Given the recent change in leadership at International Psychogeriatrics (IP), the editorial staff felt it was a good time to review where the journal has been in the last few years and how it is regarded both by International Psychogeriatric Association members and by the wider geriatrics community. The following special article was completed as part of an overall review of IP in 1997. Specifically, the article quantifies how the journal compares to others in the geriatrics field.

In 1996, new editorial management took over International Psychogeriatrics (IP), only a year after the frequency of its publication increased from semiannual to quarterly. At the request of the editorial board, an assessment of the journal was conducted by comparing it to other journals in the field of geriatrics and, specifically, geriatric psychiatry. The evaluation included both a modified citation analysis and a review of journal content. The study was undertaken in order to identify the position the journal has within its discipline. Further, it was to identify the journal's strengths and weaknesses with the overall goal of recommending changes to IP's current content and format. IP ranked seventh of 15 journals in terms of impact factor. It is primarily oriented towards the publication of original research, and features fewer longer articles than others in the field. Adding a wider variety of content may increase the overall interest in the journal. However, these changes must be weighed against the goals of the journal and its reputation as a source of original research in the field of geriatrics.

Visual hallucinations (VH) are a core feature of dementia with Lewy bodies (DLB), but little is known about their phenomenology. A total of 73 dementia patients (42 DLB, 30 Alzheimer's disease [AD], 1 undiagnosed) in contact with clinical services were assessed with a detailed standardized inventory. DLB was diagnosed according to the criteria of McKeith and colleagues, AD was diagnosed using the NINCDS-ADRDA criteria. Autopsy confirmation has been obtained when possible. VH were defined using the definition of Burns and colleagues. Detailed descriptions of hallucinatory experiences were recorded. Annual follow-up interviews were undertaken. The clinical diagnosis has been confirmed in 18 of the 19 cases that have come to autopsy. A total of 93% of DLB patients and 27% of AD patients experienced VH. DLB patients were significantly more likely to experience multiple VH that persisted over follow-up. They were significantly more likely to hear their VH speak but there were no significant differences in the other phenomenological characteristics including whether the hallucinations moved, the time of day that they were experienced, their size, the degree of insight, and whether they were complete. VH may be more likely to be multiple, to speak, and to be persistent in DLB patients. These characteristics could potentially aid accurate diagnosis.

Recent studies indicate that neuroimaging techniques such as magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography can accurately differentiate patients with Alzheimer's disease (AD) from elderly controls. This report reviews the results of neuroimaging studies of two at-risk populations: subjects with the ε4 allele of the apolipoprotein E and those with mild cognitive impairment. The results of the work published to date indicate that the presence of the ε4 allele is a risk factor for AD and that its predictive validity can be enhanced by neuropsychological and/or neuroimaging evaluation. The results also show that patients with mild cognitive impairment display a number of structural and functional imaging abnormalities that are more pronounced in the temporal and parietal lobes. We suggest that the use of neuroimaging techniques can improve the detection of subjects early in the course of AD, although the sensitivity and the specificity of this approach still await a more detailed prospective evaluation.

Noisemaking is one of the most disturbing behavior disorders associated with dementia. Standard management practices, including pharmacological interventions, are not very successful in treating the behavior. Very little research has been carried out to evaluate innovative treatments or to determine the etiology of noisemaking. In this article, we report on a series of 12 case studies in which we tested the efficacy of some psychosocial interventions in reducing the frequency of noisemaking in long-term-care residents with severe dementia. Interventions were contingent reinforcement of quiet behavior and environmental stimulation tailored to individual preferences. Of the 12 patients recruited into the study, 2 died during the course of observations, 3 were not observed to be as noisy as reported by staff, and 3 showed a clear reduction in noise during the intervention period. Four patients did not show any overall reduction in noisemaking during psychosocial interventions. Future research could differentiate between types of interventions in successful cases and attempt to control further for the consistent application of interventions by long-term-care staff.

The effects of a daily program of various activities on disturbed behavior were studied prospectively in three patients with severe dementia. Prior to the study, patients had not responded to treatment with benzodiazepines and/or neuroleptics. The study consisted of three periods, each lasting for 4 weeks: i.e., baseline, intervention, and follow-up. During each period, behavior was assessed by means of observation scales: GIP, SDAS, and CGI. Psychotropic medication was held as constant as possible. During intervention, the patients took part in a program of activities, including group, musical, physical, and social activities. During baseline and follow-up, patients followed the regular ward activities. The patients showed different responses, probably related to personal interests. Possible implications for the treatment of patients with dementia, complicated by disturbed behavior, and suggestions for future research are discussed. The enthusiasm of the nursing staff dealing with these patients was a promising result.

