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Huntington's disease (HD) is an inherited neurodegenerative disease involving motor, cognitive, psychiatric, and behavioral impairments that eventually affect work-role functioning. There is limited research regarding predictors of workplace disability in HD. The authors examined predictors of work impairment and disability in a cross-sectional cohort of employed persons with symptomatic HD participating in the worldwide Enroll-HD study.The study sample (N=316) comprised individuals with manifest HD and a CAG repeat length range between 39 and 60 and were currently engaged in paid full- or part-time employment. Univariate and multivariate logistic regression analyses identified predictors and the effect of all predictors in a fully adjusted model.Of the sample, 20.3% reported missing work due to HD, 60.1% reported experiencing impairment while working due to HD, 79.1% reported having work-related activity impairment due to HD, and 60.8% reported impairment in overall work productivity due to HD. Individuals had 25% higher odds of missing work time if they had a higher level of functional impairment (odds ratio=0.76, 95% CI=0.64, 0.91) and had three times greater odds of missing work if they were current alcohol drinkers, compared with nondrinkers (odds ratio=2.86, 95% CI=1.62, 5.03). Individuals with lower self-perceived mental health were also 5% more likely to experience impairment at work due to HD. Motor impairment was not a strong predictor of workplace disability.These findings provide important new knowledge that can inform the development of strategies or targeted intervention trials to support persons with symptomatic HD to maintain their work roles.

β-Ketosulfonamides derived from Boc or Cbz-protected amino acids bearing hydrophobic side chains were prepared in good to excellent yield by treating N-allyl, N-alkyl methanesulfonamides with n-BuLi, followed by reaction of the resulting carbanion with methyl esters of N-protected l-amino acids. The analogous reaction using the dianion derived from an N-alkyl methanesulfonamide proceeded in much lower yield. Electrophilic fluorination of the β-ketosulfonamides using Selectfluor in the presence of CsF in DMF at room temperature for 15–60 min provided β-keto-α,α-difluorosulfonamides in good to excellent yields. The allyl protecting group could be removed in good yield using cat. Pd(PPh)3)4 and dimethyl barbituric acid. When the fluorination reaction was performed with Cs2CO3 as base, β-ketosulfonamides derived from Val, Leu or Ile gave the expected β-keto-α,α-difluorosulfonamides, while β-ketosulfonamides derived from Ala, Phe, or hPhe gave the hydrates of the imino β-keto-α,α-difluorosulfonamides.

Recent developments in the understanding of the relationship between vascular risk factors, vascular cognitive disorders and dementia have led to a renewed interest in these risk factors and their management. The role of the primary care physician in the prevention, control and management of all aspects of vascular diseases is highlighted. Diagnostic criteria in the DSM, ICD and VASCOG systems are examined, in particular their relevance and usefulness in primary care settings. Cognitive domains in a “bedside” testing schedule may be helpful for the primary care physician in their daily practice. Primary and secondary care for people with vascular cognitive disorders places the primary care physician in crucial roles.

Huntington disease (HD) is a neurodegenerative condition with prominent motor (including oculomotor), cognitive, and psychiatric effects. While neuropsychological deficits are present in HD, motor impairments may impact performance on neuropsychological measures, especially those requiring a speeded response, as has been demonstrated in multiple sclerosis and schizophrenia. The current study is the first to explore associations between oculomotor functions and neuropsychological performance in HD. Participants with impaired oculomotor functioning performed worse than those with normal oculomotor functioning on cognitive tasks requiring oculomotor involvement, particularly on psychomotor speed tasks, controlling for covariates. Consideration of oculomotor dysfunction on neuropsychological performance is critical, particularly for populations with motor deficits.

Background:The literature available on the format of the feedback session following assessment of memory impairment is minimal. This study explored how this information should be presented from the perspective of patients and their families.Methods:Thirty-two semi-structured interviews were conducted with memory clinic patients and their carer at the clinic visit that followed the feedback session, to ask: what they recalled, what they found helpful, and what they thought was the best way to disclose a diagnosis of dementia. A second interview was conducted with 14 patient/carer dyads at their next appointment.Results:Recall of information from the feedback session was variable. Most respondents (76% of patients; 66% of carers) thought that a direct approach was best when informing the patient of a dementia diagnosis, and that both written information and compassion demonstrated by the doctor were helpful. Opinions on whether all the information should be given at once or in stages were divided.Conclusions:The current format of the feedback session needs revision to improve recall. Patients and their families want a direct approach to be used by a supportive and professional doctor with an opportunity to ask questions. They want the support of a family member or friend when they are told of their diagnosis and they would like a written summary to refer to afterwards.

