence base for psychosocial interventions and nonpharmacological approaches to care should ordinarily be the first option. Antipsychotics remain the pharmacological agents with most evidence to support their use while there is more limited evidence for other agents such as carbamazepine and selective serotonin reuptake inhibitors such as citalopram.

Objective: To explore the effect of exercise on cognition in depression as well as the impact of potential moderators and intervention type. Method: Controlled and uncontrolled interventional studies that described an exercise intervention and cognitive outcomes in participants with major depressive disorder (MDD) were included following a search of Pubmed, Ovid Medline, PsycInfo and Embase from inception to January 2017. Meta-analyses were conducted to calculate Hedges’ g using a random-effects model. Meta-regression explored the relationships among age, baseline cognition, frequency and duration of exercise, and cognitive outcomes. Subgroup analyses were also conducted according to type and intensity of exercise interventions. Results: Of 12 controlled studies and 3 uncontrolled studies that met inclusion criteria, 9 (642 patients) were included in the meta-analysis. No significant effect of exercise was found on global cognition (Hedges’ g = 0.08, P = 0.33, I2 = 0%) or on individual cognitive domains. Meta-regression analyses failed to find significant relationships among participant age, baseline cognition, number of exercise sessions per wk, duration of exercise per wk, total duration of exercise during the intervention, or improvement in global cognition. Interventions combining physical with cognitive activity significantly improved global cognition ( P = 0.048), whereas low-intensity interventions were also positive ( P = 0.048). Conclusions: No impact of physical exercise was found on cognition in MDD overall. However, we found that interventions combining physical and cognitive activities had a positive impact, and that lower-intensity interventions, where adherence was improved, also impacted positively. There remains a lack of high-quality data in this population.

To quantitatively summarize changes in cognitive performance in individuals with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).Metaanalysis.Individuals undergoing TAVI (N = 1,065 (48.5% male) from 18 studies, average age ≥80).The MEDLINE, EMBASE, and Cochrane Central databases were searched for original peer-reviewed reports assessing cognitive performance using standardized cognitive tests before and after TAVI. Data were extracted for cognitive scores before TAVI; perioperatively (within 7 days after TAVI); 1, 3, and 6 months after TAVI, and 12 to 34 months after TAVI (over the long term). Standardized mean differences (SMDs) were generated using random-effects models for changes in cognition at each time point. Metaregression analyses were conducted to assess the association between population and procedural characteristics and cognitive outcomes. Risk of bias was assessed.There were no significant changes from baseline in perioperative cognitive performance (SMD = 0.05, 95% confidence interval (CI) = -0.08-0.18; z = 0.75, P = .46), although overall cognitive performance had improved significantly 1 month after TAVI (SMD = -0.33, 95% CI = -0.50 to -0.16; z = 3.83, P.001). There were no differences in cognitive performance 3 and 6 months after TAVI or over the long term. Cognitive outcomes were not associated with any covariates in regression analyses.Cognitive performance is preserved after TAVI, suggesting TAVI is not detrimental to cognition.

Transcranial direct current stimulation (tDCS) has recently been investigated as a potential nonpharmacological treatment for individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD). A comprehensive literature search was performed on tDCS studies published until March 2017 using MEDLINE, Embase and PsychINFO databases. 12 articles with a total of 202 MCI or AD participants were included. Although ten of the 12 studies demonstrated positive findings with tDCS, two studies reported no effect on cognition. There was a wide range of methodological approaches used and in the cognitive functions measured. The variability in treatment response may be related to the heterogeneity in stimulation parameters including the site of stimulation, and cognitive assessments used. Patient-related factors including individual psychological, biological, and physiological status at the time of stimulation may also influence treatment response. We recommend that more comparative studies using similar patient factors and study parameters are needed in order to better understand the efficacy of tDCS in MCI and AD.

