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The Severity Indices of Personality Problems (SIPP; Verheul et al., 2008) is a popular self-report questionnaire that measures severity of maladaptive personality functioning. Two studies demonstrated the utility of the short form (SIPP-SF) among older adults but validation in clinical settings is lacking. Therefore, we examined the psychometric properties of the SIPP-SF in a large sample of older adult Dutch outpatients ( N   = 124; age range = 60-85 years, M  = 69.8, SD  = 5.3). The SIPP-SF domains showed good to excellent internal reliability (Cronbach's α = .75-.91) and effectively discriminated between participants with and without a personality disorder, as assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Convergent validity of the SIPP-SF was examined with instruments for measuring personality pathology among older adults (Informant Personality questionnaire [HAP]; Gerontological Personality Disorders Scale [GPS]). The GPS generally correlated with the SIPP-SF domains in expected directions, with small to large effect sizes. For the HAP, only 1 scale correlated with all SIPP-SF domains. No associations were found between the SIPP-SF and psychiatric symptomatology as measured by the Brief Symptom Inventory (BSI). The SIPP-SF appears to be a promising instrument for assessing maladaptive personality functioning among older adult outpatients.

Objectives: To validate the Psychogeriatric Inventory of Disconcerting Symptoms and Syndromes (PGI-DSS), a single scale in A4 format comprising four disconcerting syndromes (violence, refusal, words, and acts). The scale enables an immediate conversion of a qualitative assessment to a quantitative assessment. The PGI-DSS was compared with the Neuro Psychiatric Inventory for Nursing Homes (NPI-NH)., Design: Cross-sectional descriptive and correlational studies., Setting: Thirty geriatric care units and nursing homes., Participants: Raters interviewed nurses and nursing assistants in charge of older adults hospitalized in geriatric care units or living in nursing homes (N = 226)., Measurements: The French version of the PGI-DSS and the French version of the NPI-NH., Results: The correlation coefficient between the PGI-DSS and the NPI-NH was 0.70 (p < 0.0001). The PGI-DSS threshold score corresponding to the NPI threshold score was 17 (specificity: 87%, sensitivity: 63%). Four statistical factors, corresponding to the four clinical syndromes, explained 53.4% of the total variance. The internal consistency of the PGI-DSS (Cronbach's alpha = 0.695) was higher than that of the NPI-NH (Cronbach's alpha = 0.474). Test-retest reliability was better for the PGI-DSS than for the NPI-NH. The intraclass correlations were 0.80 [0.73; 0.86] and 0.75 [0.67; 0.83], respectively. Interrater reliability was better for the PGI-DSS than for the NPI-NH. The intraclass correlations were 0.65 [0.55-0.76] and 0.55 [0.43-0.68], respectively., Conclusion: The PGI-DSS was developed to overcome the limitations of the NPI-NH. New, brief, easy to administer in less than 4 minutes, foldable in four parts, pocket-sized, easy-to-read in the palm of the hand, PGI-DSS could have similar or better statistical properties than the NPI-NH. Whereas the 10 domains in the NPI-NH have clinical utility for clinicians, the four easily understandable syndromes in the PGI-DSS can help avoid inappropriate attitudes and can guide psychosocial interventions. It could likewise improve dialogue between caregivers and clinicians.

Introduction: Geriatrics Mobile Units are a new organisation operating in nursing homes. Their mission is to propose globally oriented neuro-psychiatric and geriatric care. The purpose of the study is to assess their activity and impact over a 21-month period., Method: A prospective single center study of UMNPG's data including intervention characteristics, patient characteristics, recommendations and reassessment after intervention. The Neuropsychiatric Inventory Nursing Home version (NPI-NH) was measured during intervention and reassessed after 30 days (Student's t-test)., Results: From March 2014 to December 2015, UMNPG conducted 288 interventions mainly for medical advices (81%), clinical assessments (54%) and health care team support (46%). The average age was 84.6±7.3years, 73.3% of whom were women. The patients were dependent (62% of GIR 1 or 2) with dementia (60%) and under several medications (83.7%). The symptoms were mainly agitation/aggression (76.4%), anxiety (75%), depression (66.7%), irritability (60.4%), aberrant motor behaviour (55.9%) and delusions (48.6%). The main proposals of UMNPG were a change in treatment (79.5%), a health care team support (85.4%) and hospitalization (8.4%). The rate of follow-up on recommendation was 83% on the 15th day and 80% on the 30th day. The rate of avoided hospitalizations was 16%. The average NPI-NH decreased (on day 0 NPI=50±19.2; on day 30 NPI=33.9±19.6, p<0.001)., Conclusion: UMNPG-EHPAD intervenes for frail elderly residents with multiple disorders in crisis situations. Medical recommendations help to support people in nursing homes and decrease NPI-NH. UMNPG-EHPAD is part of geriatric network strengthening the city/hospital connection., (Copyright © 2018 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia., Method: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and 'as needed' psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans., Results: The most problematic areas concerned the gathering of information about patients' psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services., Conclusion: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