Huntington disease (HD) is a neurodegenerative disorder that involves preferential atrophy in the striatal complex and related subcortical nuclei. In this article, which is based on a dataset extracted from the PREDICT-HD study, we use statistical shape analysis with deformation markers obtained through "Large Deformation Diffeomorphic Metric Mapping" of cortical surfaces to highlight specific atrophy patterns in the caudate, putamen, and globus pallidus, at different prodromal stages of the disease. On the basis of the relation to cortico-basal ganglia circuitry, we propose that statistical shape analysis, along with other structural and functional imaging studies, may help expand our understanding of the brain circuitry affected and other aspects of the neurobiology of HD, and also guide the most effective strategies for intervention.

Introduction Pastoral Care (PC) practitioners respond to the spiritual needs of patients and families of all spiritual orientations. The integrated PC service in an acute psychogeriatric inpatient ward at St Vincent's Aged Mental Health Service, Melbourne, Australia, was examined to investigate how PC was being accessed by inpatients. Methods A retrospective medical record file audit was undertaken of patients admitted over a 16-month period from 1 February 2009 to 30 June 30 2010 (n = 202). Results Sixty-eight percent were seen by PC practitioners during their admission. Sixty-six percent received PC assessments, 32% received PC ministry, and 10% received PC ritual or worship interventions. Other interventions (counseling/education, crisis situation, grief/ bereavement counseling) occurred infrequently. Seventy-five percent of Roman Catholic patients received PC compared to 57% of those patients with no religious affiliation. However, the overall association between religious grouping and receiving PC was not significant. Gender, religion, marital status, legal status, country of birth, language spoken, living situation, carer needs, or educational level were not related to PC contact. Whether or not an inpatient received PC assessment was unrelated to diagnostic category. Patients seen by PC were significantly more likely to engage in religious practice, have longer length of stay, and have neuropsychological, social work and occupational therapy assessments. Discussion Results suggest that PC practitioners can help optimize the clinical care of patients by developing a comprehensive understanding of their spiritual and religious needs and providing a more holistic service.

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

The increasing ageing population and subsequent increase in dementia means that the need for finding appropriate treatments has become more important. Current treatments are limited and only provide some symptomatic improvements in patients. This article reviews the recent drug advances in treatment for Alzheimer's disease which have been of varying success. It appears that a combination of these will be required.

The World Health Organization (WHO) specifies that attention to the spiritual needs of the elderly with mental health problems is essential to good patient care, yet little evidence-based practice is documented in this field. This paper reviews the literature on the provision of pastoral care services (PCS) to elderly people with mental impairment. Integration of Pastoral Care Practitioners (PCPs) into the multidisciplinary team is rare. Research into mental health clinicians' attitudes to addressing patients' spiritual needs, and the integration of PCPs into multidisciplinary teams in aged mental health are reported and discussed. The contextual needs of PCPs in aged mental health, and options for qualitative and quantitative research are explored. Further research is needed to guide the integration of PCS into multidisciplinary teams in aged persons' mental health services. Copyright © 2011 Blackwell Publishing Asia Pty Ltd.

CONTEXTO: A Seção de Psiquiatria Geriátrica da Associação Mundial de Psiquiatria (AMP), desde 1997, vem desenvolvendo Declarações de Consenso relevantespara a prática da Psiquiatria Geriátrica. Desde 2006, a Seção vem trabalhando para desenvolver uma Declaração de Consenso sobre Ética e Capacidade em pessoas idosas com transtornos mentais. MÉTODO: Uma Conferência de Consenso foi realizada em Praga em setembro de 2008. Organizada pela Seção de Psiquiatria da Pessoa Idosa da AMP, ela contou com a participação do International Council of Nurses, Alzheimer Europe e Alzheimer Disease International. Os participantes foram reconhecidos pela sua perícia nesse domínio e vieram de 11 países. Incluíam psiquiatras, uma neurologista, um enfermeiro e representantes de cuidadores familiares. RESULTADOS: Após dois dias de reuniões e debate, redigiu-se um rascunho da declaração que foi submetida para análise nas diversas organizações/associações que participaram da reunião. Após as sugestões finais recolhidas, um texto definitivo foi preparado em inglês e publicado. A presente versão em português é da responsabilidade de dois participantes lusófonos da reunião, que são também coautores da declaração de consenso final. CONCLUSÕES: Essa Declaração de Consenso oferece aos clínicos em saúde mental que cuidam de pessoas idosas com transtornos mentais, cuidadores, outros profissionais da saúde e o público em geral as definições e o debate sobre os princípios éticos que podem frequentemente ser complexos e desafiadores, apoiados em orientações práticas para satisfazer tais necessidades e padrões éticos e encorajar a boa prática clínica.BACKGROUND: The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders. METHOD: A Consensus Conference was realized in Prague, September 2008. The meeting was organized by the WPA Section of Old Age Psychiatry, with the participation of International Council of Nurses, Alzheimer Europe and Alzheimer Disease International. Participants who are recognised for their expertise in this area came from 11 countries and include psychiatrists, a neurologist, a nurse and family caregiving representatives. RESULTS: After two days of debate a draft was prepared and submitted to the organizations/associations represented at the meeting. When their respective comments were collected, a final text was prepared and published originally in English. This Portuguese version was prepared by two members of the meeting who came from Portuguese spoken countries. DISCUSSION: This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