Neuropsychiatric symptoms (NPS) may be the first manifestation of an underlying neurocognitive disorder. We undertook a review to provide an update on the epidemiology and etiological mechanisms of NPS that occur in mild cognitive impairment (MCI) and just before the onset of MCI. We discuss common clinical presentations and the implications for diagnosis and care.The authors conducted a selective review of the literature regarding the emergence of NPS in late life, before and after the onset of MCI. We discuss recent publications that explore the epidemiology and etiological mechanisms of NPS in the earliest clinical stages of these disorders.NPS have been reported in 35% to 85% of adults with MCI and also occur in advance of cognitive decline. The occurrence of NPS for the first time in later life should increase suspicion for an underlying neurocognitive disorder. The presenting symptom may provide a clue regarding the etiology of the underlying disorder, and the co-occurrence of NPS may herald a more accelerated cognitive decline.NPS are prevalent in the early clinical stages of neurocognitive disorders and can serve as both useful diagnostic and prognostic indicators. Recognition of NPS as early manifestations of neurocognitive disorders will become increasingly important as we move towards preventative strategies and disease-modifying treatments that may be most effective when deployed in the earliest stages of disease.

Depression in later life frequently persists and perpetuating factors are of immediate therapeutic relevance to clinicians. No studies of this scale have examined both clinical and neuropsychological predictors of persistent depression in a cross-national European context.4095 community dwelling older adults (≥ 50 yr) with clinically signficant depression (EURO-D ≥ 4) from eleven European countries in the Survey of Heath, Ageing, and Retirement in Europe (SHARE) were followed for a median of 28 months. Logistic regression analyses were conducted to determine predictors of persistent depression.2187 (53.4%) remained depressed at follow up. Independent predictors included: female gender, baseline functional impairment, functional decline, physical symptoms, past history of depression, increased severity of depression, early age of onset (50 yr), life events, financial distress and country of residence. Neuropsychological variables were associated with persistent depression but not independently of other variables.The assessment of depression was by self-report and the data source did not contain a number of potentially relevant predictors.Individuals at risk of persistent depression may be identified and targeted for intervention. Therapeutic interventions should adopt a multimodal approach to optimise current function, prevent further functional decline and treat symptoms of depression. Country of residence may be associated with further modifiable variables.

This chapter explores the evidence supporting inflammation-associated depression. Data to date suggest a bidirectional relationship between inflammation and depression wherein one process can drive the other. A wealth of animal and clinical studies have demonstrated an association between concentrations of pro-inflammatory cytokines - specifically interleukin (IL)-1β, IL-6, and tumor necrosis factor-α - and depressive symptoms. There is also evidence that this pro-inflammatory state is accompanied by aberrant inflammation-related processes including platelet activation factor hyperactivity, oxidative and nitrosative stress, and damage to mitochondria. These complex and interrelated mechanisms can collectively contribute to negative neurobiological outcomes that may, in part, underlie the etiopathology of depression. Mounting evidence has shown a concomitant reduction in both depressive symptoms and pro-inflammatory cytokine concentrations following treatment with pharmacological anti-inflammatory interventions. Taken together, the reviewed preclinical and clinical findings may suggest the existence of a distinct inflammatory subtype of depression in which these patients exhibit unique biochemical and clinical features and may potentially experience improved clinical outcomes with inflammation-targeted pharmacotherapy.

This chapter explores the evidence supporting inflammation-associated depression. Data to date suggest a bidirectional relationship between inflammation and depression wherein one process can drive the other. A wealth of animal and clinical studies have demonstrated an association between concentrations of pro-inflammatory cytokines - specifically interleukin (IL)-1β, IL-6, and tumor necrosis factor-α - and depressive symptoms. There is also evidence that this pro-inflammatory state is accompanied by aberrant inflammation-related processes including platelet activation factor hyperactivity, oxidative and nitrosative stress, and damage to mitochondria. These complex and interrelated mechanisms can collectively contribute to negative neurobiological outcomes that may, in part, underlie the etiopathology of depression. Mounting evidence has shown a concomitant reduction in both depressive symptoms and pro-inflammatory cytokine concentrations following treatment with pharmacological anti-inflammatory interventions. Taken together, the reviewed preclinical and clinical findings may suggest the existence of a distinct inflammatory subtype of depression in which these patients exhibit unique biochemical and clinical features and may potentially experience improved clinical outcomes with inflammation-targeted pharmacotherapy.