Objectives: To determine the frequency and quality of religious history taking of patients by clinicians working in an old age psychiatry service., Methods: A retrospective audit of 80 randomised patient files from the Koropiko Mental Health Services for Older People (MHSOP) in Middlemore Hospital, Auckland, New Zealand., Results: A total of 66 clinical records were available for analysis. A religious history was taken in 33/66 (50%) patients. However, when such histories were evaluated using the FICA assessment tool, only 10/33 (30.3%) histories contained detailed information regarding the patient's religiousness., Conclusions: The infrequency and low quality of religious histories discovered in this audit suggest that clinicians need more training in taking a religious history from patients.

Objective: To improve patient care/outcome, an evaluation was conducted of nursing procedures and protocols for pro re nata (PRN) medications., Methods: A 14-day chart review was conducted for 27 patients with mood and thought disorders (MTD) and for 24 patients with organic disorders (OD) at a geriatric psychiatric hospital, and a questionnaire was completed by 20 nurses., Results: 377 PRNs were administered to patients in the MTD and OD units (240 and 137, respectively). The majority of PRNs were administered during the evening shifts on the MTD unit and during the day shifts on the OD unit. Chart notes indicated the behavior requiring PRN administration was not always specifically described and therapeutic interventions were not often attempted before PRN administration. Inconsistency between chart notes and medication record books was noted in the majority of cases. It was often not known whether the PRN was initiated by the staff, patient, or family. PRNs were reported to be not effective in the majority of cases., Conclusions: Documentation was suboptimal and effectiveness was poor., Clinical Implications: It would be worthwhile to train all staff in a patient-centered or ecopsychosocial (i.e., non-pharmacological) model of care, which would provide staff alternatives to PRNs. In that context, it would be important to implement standards of practice into geriatric psychiatry inpatient settings for PRN administration and documentation.