CONTEXTO: A Secao de Psiquiatria Geriatrica da Associacao Mundial de Psiquiatria (AMP), desde 1997, vem desenvolvendo Declaracoes de Consenso relevantespara a pratica da Psiquiatria Geriatrica. Desde 2006, a Secao vem trabalhando para desenvolver uma Declaracao de Consenso sobre Etica e Capacidade em pessoas idosas com transtornos mentais. METODO: Uma Conferencia de Consenso foi realizada em Praga em setembro de 2008. Organizada pela Secao de Psiquiatria da Pessoa Idosa da AMP, ela contou com a participacao do International Council of Nurses, Alzheimer Europe e Alzheimer Disease International. Os participantes foram reconhecidos pela sua pericia nesse dominio e vieram de 11 paises. Incluiam psiquiatras, uma neurologista, um enfermeiro e representantes de cuidadores familiares. RESULTADOS: Apos dois dias de reunioes e debate, redigiu-se um rascunho da declaracao que foi submetida para analise nas diversas organizacoes/associacoes que participaram da reuniao. Apos as sugestoes finais recolhidas, um texto definitivo foi preparado em ingles e publicado. A presente versao em portugues e da responsabilidade de dois participantes lusofonos da reuniao, que sao tambem coautores da declaracao de consenso final. CONCLUSOES: Essa Declaracao de Consenso oferece aos clinicos em saude mental que cuidam de pessoas idosas com transtornos mentais, cuidadores, outros profissionais da saude e o publico em geral as definicoes e o debate sobre os principios eticos que podem frequentemente ser complexos e desafiadores, apoiados em orientacoes praticas para satisfazer tais necessidades e padroes eticos e encorajar a boa pratica clinica.

The present paper describes the unique mental health training cooperation between two countries involving three training sites to facilitate the improvement of mental health care and service delivery in China. The priority is to build workforce capacity to deliver appropriate mental health care and rehabilitation in the community. In response to this challenge, a training program was collaboratively planned between partners in both countries to provide a comprehensive training program for multiskilled case workers for mainland China. The development and key activities of the training and exchange program correspond to a diverse range of training programs across multiple levels of staff and sectors. The tripartite training program represents a unique, large scale training program that has contributed significantly to developing one of the largest global national mental health program of reform and building a national community mental health service system for China. Over their many years of cooperation, the Australian and Chinese partners have developed a model for successful collaboration, one based on mutual respect, exchange of expertise and a deep appreciation of cultural difference and its influences on broad aspects of health system development.

Academic Unit for Psychiatry of Old Age, St Georges Hospital, The University of Melbourne, Melbourne, AustraliaCorrespondenceAnita Mei Yoke Goh DPsych, Academic Unitfor Psychiatry of Old Age, The University ofMelbourne, St Georges Hospital, 283 CothamRoad, Kew, Vic. 3101, Australia.Tel: 161 3 9816 0513Fax: 161 3 9816 0403Email: goha@unimelb.edu.auDOI:10.1111/j.1758-5872.2009.00017.x

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.

The uptake of predictive testing for Huntington disease informs our understanding of decision making by those at risk and assists with planning for service provision. Uptake figures have been reported from several centers based on the total number of people who have undertaken predictive testing as a percentage of those estimated to be at 50% risk in the region. This method produced a figure of 35% from our own service, much higher than observation of the local pedigrees indicated, and higher than other published reports. We have identified some errors in the commonly used formula. The major errors are the use of the cumulative total of those who have had testing with a static denominator of those at 50% risk, and the failure to exclude from the at-risk group those who are too young and therefore ineligible to test.We report data from the Huntington Disease Register of Victoria and estimate the prevalence to be 8 per 100,000 in 1999. Additional data on individuals at risk were collated. We found that for every diagnosed person there were 4.2 individuals at 50% risk, a lower ratio than one to five hypothesized in the literature. We examined these ratios in the context of uptake.Significantly, we provide a solution to the calculation of uptake with a formula that factors in a dynamic denominator and corrects for the number of years testing has been offered. Using this formula, we calculated an uptake of 13.0-15.4% for the state of Victoria, Australia. This formula can be used to compare uptake across different centers.