The efficacy and safety of risperidone, haloperidol, and thioridazine for treating dementia-associated behavioral disturbances were evaluated in a retrospective study of 186 patients aged 65 years or older with DSM-III-R or DSM-IV diagnoses of Alzheimer's dementia, senile dementia NOS, or organic brain syndrome. Study patients were selected from the charts of 12,000 residents of 60 long-term-care facilities in New Jersey if they were treated with one of the three agents for behaviours dangerous to themselves or others. The 186 selected patients included 60 treatedwith risperidone (mean, 1 mg/day), 83 with haloperidol (mean, 2 mg/day), and 43 with thioridazine (mean, 33 mg/day). Target behaviors were violence (74 patients), shouting (31), delusions (26), paranoia (19), pacing (3), and mixed behaviors (33). Target behaviors improved in 94% of patients given risperidone, 65% given haloperidol, and 67% given thioridazine (p < .001). Treatment failures (treatment discontinued in patients because of side effects or no improvement) were more frequent in patients started on haloperidol (28) or thioridazine (15) than on risperidone (3). Extrapyramidal symptoms were reported in 7% of patients taking risperidone, 22% taking haloperidol, and 18% taking thioridazine. Safe, effective doses are readily achieved with risperidone but difficult to achieve with haloperidol or thioridazine because their effective doses often cause unacceptable side effects. These data are only suggestive because no guidelines exist for defining or measuring behavioral disturbances or for how they are affected by social, psychological, or environmental factors.

In the studies on the effects of temporary institutional respite (TIR) published to date, a slight reduction of subjective burden has been established. The hope that this form of respite care might have a positive effect on the activities of daily living or on the health of the care recipients has not yet been confirmed. A considerable deficit in the methodology applied might be a reason for this. There is no denying the fact that there is a clear need for respite services, particularly because every seventh person providing care for a dementia patient requiring personal care belongs to a high-risk group that is characterized by serious reduction in his or her physical health and psychological well-being. TIR is primarily utilized by adult child caregivers (daughters and daughters-in-law) affected by high subjective burden who are providing care for dementia patients with extensive nursing needs.

We examined the factor structure of the 28-item Dementia Mood Assessment Scale (DMAS), an instrument to assess depressive symptoms in older adults with cognitive impairment, in a cohort of 165 community-dwelling elderly with varying degrees of cognitive impairment. Factor analysis using principal components analysis and varimax rotation was performed to explore the presence of subscales and examine construct validity. A five-factor structure involving all 28 items accounting for 63.2% of the variance in the DMAS scores was derived. Factors were named: Depressed Affect, Environmental Interaction, Diurnal Patterns, Agitation/Suspicion, and Somatic Indicators. This factor structure reflects the often differing presentations of depressive symptoms in older adults with varying degrees of cognitive function and established the construct validity of the DMAS in this population. We conclude that the DMAS may be used for differentiated clinical assessment of depressive symptoms along major dimensions of depressive illness in this cohort of elderly.

A patient with delusional parasitosis has a strong conviction of being infested with parasites: for example, lice or worms. Such a patient is not satisfied with assurances or test results that no parasites are present, but is so convinced that he or she will go as far as to bring the parasites in “matchboxes” to a physician. Subjectively worried, the patient may try to pick the parasites out of the skin, causing cutaneous lesions and even ulcerations. The condition is classified as a delusional/paranoid disorder, somatic type according to DSM-III-R. Not much is known epidemiologically of this rare disorder, which usually affects older women who often are isolated socially. Therapy is regarded as difficult, and a wide variety of treatment methods have been attempted. In this article six female cases are presented, showing that a typical patient is an elderly woman who has suffered losses or is socially isolated. These patients lack deeper psychiatric insight into their problem, so they are mostly in the care of nonpsychiatric physicians. Treatment with a low dose of high-potency neuroleptics combined sometimes with antidepressants appears to be effective. Reducing social isolation is also important.

Normal-pressure hydrocephalus (NPH) is a common cause of potentially reversible dementia. It can present with psychiatric manifestations that may hinder its diagnosis. A 68-year-old man presented with a paranoid psychosis and mild cognitive impairment, but no neurological signs or classic “triad.” Gait disturbance and urinary incontinence developed later in the course of illness after the diagnosis of NPH had already been made on computed tomographic (CT) scanning. A lumbo-peritoneal shunt was performed, followed by full remission of psychotic symptoms, as well as considerable improvement in functioning, continence, and gait. This case demonstrates the need to consider NPH when older patients present with psychotic symptoms, particularly in the presence of cognitive impairment, gait disturbance, or incontinence. The decision whether to perform a shunting operation is often difficult, because selection of patients with good prognosis is still inaccurate. CT scanning of the brain is an important investigation in older patients presenting with both functional and organic disorders.

Aggressive behavior among the elderly is a neglected area of research. An 18-week prospective study of aggressive behavior on a continuing-care psychogeriatric ward provided data to examine the relationship between two aggression scales (SOAS and RAGE). There was a strong and significant correlation between the SOAS and RAGE scales for the total and the subscale scores. Both these scales appear useful in measuring aggressive behavior among continuing-care psychogeriatric inpatients. Also, the nursing staff can be trained to complete these scales effectively.