Autism spectrum disorders (ASD) are difficult to detect in old age. This study examined if ASD symptoms in older adults (age > 60) can be detected with the Dutch informant personality questionnaire, (Hetero-Anamnestische Persoonlijkheidsvragenlijst, HAP) in a mental health setting. Patients with ASD (N = 40) were compared to patients with a different psychiatric diagnosis (N = 43; personality disorders excluded). The ASD group had significant higher scores on the scales 'Socially avoidant behavior', 'Rigid behavior' and 'Unpredictable and impulsive behavior'. These scales were able to discriminate between individuals with or without ASD. The HAP can thus be used as a screening instrument for ASD symptoms in elderly patients. Further research is needed to clarify what items have the best predictive validity for ASD symptoms.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals., Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles., Results: Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported., Conclusions: Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GMM has been on advisory boards or a speaker for Janssen, Lilly, Lundbeck, and Pfizer. BNF has received honoraria for ad hoc speaking or advising/consulting or received research funds from Alternative Funding Plan Innovations Award, AstraZeneca, Brain & Behavioral Foundation, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Daiichi Sankyo, Eli Lilly, Hamilton Health Sciences Foundation, J. P. Bickell Foundation, Lundbeck, Lundbeck International Neuroscience Foundation, Ontario Brain Institute, OMHF, Ontario Ministry of Research and Innovation, NSERC, Pfizer, Servier, Society for Women’s Health Research, Sunovion, and the Teresa Cascioli Charitable Foundation. ZI has received honoraria for ad hoc speaking or advising/consulting or received research funds from Canadian Biomarker Integration Network for Depression, Canadian Consortium for Neurodegeneration and Aging, Canadian Institutes of Health Research, Janssen, Joan and Clifford Hatch Foundation, Katthy Taylor Chair in Vascular Dementia, Lundbeck, National Institute of Aging, Ontario AFP Innovation Fund, Otsuka, Pfizer, and Sunovion. NJ has no financial conflicts to declare. MS has no financial conflicts to declare. RJV has no financial conflicts to declare. SHK has received honoraria for ad hoc speaking or advising/consulting or received research funds from Allergan, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Janssen, Lundbeck, Ontario Brain Institute, Pfizer, St. Jude Medical, Servier, and Sunovion. RWL has received honoraria for ad hoc speaking or advising/consulting or received research funds from Asia-Pacific Economic Cooperation, AstraZeneca, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Coast Capital Savings, Johnson & Johnson, Lundbeck, Lundbeck Institute, Medscape, Pfizer, St. Jude Medical, Takeda, University Health Network Foundation, and Vancouver Coastal Health Research Institute. RVM has received speaker and consultant honoraria or research funds from Allergan, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association Eli Lilly, Johnson & Johnson, Lallemand, Lundbeck, Merck, Ontario Brain Institute, Ontario Mental Health Foundation, Otsuka, Paladin, Pfizer, Queen’s University, Sunovion, Takeda, the University Health Network Foundation, and Valeant. SVP has been a consultant to Bristol Myers Squibb, Lundbeck, and Takeda; has had a research contract with Assurex; and has equity in Mensante. AVR has received speaker and consultant honoraria or research funds from Bristol-Myers Squibb, Canadian Depression Research and Intervention Network, Canadian Foundation for Innovation and the Ministry of Economic Development and Innovation, Canadian Institutes of Health Research, Grand Challenges Canada, Janssen, Lundbeck, Ontario Mental Health Foundation, Pfizer, and Sunovion., (© The Author(s) 2016.)

Background: There is little research evidence as to whether general adult psychiatry or old age psychiatry should look after old people with enduring mental illness., Aims: To compare the extent to which general adult and old age psychiatric services meet the needs of older people with enduring mental illness., Method: A total of 74 elderly patients with functional psychiatric disorders were identified by reviewing the notes of patients over the age of 60 living in a defined inner urban catchment area. Data were collected on the morbidity and needs of the sample. Needs were assessed using the Elderly Psychiatric Needs Schedule (EPNS)., Results: The participants in contact with old age psychiatry had significantly fewer unmet needs compared with those in contact with general adult psychiatry (2.8 v. 5.6, t = 2.2, P<0.03). Total needs were not significantly different between those managed by old age and general adult services (8.0 v. 6.5 respectively, t = 1.2, P = 0.2)., Conclusions: This study found that old age psychiatry services were better placed to meet the needs of elderly people with mental illness. This finding supports the need for a separate old age psychiatry service., (© The Royal College of Psychiatrists 2015.)

Responses of 1,442 consecutive participants in psychogeriatric day care (mean age 78.8; SD 6.5) to 15 items of a mood questionnaire were analyzed by Mokken scale analysis which is based on nonparametric item response theory models. As from 2002, 825 participants also answered eight self-esteem questions. For the purpose of an exploratory and confirmatory study the sample was split into random halves. The sample represented a broad range of cognitive impairment, from moderately severe to mild dementia. An automated item selection procedure available in the R package mokken revealed a scale for emotional well-being consisting of nine items fitting the monotone homogeneity model of unidimensionality and adequate person separation (Loevingers H=0.37; SE=0.02; Cronbach's coefficient alpha=0.79; SE=0.02). A confirmatory analysis in the second random half of the sample confirmed these results. The scale for emotional well-being consists of the items feeling 'contented', 'healthy', 'tired', 'lonely', 'down', 'in good spirits', 'helpless', 'weak' and 'having faith in the future'. Mokken scale analysis of the eight self-worth items confirmed the unidimensionality and discriminatory power of the self-esteem scale (H=0.41; SE=0.03; Cronbach's alpha=0.80; SE=0.02). Emotional well-being was positively associated with self-worth (Spearman correlation=0.56; 95%-confidence interval [0.49;0.62]). The two scales allow the objective ordering of persons on the latent variables of emotional well-being and self-worth by their test scores. Three case vignettes illustrate application of the indicators in clinical psychogeriatric practice.