Associate-recognition has received little attention as a potential clinical tool for detecting early Alzheimer's disease (AD). As an important preliminary stage to investigating the paradigm's diagnostic utility, we designed and administered a verbal associate-recognition task to healthy elderly participants (n = 62) and compared their performance to that on traditional cued-recall PAL. In both test conditions, the stimulus list comprised of a mixture of highly imageable and less imageable word pairs. Overall, performance on the associate-recognition task was superior to that on the cued-recall analogue. This 'recognition advantage' was not attributable to the higher baseline or chance guessing rate in the associate-recognition condition, as the size of the recognition advantage varied across learning trials and stimulus imageability. In comparison to performance on the imageable stimuli, performance on the less imageable stimuli was poor in both associate-recognition and cued-recall conditions. Across the delay, performances were more likely to drop in the cued-recall condition than the associate-recognition condition. These results suggest that verbal associate-recognition may be clinically efficacious and better tolerated in elderly populations than traditional cued-recall paradigms. Although these results are encouraging, further research is required to examine the utility of associate-recognition in clinical populations, particularly early AD.

The primary impairment in early Alzheimer's disease (AD) is encoding/consolidation, resulting from medial temporal lobe (MTL) pathology. AD patients perform poorly on cued-recall paired associate learning (PAL) tasks, which assess the ability of the MTLs to encode relational memory. Since encoding and retrieval processes are confounded within performance indexes on cued-recall PAL, its specificity for AD is limited. Recognition paradigms tend to show good specificity for AD, and are well tolerated, but are typically less sensitive than recall tasks. Associate-recognition is a novel PAL task requiring a combination of recall and recognition processes. We administered a verbal associate-recognition test and cued-recall analogue to 22 early AD patients and 55 elderly controls to compare their ability to discriminate these groups. Both paradigms used eight arbitrarily related word pairs (e.g., pool-teeth) with varying degrees of imageability. Associate-recognition was equally effective as the cued-recall analogue in discriminating the groups, and logistic regression demonstrated classification rates by both tasks were equivalent. These preliminary findings provide support for the clinical value of this recognition tool. Conceptually it has potential for greater specificity in informing neuropsychological diagnosis of AD in clinical samples but this requires further empirical support. (JINS, 2008,14, 591–600.)

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

Research in preclinical mutation carriers for Huntington's disease (HD) aims to find measures sensitive to preclinical decline. This study investigated attentional abilities in mutation carriers and noncarriers. Mutation carriers demonstrated a normal "attentional blink" during rapid serial visual presentation, normal covert visual orienting, and normal directing of attention to tactile stimuli. However, they were more likely than noncarriers to make anticipatory responses before target presentation. Additionally, those closer to estimated onset of HD demonstrated larger "inhibition of return" effects. The findings suggest potential changes in cognitive inhibition of unwanted responses, and in automatic inhibition of visual orienting, in preclinical HD.

© 2015 Wiley Periodicals, Inc. Huntington disease (HD) is most widely known for its selective degeneration of striatal neurons but there is also growing evidence for white matter (WM) deterioration. The primary objective of this research was to conduct a large-scale analysis using multisite diffusion-weighted imaging (DWI) tractography data to quantify diffusivity properties along major prefrontal cortex WM tracts in prodromal HD. Fifteen international sites participating in the PREDICT-HD study collected imaging and neuropsychological data on gene-positive HD participants without a clinical diagnosis (i.e., prodromal) and gene-negative control participants. The anatomical prefrontal WM tracts of the corpus callosum (PFCC), anterior thalamic radiations (ATRs), inferior fronto-occipital fasciculi (IFO), and uncinate fasciculi (UNC) were identified using streamline tractography of DWI. Within each of these tracts, tensor scalars for fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity coefficients were calculated. We divided prodromal HD subjects into three CAG-age product (CAP) groups having Low, Medium, or High probabilities of onset indexed by genetic exposure. We observed significant differences in WM properties for each of the four anatomical tracts for the High CAP group in comparison to controls. Additionally, the Medium CAP group presented differences in the ATR and IFO in comparison to controls. Furthermore, WM alterations in the PFCC, ATR, and IFO showed robust associations with neuropsychological measures of executive functioning. These results suggest long-range tracts essential for cross-region information transfer show early vulnerability in HD and may explain cognitive problems often present in the prodromal stage.