Background: Depression is a risk factor for Cardiovascular Disease (CVD). It has been reported that somatic symptoms of depression and not cognitive symptoms are associated with increased risk although findings have been inconsistent. Few studies have examined whether co-morbid anxiety confers additive risk. Methods: We conducted a cross sectional analysis of 7872 community dwelling adults aged 50 years and over from The Irish LongituDinal Study on Ageing (TILDA). Depressive and anxiety symptoms were assessed with Center for Epidemiologic Studies Depression (CES-D) scale and the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), respectively. We conducted logistic regression analyses to determine the relationship between depression, anxiety, individual depressive symptoms and CVD. We further determined whether co-morbid anxiety was associated with increased risk. Results: Seven hundred and thirty eight (9.4%) study participants reported clinically significant depression. Depression was associated with 80% increased risk of CVD following adjustment for cardiovascular risk factors. Individual depressive symptoms most consistently associated with CVD included low mood, sadness, amotivation, fatigue, diminished appetite and concentration difficulties. Anxiety was associated with increased risk of CVD but did not confer additive risk in participants with depression. Limitations: Cross sectional design. Conclusion: Core symptoms of depression, which are both cognitive and somatic in nature, are associated with increased risk of CVD while co-morbid anxiety did not confer additive risk. It is important that clinicians give due regard both to both cognitive and somatic symptoms of depression when determining cardiovascular risk. Future longitudinal investigation should confirm these findings and explore potential pathological mechanisms.

Objective To explore the incremental effects of patient dependence and function on costs of care for patients with Alzheimer's disease (AD) and amnestic mild cognitive impairment (MCI) in Ireland. Methods Cost analysis based on reported resource use for a cross-section of 100 community-based people with AD and MCI. Formal care included general practice visits, hospitalizations, outpatient clinic consultations, accident and emergency visits, respite care, meals on wheels services and other health and social care professional consultations. Informal care included time input provided by caregivers. Resource unit costs were applied to value formal care and the opportunity cost method was used to value informal care. Patient dependence on others was measured using the Dependence Scale and patient functional capacity using the Disability Assessment for Dementia scale. Multivariate regression analysis was used to model the cost of care. Results Both dependence and function were independently and significantly associated with total formal and informal care cost: a one point increase in dependence was associated with a €796 increase in total cost and a one point improvement in function with a €417 reduction in total cost over 6 months. Patient function was significantly associated with formal care costs, whereas patient function and dependence were both significantly associated with informal care costs. Conclusion The costs of care for patients with AD and MCI in Ireland are substantial. Interventions that reduce patient dependence on others and functional decline may be associated with important economic benefits. Copyright © 2012 John Wiley & Sons, Ltd.

Background: Our aim was to investigate the relationship between frailty and health-related quality of life (HR-QOL) in cognitively impaired elderly individuals. Methods: A cross-sectional observational study of a convenience sample of 115 patients with a diagnosis of Alzheimer’s dementia or mild cognitive impairment. Frailty was measured using the biological syndrome model and HR-QOL was measured using the DEMQOL-Proxy. Regression models were constructed to establish the factors associated with HR-QOL. Results: Frailty and neuropsychiatric symptoms were associated with HR-QOL, with Mini-Mental State Examination (MMSE) scores ≥21 ( P = .037, P ≤ .001, and R2 = .362). Functional limitation was associated with HR-QOL, with MMSE scores ≤20 ( P = .017 and R2 = .377). Conclusion: Frailty and neuropsychiatric symptoms were the determinants of HR-QOL in the earlier stages of cognitive impairment. Functional limitation predicted HR-QOL in the later stages of cognitive impairment. Frailty may represent a novel modifiable target in early dementia to improve HR-QOL for patients.

Background: Life satisfaction is a subjective expression of well-being and successful aging. Subjective well-being is a major determinant of health outcomes in older people. The aim of this study was to determine which factors predicted well-being in older people living in the community as measured by their satisfaction with life.Methods: The relationship between life satisfaction, as measured by the Life Satisfaction Index (LSI-A) and physical, cognitive and demographic variables was examined in 466 older people living in the community using a stepwise regression modelResults: Depression, loneliness, neuroticism, extraversion, recent participation in physical activity, age and self-reported exhaustion, were the independent predictors of life satisfaction in our elderly cohort.Conclusion: Subjective well-being, as measured by the Life Satisfaction Scale, is predicted by depression, loneliness, personality traits, recent participation in physical activity and self-reported exhaustion. The mental and emotional status of older individuals, as well as their engagement in physical activity, are as important as physical functionality when it comes to life satisfaction as a measure of well-being and successful aging. These areas represent key targets for intervention.