Background: There are still substantial uncertainties over best practice in delirium care. The European Delirium Association (EDA) conducted a survey of its members and other interested parties on various aspects of delirium care., Methods: The invitation to participate in the online survey was distributed among the EDA membership. The survey covered assessment, treatment of hyperactive and hypoactive delirium, and organizational management., Results: A total of 200 responses were collected (United Kingdom 28.6%, Netherlands 25.3%, Italy 15%, Switzerland 9.7%, Germany 7.1%, Spain 3.8%, Portugal 2.5%, Ireland 2.5%, Sweden 0.6%, Denmark 0.6%, Austria 0.6%, and others 3.2%). Most of the responders were doctors (80%), working in geriatrics (45%) or internal medicine (14%). Ninety-two per cent of the responders assessed patients for delirium daily. The most commonly used assessment tools were the Confusion Assessment Method (52%) and the Delirium Observation Screening Scale (30%). The first-line choice in the management of hyperactive delirium was a combination of non-pharmacological and pharmacological approaches (61%). Conversely, non-pharmacological management was the first-line choice in hypoactive delirium (67%). Delirium awareness (34%), knowledge (33%), and lack of education (13%) were the most commonly reported barriers to improving the detection of delirium. Interestingly, 63% of the responders referred patients after an episode of delirium to a follow-up clinic., Conclusions: This is the first systematic survey involving an international group of specialists in delirium. Several areas of lack of consensus were found. These results emphasise the importance of further research to improve care of this major unmet medical need.

Background: Depression within the geriatric patient population is an important issue as it is associated with increased mortality. Such depression may have a different aetiology to that in younger patients and be associated with comorbid chronic physical health problems or cognitive impairment. However, there is no specific UK guideline for the treatment of depression within elderly patients. The first-line pharmacological treatment recommended by the National Institute for Health and Care Excellence (NICE) is to use a serotonin-selective reuptake inhibitor (SSRI). Unfortunately these can have significant side-effects in the elderly such as hyponatraemia. Sertraline is one such SSRI commonly used in the geriatric population. Mirtazapine, a noradrenergic and specific serotonergic antidepressant (NaSSa) is seeing increasing usage as an alternative agent. Here we evaluate the role of using the NaSSA in place of the SSRI and how such drugs may be cross-titrated., Methods: PubMed and an internet search engine were used to identify relevant studies and information sources., Conclusions: Limited evidence suggests that for certain elderly patients, mirtazapine may be preferable to sertraline for treatment of depression. It may also be more cost-effective in patients who have dementia. The choice is highly dependent upon individual co-morbidities and subsequent polypharmacy. If required, sertaline can be cross-titrated to mirtazapine.

Two distinct changes in Dutch care provisions coincide. On the one hand emancipated civilians want to take, or are stimulated to take, more responsibility, on the other budget cuts restrict access to and the quality of care. Self-help and informal care are back on the agenda. As a consequence a new playing field emerges that requires politicians and professionals to balance their care responsibilities with the demands of informal care, social networks, housing, financial capacities, formal public care provisions, and the mechanism that are able to craft and calibrate these different demands. As a result of this new emerging playing field more and more civilians are organizing themselves in voluntary care associations, which are based on the principles of reciprocity and mutuality. They contribute to the dynamics of the new playing field by forcing national and local politicians and care professionals to reconsider their positions and policies. Their demand for more tailored care services requires a pro-active, risk taking, and innovative attitude of those responsible.

The National Institute of Mental Health and the National Action Alliance for Suicide Prevention have requested input into the development of a national suicide research agenda. In response, a working group of the American Association for Geriatric Psychiatry has prepared recommendations to ensure that the suicide prevention dialogue includes older adults, a large and fast-growing population at high risk of suicide. In this Open Forum, the working group describes three methodology roadblocks to research into suicide prevention among elderly persons and three paradigms that might provide directions for future research into suicide prevention strategies for older adults.