A brief review of classification in psychiatry from Kraepelin to ICD-10 and DSM-IV reveals that the categorical paradigm inherent in these nosological systems has certain inadequacies when applied to dementia specifically and cognitive impairment in general. There are “outcasts” from these two systems that, with the rapid advances in an understanding of cognitive disorders, expose significant limitations in them. As and when they are revised, serious consideration of a different view, accepting a dimensional paradigm, would contribute to a more inclusive and clinically relevant nosology for dementia and cognitive disorders.

Objective: To summarise studies reporting rates of depression (for the general population and older samples) and suicide in the Asia Pacific region. Methods: Information on local data was collected from the members of the SEBoD International Advisory Board on known epidemiological studies. Additionally, online searches were conducted using Medline and PsycInfo for the period 1994–2004. Results: Across the Asia Pacific region, rates of current or 1-month major depression ranged from 1.3% to 5.5%, rates of major depression in the previous year ranged from 1.7% to 6.7%, and lifetime rates ranged from 1.1% to 19.9%, with a median of 3.7%. Rates of suicide in the Asia Pacific region are now similar to those in Europe and the Americas. The exceptions include China and South Korea. Conclusions: Epidemiological studies in Asian populations are rare and use various diagnostic criteria. However, studies indicate that rates of depression in Asia Pacific, whilst lower, are comparable to other western countries. As such, depression as a health issue in Asia Pacific demands greater recognition. It is important that Asian countries should have the human and financial resources to conduct large scale epidemiological surveys not only in the area of depression, but also in the broader field of mental disorders.

Disturbances of walking have been described in people with Huntington's disease (HD), although the nature of the deficits have not yet been well defined. The purpose of this investigation was to determine whether people with HD have a deficit in the regulation of footstep timing during walking. The footstep patterns of 30 people with HD and 30 matched comparisons were measured at self-selected slow, preferred, and fast speeds. Subjects were also instructed to match their footsteps to auditory metronome cues set at 80 and 120 beats per minute. Gait speed, cadence, stride length, and double limb support as a percentage of the gait cycle were measured using a computerized foot-switch system. People with HD demonstrated a disorder in their ability to regulate cadence, manifest as a reduced step frequency when walking at preferred speed and when required to increase their speed. For all walking conditions, people with HD had increased variability of footstep cadence. They also had difficulty synchronizing their footstep timing to an auditory cue. For all walking conditions, people with HD had reduced stride length. Thus, in HD, there is a disorder in the regulation of footstep timing, with increased variability, a restricted cadence range, difficulty synchronizing footsteps to an auditory cue and reduced stride length. The exact neural correlates of this timing disorder are yet to be determined.

One consistent functional imaging finding from patients with major depression has been abnormality of the anterior cingulate cortex (ACC). Hypoperfusion has been most commonly reported, but some studies suggest relative hyperperfusion is associated with response to somatic treatments. Despite these indications of the possible importance of the ACC in depression there have been relatively few cognitive studies ACC function in patients with major depression. The present study employed a series of reaction time (RT) tasks involving selection with melancholic and nonmelancholic depressed patients, as well as age-matched controls. Fifteen patients with unipolar major depression (7 melancholic, 8 nonmelancholic) and 8 healthy age-matched controls performed a series of response selection tasks (choice RT, spatial Stroop, spatial stimulus-response compatibility (SRC), and a combined Stroop + SRC condition). Reaction time and error data were collected. Melancholic patients were significantly slower than controls on all tasks but were slower than nonmelancholic patients only on the Stroop and Stroop + SRC conditions. Nonmelancholic patients did not differ from the control group on any task. The Stroop task seems crucial in differentiating the two depressive groups, they did not differ on the choice RT or SRC tasks. This may reflect differential task demands, the SRC involved symbolic manipulation that might engage the dorsal ACC and dorsolateral prefrontal cortex (DLPFC) to a greater extent than the, primarily inhibitory, Stroop task which may engage the ventral ACC and orbitofrontal cortex (OFC). This might suggest the melancholic group showed a greater ventral ACC-OFC deficit than the nonmelancholic group, while both groups showed similar dorsal ACC-DLPFC deficit.