Self-efficacy is the belief that one can perform a specific task or behaviour and is a modifiable attribute which has been shown to influence health behaviours. Few studies have examined the relationship between self-efficacy for dementia-related tasks and symptoms of burden and depression in caregivers.Eighty four patient/caregiver dyads with Alzheimer's disease were recruited through a memory clinic. Patient function, cognition and neuropsychiatric symptoms were assessed together with caregiver burden, personality, depressive symptoms, coping strategies and self-efficacy for completing tasks related to dementia care.33% (28) of caregivers reported significant depressive symptoms (CES-D ≥ 10). In multivariate analyses, caregiver burden was predicted by self-efficacy for symptom management, neuroticism, patient function and neuropsychiatric symptoms while caregiver depression was predicted by self-efficacy for symptom management, caregiver educational level, neuroticism, emotion-focused coping, dysfunctional coping and patient function. In patients with moderate to severe impairment (MMSE ≤ 20), self-efficacy for symptom management behaved as a mediator between patient neuropsychiatric symptoms and symptoms of burden and depression in caregivers.Further longitudinal investigation is warranted to determine if self-efficacy might be usefully considered a target in future interventional studies to alleviate symptoms of burden and depression in Alzheimer's caregivers.

The dependence scale has been designed to be sensitive to the overall care needs of the patient and is considered distinct from standard measures of functional ability in this regard. Little is known regarding the relationship between patient dependence and caregiver burden. We recruited 100 patients with Alzheimer’s disease or mild cognitive impairment and their caregivers through a memory clinic. Patient function, dependence, hours of care, cognition, neuropsychiatric symptoms, and caregiver burden were assessed. Dependence was significantly correlated with caregiver burden. Functional decline and dependence were most predictive of caregiver burden in patients with mild impairment while behavioral symptoms were most predictive in patients with moderate to severe disease. The dependence scale demonstrated good utility as a predictor of caregiver burden. Interventions to reduce caregiver burden should address patient dependence, functional decline, and behavioral symptoms while successful management of the latter becomes more critical with disease progression.

Background Depression and anxiety have been reported to be independently predictive of conversion to Alzheimer's disease (AD) in patients with mild cognitive impairment (MCI). Anxiety symptoms have been less well studied and findings in this regard have been inconsistent. The objectives of this study are to determine which symptoms among a range of neuropsychiatric symptoms known to commonly occur in patients with MCI are predictive of later conversion to AD. We also wish to determine whether these symptoms track existing measures of declining cognitive and functional status or may be considered distinct and sensitive biomarkers of evolving Alzheimer's pathology. Methods One hundred and sixty-one patients with MCI were identified from consecutive referrals to a memory clinic. Univariate, multivariate and cox regression analyses were conducted. Results Seventy-six per cent of all patients had at least one neuropsychiatric symptom at baseline of which anxiety (52%), affective disturbance (37%) and aggression (32%) were the most common. Increasing symptom frequency was observed with increasing clinical severity. Anticipatory anxiety and activity disturbances were significantly associated with earlier conversion to AD although this association did not remain significant following adjustment for cognitive status at baseline. Conclusion Neuropsychiatric symptoms and anxiety symptoms in particular are common in patients with MCI. In this sample anxiety for upcoming events and purposeless activity frequently co-occurred and were significant clinical predictors of earlier conversion to AD. However, these findings were not independent of cognitive status at baseline and therefore may be markers of severity rather than independent predictors of disease progression. Copyright © 2010 John Wiley & Sons, Ltd.