Background: The situation for older persons with mental disorders other than dementia disorders has scarcely been studied. The older population is increasing worldwide and along with this increase the prevalence of mental disorders will also rise. The treatment of older persons with mental disorders entails complex challenges, with drugs constituting the major medical treatment. Knowledge of geriatric psychiatry is essential for providing older persons with appropriate treatment and care. This study aimed to evaluate the prescription of drugs for mental disorders to older persons (≥ 65) in Sweden, focused on the medical specialties of the prescribing physicians., Methods: Data concerning drug treatment for older persons from 2006 to 2008 was gathered from the Swedish Prescribed Drug Register. Mental disorders, defined as affective, psychotic and anxiety disorders (ICD-10 F20-42) were evaluated in order to identify associated drugs. Included was a total of 188,024 older individuals, who collectively filled 2,013,079 prescriptions for the treatment of mental disorders. Descriptive analyses were performed, including frequency distribution and 95% CI. The competence of the prescribers was analyzed by subdividing them into five groups: geriatricians, psychiatrists, general practitioners (GPs), other specialists, and physicians without specialist education., Results: GPs represented the main prescribers, whereas geriatricians and psychiatrists rarely prescribed drugs to older persons. Benzodiazepines and tricyclic antidepressants were the most commonly prescribed drugs. Women were prescribed drugs from geriatricians and psychiatrists to a greater extent than men., Conclusions: This study examined the prescription of psychotropic drugs to older persons. Physicians specialized in older persons' disorders and mental health were rarely the prescribers of these drugs. Contrary to clinical guidelines, benzodiazepines and tricyclic antidepressants were commonly prescribed to older persons, emphasizing the need for continuous examination of pharmaceutical treatment for older persons. The results indicate a future need of more specialists in geriatrics and psychiatry.

This article examines the history of accreditation in psychology and applies the lessons learned to the Association for Gerontology in Higher Education's (AGHE) consideration of forming an organization to accredit programs in gerontology. The authors identify the challenges met and unmet, the successes and failures, and the key issues that emerged from psychology's experience with accreditation. Psychology has been accrediting programs in clinical psychology for more than 65 years, and the process has been marked by several false steps, considerable tension, and some controversy and at times significant dissatisfaction. The accreditation process that has emerged today, which includes counseling, school psychology, graduate practica, and postdoctoral practica sites, is generally well received yet some tensions exist. The authors apply the lessons learned from psychology's evolution to AGHE. The experience of psychology suggests a need for clear minimum standards and consistency across programs in training goals, if not in curricula and practica. However, setting standards for specific curricula and practice content may result in a similar contentiousness that has plagued psychology. Ultimately, the authors conclude that the benefits of accreditation of programs outweigh the deficits.

Introduction: Since the late 1980s, British Columbia (BC) Canada has been undergoing a process of regionalization of health services which includes decentralization and the demand for self-sufficiency with respect to caring for people with mental health issues. In BC, regionalization has meant the continued downsizing of its one large provincial psychiatric hospital Riverview, which has resulted in relocating patients from this hospital to cities and towns throughout BC, and the establishment and/or renovation of psychiatric tertiary-care facilities to treat local community members who experience mental ill health. In the context of the relocation of psychiatric tertiary care, communities in northern BC face the specific challenge of having to provide these specialized services in remote settings, not only for people transferred from Riverview, but also for the increasing number of people 'aging-in-place' in a region that has the fastest growth of older adults in BC. Little is known about the capacity of these remote communities to manage change, develop broader models of care, and integrate people with psychogeriatric mental health issues with residents at existing facilities., Methods: This study employed a qualitative research design which involved field research in the rural community where people were transferred, and interviews and focus groups with key people involved in the transfer process. In the analysis of the data a gender-based lens was applied to clarify the differing needs and concerns of male and female patients and to attend to possible needs relating to culture and ethnicity., Results: The findings illustrate persistent 'hinterland-metropolis' and 'front-line versus administrative staff' tensions, with respect to resource distribution and top-down governance, and demonstrate the need for more transparent and comprehensive planning by health authorities with respect to instituting mental health reforms in a northern context, as well as improved communication between administrative and front-line staff. The research suggests that it is important to attend to the differing needs of women and men in the context of psychogeriatric care, as well as to other factors such as ethnicity and culture, in order to provide appropriate care. Finally, building community capacity to deal with the complex needs of patients is severely hampered not only by facility and regional health authority staff turnover, but also the stresses inherent to working in northern communities which include geographic, social and economic challenges., Conclusion: Increased local engagement is a way to identify and address challenges related to relocating psychogeriatric care to northern and remote settings, and to enhance psychogeriatric care provision in similar locales. While provincial and regional level 'big picture' planning is a necessity, study participants highlighted the critical role of local perspective and expertise.