The vestibulo-ocular reflex (VOR) stabilizes gaze during movement, in conjunction with other afferent information: visual, proprioceptive, and somaesthetic. The reflex can either be augmented or suppressed, depending on visual requirements, and undergoes long-term adaptation to compensate for physical changes in the subject. Importantly, over relatively short periods of time, the VOR should function consistently under the same circumstances. This study examines VOR function in patients with Huntington's disease (HD), with a view to investigating cortical influences on the reflex. Horizontal eye movements were recorded in 9 patients with HD and 7 normal subjects, using the scleral search coil technique, in response to high frequency, unpredictable head rotations imposed manually. To establish base VOR function, recordings were made in darkness, without instruction, before and after wearing x2 magnifying lenses for a period of 2 hours to adapt the reflex. Recordings were also made before adaptation, while fixating a stationary visual target (VOR augmentation), and while fixating a target moving with the head (VOR suppression). Although results suggest that the VOR is preserved in HD, with relatively normal gain values and appropriate augmentation and suppression of the reflex with visual input, patients were unable to adapt the VOR to altered visual conditions. This represents a novel finding in HD and suggests that cortical structures compromised in HD exert influences on the long-term adaptation of the VOR.

With increasing understanding of BPSD, the question of whether there are differences between BPSD of AD and VaD may be raised. The available evidence from the Cache County Study, the role of vascular risk factors in late-life depression, and vascular pathology in AD and VaD all converge to explore the impact of vascular burden on cerebral function and BPSD. This article argues that there may be domain differences in BPSD between AD and VaD and suggests that BPSVaD may be a concept to be pursued with possible useful clinical implications.

Objective One of the main goals of the World Psychiatric Association (WPA) section on old age psychiatry is to promote its discipline and consequently to help member societies to promote and develop locally specific medical education programmes in old age psychiatry. In order to target its support to the needs expressed by the member societies, the section conducted a survey within the WPA during the year 2001. Method A questionnaire was sent to each of the 116 WPA member societies in 93 countries. It assessed the level of development of medical education in old age psychiatry in each country, as well as the perceived needs in educational material. Results Answers were obtained from 50 WPA member societies (response rate 54%) from 48 countries (response rate 52%). The existence of specific old age psychiatry services was reported in 40 (83%) countries, but the discipline is recognized as a subspecialty in only 13 (27%). Formal teaching in old age psychiatry was reported at the undergraduate level in 44 (92%) countries. Specific learning objectives for postgraduate training were reported in 30 (86%) of the countries where the discipline is not yet recognized as a subspecialty. Specific Continuing Medical Education (CME) programs were however reported in only 50% of the countries. Support for the development of educational material was mostly thought to be useful at the postgraduate level. Depression, dementia, psychopharmacology and psychotherapy were among the most frequently cited areas in which educational material might be usefully provided. Conclusion Support for the development of postgraduate training is seen as the most pressing need by WPA member societies. Such support could help to increase the level of recognition of the discipline locally and hence provide more effective support to older people with mental disorders. Copyright © 2003 John Wiley & Sons, Ltd.

BACKGROUND: Atypical antipsychotics are commonly used in the management of schizophrenia in late life with evidence suggesting they induce lower rates of motor disturbance, but have similar efficacy to conventional antipsychotics. Trials in the elderly have been either retrospective, small, of short duration or of a single-arm design. AIMS: To demonstrate the effects upon motor side-effects, efficacy, safety and quality of life (QOL) of switching elderly patients with schizophrenia from conventional antipsychotics to olanzapine or risperidone. METHODS: Elderly patients with schizophrenia were randomly allocated to olanzapine or risperidone and followed through an open-label crossover period. Between and within group intention to treat analyses were conducted. RESULTS: 66 patients were randomised (mean age 69.6 [SD +/- 6.2]). Four (11.8%) patients on olanzapine and 8 (26.7%) patients on risperidone failed to complete the crossover because of treatment failure [Odds Ratio (OR) = 2.73[0.73-10.2] p = 0.14]. The mean doses upon completion of switching in each arm were 9.9 mg (SD = 4.2) and 1.7 mg (SD = 1.2) for olanzapine and risperidone respectively. In both arms there was improvement in Parkinsonism, though only olanzapine was associated with a reduction in dyskinetic symptoms. The Brief Psychiatric Rating Scale, Scale for the assessment of Negative Symptoms and Montgomery and Asberg Depression Rating Scale scores all improved through the crossover period in both arms with no between group differences. Treatment with olanzapine was associated with a better response over risperidone on the psychological domain of the World Health Organisation-Quality Of Life [Brief] (WHO-QOL-BREF) scale ( p = 0.02). Patients in the olanzapine arm also demonstrated improvement from baseline in the WHO-QOL-BREF physical, psychological and health satisfaction domains, but risperidone had no effect on any Quality of Life (QOL) measure. CONCLUSIONS: After switching from a conventional antipsychotic, olanzapine and risperidone were associated with improvement in core symptoms of schizophrenia and motor side effects. Subjects switched to olanzapine were more likely to complete the switching process and show an improvement in psychological QOL. Copyright 2003 John Wiley & Sons, Ltd