Background The Cambridge cognitive examination (CAMCOG) is a mini neuropsychological battery which is well established and widely used. The utility of the CAMCOG in detecting prodromal Alzheimer's disease (AD) in patients with mild cognitive impairment (MCI) has not been determined. The objectives of this study are: to establish which subtests of cognitive domains contained within the CAMCOG are predictive of conversion to AD, to compare these with an extended version of the delayed word recall (DWR) test and to establish optimal cut points for all measures used. Methods 182 patients with MCI were identified from consecutive referrals to a memory clinic. Logistic regression, cox regression and receiver operating characteristic curve (ROC) analyses were conducted. Results The DWR displayed the best sensitivity (77%) and specificity (76%). The composite memory score contained within the CAMCOG achieved similar sensitivity (78%) and specificity (74%). The recognition component of the extended DWR demonstrated good specificity (85%) but poor sensitivity (57%). The optimal predictive model combined category fluency with the DWR and achieved predictive accuracy of 83%. Conclusion The DWR, which is a test specifically designed to have high predictive accuracy for AD, performed best. The composite measure of memory contained within the CAMCOG performed similarly well. The DWR has the advantage of being brief, easy to administer and suitable for use in non-specialist settings. The CAMCOG takes longer to administer but provides information regarding additional cognitive domains and is sensitive to change over time. Category fluency may be usefully combined with the DWR to improve predictive accuracy. Copyright © 2010 John Wiley & Sons, Ltd.

The older population are at a high risk for suicide. This study sought to learn more about the characteristics of suicide in the oldest-old and to use a cluster analysis to determine if oldest-old suicide victims assort into clinically meaningful subgroups.Data were collected from a coroner's chart review of suicide victims in Toronto from 1998 to 2011. We compared two age groups (65-79 year olds, n = 335, and 80+ year olds, n = 191) and then conducted a hierarchical agglomerative cluster analysis using Ward's method to identify distinct clusters in the 80+ group.The younger and older age groups differed according to marital status, living circumstances and pattern of stressors. The cluster analysis identified three distinct clusters in the 80+ group. Cluster 1 was the largest (n = 124) and included people who were either married or widowed who had significantly more depression and somewhat more medical health stressors. In contrast, cluster 2 (n = 50) comprised people who were almost all single and living alone with significantly less identified depression and slightly fewer medical health stressors. All members of cluster 3 (n = 17) lived in a retirement residence or nursing home, and this group had the highest rates of depression, dementia, other mental illness and past suicide attempts.This is the first study to use the cluster analysis technique to identify meaningful subgroups among suicide victims in the oldest-old. The results reveal different patterns of suicide in the older population that may be relevant for clinical care.

Background:There has been an increasing interest in the relationship between severity of disease and costs in the care of people with dementia. Much of the current evidence is based on cross-sectional data, suggesting the need to examine trends over time for this important and growing cohort of the population.Methods:This paper estimates resource use and costs of care based on longitudinal data for 72 people with dementia in Ireland. Data were collected from the Enhancing Care in Alzheimer's Disease (ECAD) study at two time points: baseline and follow-up, two years later. Patients’ dependence on others was measured using the Dependence Scale (DS), while patient function was measured using the Disability Assessment for Dementia (DAD) scale. Univariate and multivariate analysis were used to explore the effects of a range of variables on formal and informal care costs.Results:Total costs of formal and informal care over six months rose from €9,266 (Standard Deviation (SD): 12,947) per patient at baseline to €21,266 (SD: 26,883) at follow-up, two years later. This constituted a statistically significant (p = 0.0014) increase in costs over time, driven primarily by an increase in estimated informal care costs. In the multivariate analysis, a one-point increase in the DS score, that is a one-unit increase in patient's dependence on others, was associated with a 19% increase in total costs (p = 0.0610).Conclusions:Higher levels of dependence in people with Alzheimer's disease are significantly associated with increased costs of informal care as the disease progresses. Formal care services did not respond to increased dependence in people with dementia, leaving it to families to fill the caring gap, mainly through increased supervision with the progress of disease.