Background: Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component., Purpose: We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines., Data Sources: We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites., Study Selection: Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers., Data Extraction: From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength., Data Synthesis: No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation., Limitations: The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori., Conclusion: Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The Health of the Nation Outcome Scales65+(HoNOS65+) seems to be a useful instrument for effect measuring in elderly psychiatry. The instrument is implemented as an outcome measure within a psychiatric unit for older persons. From 244 patients a repeated assessment is completed: at the start of the treatment and at discharge. Our goal is to determine the sensitivity of change of the Health of the Nation Outcome Scales65+ for patients who are in treatment for a limited period. The sensitivity of change is examined for outpatients and inpatients and for four diagnostic groups (mood disorders, organic disorders, psychotic disorders and others) according to their DSM-IV diagnoses. Comparisons between first and second assessment were done using pairwise t-tests. Inpatients as well as outpatients showed a significant change between intake and discharge. This also holds for all four diagnostic groups. The conclusion is that the HoNOS 65+ is sensitive to change and meets the criteria for a clinical outcome indicator in elderly psychiatric patients.

Background: Within the mental health care services for older persons there is a growing need for insight into and evaluation of the results of clinical treatment. The Health of the Nations Outcome Scales 65+ (honos65+) is a promising instrument for the assessment of mental, social and physical health in older persons, but it is not yet known whether it is valid for older persons in the Netherlands., Aim: To assess the reliability, validity and sensibility to change of the honos65+ when applied to older persons with psychiatric disorders., Method: The bio-psycho-social level of functioning of clients aged 60 and over (n=168) receiving mental health care was assessed by means of existing and validated measuring instruments and the results were compared with those obtained with the honos65+. Three months later the population sample was re-assessed in order to test the extent to which the honos65+ was sensitive to change., Results: The reliability and validity of the honos65+ could be ascertained for 168 clients aged 60 and over. After three months 116 clients were re-assessed so that the sensitivity of the honos65+ to change could be noted., Conclusion: The honos65+ is a reliable and valid instrument for assessing clients with affective disorders such as depression and anxiety and for detecting changes in clients’ problems and functioning. No conclusions could be reached regarding the reliability and validity of the honos65+ when used for clients with other psychiatric disorders because the clinical subgroups were too small for patterns to be detected.

Background: In psychiatry for older adults (> 60 years) personality disorders play an important part in diagnosis and treatment and in the advice given to health professionals and carers on how to deal with this age group. So far, however, research in this area has been inadequate., Aim: To investigate age-related diagnostic and therapeutic aspects of personality disorders occurring in adults over the age of 60., Method: A Delphi-study was conducted among 35 Dutch and Belgian experts in the field of personality disorders in older adults. This multidisciplinary panel consisted of psychiatrists, psychologists, psychotherapists, geriatricians and psychiatric nurses. In four rounds 21 gerontological statements to be assessed on a 5-point Likert scale were presented to the panel of experts. Agreement was said to be reached when at least two thirds of the experts agreed or fully agreed with a statement.RESULTS Satisfactory agreement was reached in the case of 20 of the 21 diagnostic and/or therapeutic statements about older adults with personality disorders. CONCLUSION There seem to be various age-specific aspects in the diagnosis and treatment of personality disorders in older adults. Therefore, it is advisable to pay more attention to this highly complex group of older adults when guidelines and protocols are being drawn up and scientific research is being planned or conducted.

Background: Challenges to wills on the basis of lack of testamentary capacity and/or undue influence are likely to increase over the next generation. Since contemporaneous assessment of testamentary capacity can be a powerful influence on the outcome of such challenges, there will be an associated increase in requests for expert assessment of testamentary capacity. There is a need to provide such potential experts with the knowledge and guidelines necessary to conduct assessments that will be helpful to the judicial system., Methods: A subcommittee of the International Psychogeriatric Association (IPA) task force on "Testamentary Capacity and Undue Influence" was formed to establish guidelines for contemporaneous assessment of testamentary capacity., Results: The task-specific criteria for testamentary capacity as outlined by Lord Chief Justice Cockburn in the well-known Banks v. Goodfellow case are described. Additional issues are identified for probing and documentation. This is designed to determine whether the testator can formulate a coherent, rational testamentary plan that connects his/her beliefs, values and relationships with the proposed disposition of assets. Rules of engagement by the expert assessor are defined as well as an approach to the clinical examination for testamentary capacity resulting in a clear and relevant report., Conclusion: Guidelines for experts who are asked to provide a contemporaneous opinion on testamentary capacity should help to inform disputes resulting from challenges to wills. A consistent clinical approach will help the courts to make their determinations.