The elderly psychiatrically ill constitute a high proportion of the patients who receive electroconvulsive therapy (ECT). There is evidence to say that the efficacy of ECT may be enhanced in the elderly. Clinical and biological markers are increasingly being recognised as predictors of outcome to ECT. The doses of anticholinergic, anaesthetic and relaxant agents may need to be modified in accordance with physiological changes associated with aging. ECT stimulus and ECT technique should be selected against the background of increased seizure threshold and possibility of greater ECT-induced cognitive dysfunction in the elderly, particularly those with pre-existing cognitive or neurologic impairment. New brain-imaging techniques and biochemical measures of brain damage have proved that ECT does not cause brain damage. The physical risk with ECT is considered to be low. There is some evidence to say that cardiovascular complications reported with ECT are related to the nature of pre-existing cardiac disease. Although the short-term response to ECT in the elderly is quite good, post-ECT relapse rates are quite high. Continuation-maintenance ECT has a definite role in minimising relapses and recurrences in the elderly, taking care not to enhance physical and cognitive risks. With increasing administration of outpatient ECT, it is important to refine methods for monitoring patients for adverse effects of treatment. The roles of repetitive trans-cranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS) in geriatric psychiatry are yet to be established.

Mental rotation (MR) performance may be used as an index of mental slowing or bradyphrenia, and may reflect, in particular, speed of motor preparation. MR was employed with a sample of both melancholic (na 8) and non-melancholic (na 9) unipolar depressed patients and healthy controls (na 10) to determine if motor slowing associated with depression might be reflected in slowed motor preparation (as reflected in slope of the MR function) independent of actual motor slowing (overall response time). Both melancholic and non-melancholic patients showed a generalised slowing relative to controls, perhaps reflecting bradykinesia and akinesia. This effect was significantly greater in the melancholic group than in the non-melancholic group. Relative to both the controls and the non-melancholic groups, the melancholic patients showed a progressive slowing with increasing angle of orientation indicating a specific slowing of MR. This deficit suggests a role of slowed motor planning in the psychomotor retardation of patients with melancholic depression.

The International Psychogeriatric Association (IPA) being the leading international organization in the promotion of mental health and effective treatment of mental disorders in the elderly, has a long standing enviable tradition and track record in providing leadership in this field.

Movement-related potentials (MRPs) reflect increasing cortical activity related to the preparation and execution of voluntary movement. Execution and preparatory components may be separated by comparing MRPs recorded from actual and imagined movement. Imagined movement initiates preparatory processes, but not motor execution activity. MRPs are maximal over the supplementary motor area (SMA), an area of the cortex involved in the planning and preparation of movement. The SMA receives input from the basal ganglia, which are affected in Huntington's disease (HD), a hyperkinetic movement disorder. In order to further elucidate the effects of the disorder upon the cortical activity relating to movement, MRPs were recorded from ten HD patients, and ten age-matched controls, whilst they performed and imagined performing a sequential button-pressing task. HD patients produced MRPs of significantly reduced size both for performed and imagined movement. The component relating to movement execution was obtained by subtracting the MRP for imagined movement from the MRP for performed movement, and was found to be normal in HD. The movement preparation component was found by subtracting the MRP found for a control condition of watching the visual cues from the MRP for imagined movement. This preparation component in HD was reduced in early slope, peak amplitude, and post-peak slope. This study therefore reported abnormal MRPs in HD, particularly in terms of the components relating to movement preparation, and this finding may further explain the movement deficits reported in the disease.

Objective: The purpose of this review is to highlight the prevalence of mental disorders in Australian nursing homes and to provoke discussion of the current inadequacy of mental health services in these facilities. Method: Comparisons were made between mental health care in Australian and United States (US) nursing homes. Relevant literature was reviewed. Results and Conclusions: In both US and Australian nursing homes, the prevalence of mental disorders is high, but there is under-recognition and under-treatment of these conditions. When adequately resourced, old age psychiatry services can have a beneficial impact on mental health care in nursing homes.

Psychogeriatricians commonly undertake home visits, often under unusual and sometimes challenging circumstances. We report a home visit to a zoo to see an unusual case, a 49-year-old confused gorilla. A diagnosis of post-infarct delirium was made, subsequently validated by autopsy. We describe a primate observation scale which was used in the assessment of cognition this case, which may be helpful for use when cognitive assessment of primates is required.