Dementia draws on a variety of public and private resources. There is increasing pressure to define the cost components in this area to improve resource allocation and accountability. The aim of this study was to characterize frailty in a group of cognitively impaired community-dwelling elders and evaluate its relationship with cost and resource utilization.We assessed a cross-sectional, convenient sample of 115 cognitively impaired patients of age55 years who attended the National Memory Clinic in St James' University Hospital, a Trinity College-affiliated hospital in Dublin, Ireland. Participants had a clinical diagnosis of possible Alzheimer's disease or mild cognitive impairment. Frailty was measured using the biological syndrome model. Formal health and social care costs and daily informal caregiving costs were collected and the total costs of care estimated by applying the appropriate unit cost estimate for each resource activity. Stepwise regression models were constructed to establish the factors associated with increased care costs.Patient dependence, frailty and number of co-morbid illnesses explained 43.3% of the variance in observed daily informal care costs in dementia and cognitively impaired patients. Dependence was the sole factor retained in an optimal model explaining 19% of the variance in formal health and social care costs.Frailty retained a strong association with daily informal care costs even in the context of other known risk factors for increasing care costs. Interventions that reduce frailty as well as patient dependence on others may be associated with cost savings.

Antiepileptic drugs (AEDs) are a class of medications that have received considerable attention as possible treatments for agitation and aggression in patients with dementia. This attention has been driven in equal measure by promising findings from limited trial and observational data and the desire to find treatments with improved tolerability. Their use, to date, has been largely confined to circumstances where first-line treatments have proven inadequate or are poorly tolerated. In recent years there has been some growth in the evidence base, and we can now make more informed recommendations regarding a number of older AEDs. Carbamazepine continues to have the best evidence to support its use, although the evidence base remains relatively small and concerns regarding tolerability limit its use. There is now more consistent evidence that valproate preparations should not be used for agitation and aggression in dementia. Despite a lack of high-quality data, some results have been reported for several newer medications, including levetiracetam, oxcarbazepine, gabapentin, topiramate and lamotrigine, and a number of these warrant further investigation. Recent findings and implications for clinical practice are discussed.

Background: The desire to institutionalize is an important predictor of future institutionalization. Few studies have examined potentially modifiable caregiver characteristics which might be the focus of future interventional strategies. Methods: A total of 102 patient/caregiver dyads with Alzheimer’s disease (n = 84) or mild cognitive impairment were recruited through a memory clinic. Cross-sectional analyses of a range of patients, caregivers, and context of care-related characteristics were conducted. Results: Caregiver desire to institutionalize was significantly associated with a number of potentially modifiable variables including caregiver coping style, self-efficacy, depression, burden, and the presence of an unmet service need. In a multivariate analysis, caregiver burden, depression, and nonspousal status were the only significant independent predictors of caregiver desire to institutionalize in a model which correctly classified 80.4% of caregivers. Conclusions: Interventions which seek to reduce caregiver desire to institutionalize should adopt a multifactorial approach to reduce symptoms of burden and depression in caregivers.

In Ireland, the population aged 65 years and over is projected to increase by 20,000 annually with the proportion of the population aged over 65 years doubling over the next 30 years. It is estimated that up to 60% of older people in hospital have or can develop a mental disorder during their admission (Royal College of Psychiatrists, 2005). The needs of older adults are distinct in many ways and a previous systematic review found that old age psychiatry services for hospitalized older adults are effective (Draper and Low, 2005). With regard to models of service provision, there is evidence that a liaison type service is superior to consultation only. The latter service is limited and reactive whereas a dedicated liaison service is proactive and is more likely to succeed in having good mental healthcare adopted as the standard of care within a hospital (Royal College of Psychiatrists, 2005). Consultation–Liaison (CL) services have been associated with decreased psychiatric morbidity, improved function, reduced length of stay, fewer readmissions, and increased cost-effectiveness compared with usual care (Royal College of Psychiatrists, 2005, Parsonage and Fossey, 2011). In Ireland, specialist community services for older adults have developed steadily, while CL services have remained relatively neglected with no specific recommendations regarding CL services for older adults in national guidelines (Department of Health, 2006). This is not necessarily out of step with international trends where in spite of increasing rates of referral to CL services for older adults in the United Kingdom and the United States there is a reported lack of emphasis upon this important area of service provision (Anderson et al., 2011). Consequently, little is known about age-specific CL services for older adults in Ireland, and service development has proceeded in an unstructured way. In particular, it is not known whether such a service is available within each area and if so, what the nature and extent of the services provided are.

We report the case of a 22 year old female diagnosed with dermatitis artefacta. This is an uncommon diagnosis and provides a unique therapeutic challenge for psychiatrists and dermatologists alike. We describe how early intervention and a close collaborative approach is central to securing a favourable outcome for patients.