The elderly often present with anxiety disorders in primary care, and specific treatment options in that setting are needed. In a randomised clinical trial, 7 sessions of cognitive behavioural therapy performed in the primary care setting by very experienced cognitive behavioural therapists was found to reduce worry, depressive symptoms and general health symptoms. However, severity of generalised anxiety disorder did not improve, and medication use did not diminish during the intervention. In the Dutch primary care setting, implementation of such a therapeutic option would require an organisational intervention. Moreover, such an intervention should be combined with an intervention aimed at reducing benzodiazepine use, i.e. in a collaborative care model specifically designed for anxiety disorder in the elderly.

This article deals with the question of whether the recently published Multidisciplinary guideline on Personality disorders is unreservedly applicable to older persons. It is concluded that the guideline is on the whole of clinical relevance with regard to older persons, but for such persons certain aspects of the guideline concerning for instance the course of the disorder, diagnosis and treatment, need to be modified. Since the Netherlands has a steadily ageing population, greater concern for older persons with personality disorders is not only of clinical relevance, but is also essential for scientific research in the future.

Purpose of Review: Recent studies on five aspects of geriatric depression, namely subsyndromal depression, risk factors and association with chronic pain, cardiovascular disease and cognitive impairment, are reviewed., Recent Findings: Subsyndromal depression in the elderly population is not uncommon in east Asia; the prevalence is about 8-9%. Risk factors of geriatric depression include poor health, brain injury, low folate and vitamin B12 and raised plasma homocysteine levels. Depressed elderly with chronic pain are prone to suicidal ideation. Depression is a risk factor for cardiovascular diseases and mortality in coronary heart disease., Summary: The growing interest in research on geriatric depression could focus on early diagnosis to help doctors treat depression better at primary care level.

This case study demonstrates how leadership was harnessed to turn around a decline in the performance of an aged persons' mental health service - the Namarra Nursing Home at Caulfield General Medical Centre in Melbourne, Australia. In 2000 the nursing home faced a crisis of public confidence due to failings in the management of quality, clinical risk and human resources within the service. These problems reflected structural and operational shortcomings in the clinical directorate and wider organisation. In this article, we detail the process of turnaround from the perspective of senior executive managers with professional and operational responsibility for the service. This turnaround required attention to local clinical accountability and transformation of the mental health program from a collocated but operationally isolated service to one integrated within the governance structures of the auspicing organisation.

Background: In the last few years mental healthcare has had to become increasingly accountable to health insurance companies, the government and patient groups with regard to the efficacy, appropriateness and patient-friendliness of the care provided. Routine outcome assessment, based on various measuring instruments, is likely to become more and more frequent in the years to come., Aim: To assess whether the Health of the Nation Outcome Scales for elderly people (HoNOS65+) can be successfully implemented within a psychiatric unit for older persons, whether the instrument is suitable for use in clinical practice and whether it provides an adequate picture of the older population in general., Method: The implementation phase consisted of training 51 social workers within the various sections of the unit. The trained social workers used the HoNOS65+ with 387 patients from various units for older persons within Lentis., Results: The social workers found the HoNOS65+ to be a useful instrument and for each treatment setting and diagnosis it differentiated significantly between types of behaviour problems, symptoms and social problems., Conclusion: The HoNOS65+ can be used profitably with individual patients and patient groups and it highlights the problems in relevant areas of psychiatry for older persons.