The ability of Huntington's disease patients to co-ordinate their two hands with and without external cueing was investigated. Twelve Huntington's disease patients and sex- and age-matched controls performed a bimanual cranking task at two speeds (0.5 Hz, 1.5 Hz) and phase relationships (in-phase, anti-phase), with and without an external metronome cue. Data were sampled at 200 Hz, and raw displacement data for each hand, mean and standard deviation measures of the relative positions of the two hands and their velocities were then calculated. All participants could perform the in-phase movement, at both speeds; however. the Huntington's disease patients were more variable and less accurate than the control participants, particularly at the fast speed. While controls could perform the anti-phase movement, in which rotation of the cranks differed by 180 degrees at both speeds, Huntington's disease patients were unable to do so at either speed, reverting to the in-phase movement at the slow speed. An external metronome cue did not improve the performance of the Huntington's disease patients, which differentiated this group from patients suffering from Parkinson's disease. The Huntington's disease patients' inability to perform the anti-phase movement may be due to damage to the basal ganglia and its output regions.

Clinical observation points to similarities between psychomotor retardation in major depression and bradykinesia in Parkinson's disease (PD). While common elements of neuropathology have been proposed to account for this, experimental investigations of this possible link have been few and inconclusive. The present study attempts to determine whether patients with depression display the characteristically Parkinsonian reliance on external cues; and if so, whether this is common to both melancholic and non-melancholic patients. Twenty three patients with unipolar major depression (11 melancholic and 12 non-melancholic) and 24 age-matched healthy controls performed a serial choice reaction time task known to be sensitive to Parkinsonian movement deficits. The melancholic patients showed a Parkinsonian pattern of impairment on the task, exhibiting a particular difficulty when initiating movements in the absence of external cues. This was largely alleviated when a moderate amount of external cueing was provided. At a high level of advance information, melancholic patients were again slow relative to controls. A base-line measure of bradykinesia and a derived measure of dependence upon external cues both correlated significantly with CORE (measure of psychomotor disturbance) ratings. The non-melancholic patients did not show any measurable motor impairment. This cue-dependent deficit may be due to an underlying basal ganglia dysfunction similar to that involved in PD, i.e. a failure of internal cueing. Difficulty with a high level of external cueing might reflect bradyphrenia or a prefrontal motor deficit of ability to plan multiple upcoming movements simultaneously. The results suggest that depression subtypes involve differing patterns of fronto-striatal impairment.

We report a pair of monozygotic Huntington's disease (HD) twins who, although sharing identical CAG repeat lengths, not only present with marked differences in clinical symptoms but also behavioral abilities as measured by our experimental procedures. Both HD twins and two healthy control subjects were tested twice over 2 years. Patient A was generally more impaired at a motor level, whereas Patient B showed greater attentional impairment; Patient B, however, showed more progressive deterioration. The control subjects' performance remained consistent over the 2-year interval. Patient A clinically had the more hyperkinetic hypotonic variant of the disease, whereas Patient B, who was the more impaired, presented with a more hypokinetic hypertonic (rigid) variant. The influences of epigenetic pre- and postnatal environmental factors should not be ignored.

Between 1990 and 1997, we performed 29 allogeneic BMTs for acute lymphoblastic leukemia (ALL) patients with HLA-identical sibs. Their median age was 31 years (range 15 to 43); there were 15 males and 14 females. The conditioning protocol was Cy-TBI (n = 15), VP16-Cy-TBI(n = 12), CBV (n = 1) and Bu-Cy (n = 1). Cyclosporin and methotrexate were used for GVHD prophylaxis. The median disease-free survival (DFS) was 12 months (range 1 to 92) with an actuarial 4-years DFS of 42.3 per cent. Three patients died of transplant-related complications before 100 days. Relapse occurred in 11 cases at a median time of 5 months (range 3 to 14). All nine patients relapsing within one year died form resistant leukemia. Three patients died of late treatment-related complications. There were 13 survivors (median follow-up 38 months, range 12-98), with 12 in remission. Only four had limited cGVHD, and all had 100 per cent performance scores. One patient also cleared her chronic hepatitis B carrier status due to acquired immunity. The DFS rates amongst CR1 cases and R1/CR2 cases were comparable (p = 0.39). No long-term DFS is obtained from patients with resistant disease (n = 4). The survival results for BMT at CR1 were superior to those using intensive chemotherapy consolidation (p = 0.29), mainly due to poor late results in the chemotherapy arm. For young ALL patients with HLA-matched siblings, the option of BMT should be considered in light of local consolidation survival results.