Purpose of Review: An increasing proportion of the world's population is over the age of 65 years. Specialist mental health services for older people have been developed in many countries. The way services develop depends partly on how healthcare arrangements have evolved in that jurisdiction, as well as on finances, culture and attitudes towards elderly and disabled individuals. Health planners in developing countries recognize that considerable increases in their elderly populations and numbers of individuals with disability are imminent. It will be important to ensure that older people with mental disorders receive appropriate treatment. This review discusses recent findings and observations about psychogeriatric services in the community and in long-term care facilities, and aims to suggest how to improve or develop such services., Recent Findings: The prevalence of mental disorders in long-term care facilities is high, but services to deal with them are usually not optimal. When appropriately staffed and organized, community psychogeriatric services, day care and collaborative care can be effective in reducing mental health problems and preventing admissions., Summary: Recent reviews and research have provided useful guidance regarding aspects of current psychogeriatric services that work well and those that need to be improved. A person-centred approach is favoured.

Introduction: HoNOS (Health of the Nation Outcomes Scale) is an outcome measure used by mental health professionals aiming to give a snapshot of a person's psychiatric symptoms and psychosocial functioning., Aim: HoNOS65+ was introduced as a routine outcome measure in our service as part of the New Zealand Mental Health Standard Measures of Assessment and Recovery Outcomes Initiative. The aim of this paper is to report the findings from the use of this tool in our acute psychogeriatric inpatient unit., Method: This is a retrospective analysis of the HoNOS database from 2002 to 2005. Service users were classified into two groups (organic disorders and functional disorders) according to their ICD-10 clinical coding diagnoses. Statistical analysis was performed to compare the HoNOS65+ scores at admission and discharge within each group., Results: There were 431 start episodes and 452 end episodes completed. However, only 130 of these episodes were matched and were usable in this analysis. 29(21%) service users with diagnoses of organic disorders and 101(72%) with diagnoses of functional disorders. The mean total HoNOS65+ score reduced significantly for both groups from admission (organic: 16.45; functional: 14.00) to discharge (organic: 12.34; functional: 8.76). For the organic group, significant improvement was observed in 2 (behaviour and symptoms) subscales; and for the functional group, significant improvement was observed in 3 (behaviour, impairment, and symptoms) subscales., Conclusion: The findings provide objective evidence to support the clinical impression that psychogeriatric inpatient treatment is an effective intervention for both organic and functional disorders. We identified a lack of improvement in the social subscale for both groups. The social subscale scores on admission were relatively low and the lack of improvement might be because specific interventions were not necessary during the inpatient episode. Further exploration of this subscale would be useful in clarifying whether there is a need to plan service development to address these aspects of service users' care during the acute admission phase.

Fear of falling is common in older persons. Different methods have been developed to assess fear of falling. The most well-know measure is the 10-item Falls Efficacy Scale (FES). However, the FES items (a) focus on low functioning older persons and particularly on in-home activities, (b) do not comprise social activities, and (c) were developed from a US perspective so that translation in European languages is hampered. To solve these issues, the 16-item Falls Efficacy Scale-International (FES-I) was recently developed within the Prevention of Falls Network Europe (ProFaNE). In this article, the Dutch version of the FES-I is presented and the psychometric properties in 213 Dutch persons aged 70 years of age and over are described. The FES-I showed to be unidimensional and internally consistent; the Cronbach alpha coefficient was 0.96. The 4 week test-retest intra-class correlation coefficient was 0.82. The associations of the FES-I sumscores with age, gender, falls history and overall fear of falling was as expected, indicating construct validity. In addition, the FES-I discriminated in the same extent as the original 10-item FES scale. We conclude that the FES-I showed acceptable reliability and construct validity and may be useful in cross-national research. Future studies should focus on the sensitivity to change of FES-I.

Recent policy initiatives within the United Kingdom have recognized that effective care for older people can only be achieved if health care staff are willing and skilled enough to address patient needs in a holistic way. The preliminary stages of the action research project described here focused on the perceptions of nursing staff regarding the factors that impacted on their ability to address mental health needs within a general hospital ward. A phenomenological approach allowed us to identify the experience of addressing mental health needs in this setting from the perspective of the research participants. A focus group was facilitated with nursing staff whose primary professional focus was the provision of physical health care within an older adult unit. Thematic content analysis was used to analyse the focus group data, and four key themes emerged, namely 'disruption', 'role conflict', 'professional resources' and 'professional distress'. These themes provide a focus for the ongoing development of the action research methods and will embed future work in the experience of those charged with ensuring that mental health care is a key element of their practice. This study highlights the urgent need for further work in this area, as we contend that it is only by addressing the professional needs of the staff concerned, that effective patient-centred care can be ensured.