Predictive Factors for Conversion to Dementia in Individuals with Early-Onset Mild Cognitive Impairment.

INTRODUCTION: There is little research on factors predicting conversion to dementia in early-onset mild cognitive impairment (eoMCI), a transitional stage between healthy ageing and dementia in individuals below the age of 65. We aimed to examine whether sociodemographic and clinical factors at initial presentation predicted dementia progression in a cohort of eoMCI patients attending a memory service, at a university teaching hospital in the UK. METHODS: This is a retrospective case note study of individuals diagnosed with eoMCI between 2000 and 2013 at the Younger Person's Memory Service (YPMS) in Leicestershire, England. Data collected at assessment included social factors, demographic characteristics, and medical and psychiatric history, as well as standardized cognitive assessment scores. Variables were analysed using χ2 or independent sample t tests to identify associations. A Cox regression survival analysis was done to identify predictive factors for dementia conversion. An ROC analysis for total CAMCOG was used to investigate sensitivity and specificity for dementia converters versus non-converters. RESULTS: Out of 531 subjects who attended YPMS, 65 patients were given a diagnosis of eoMCI (47.7% female; mean age 56.4 ± 7.54 years). Of these, 21 (32.3%) converted to dementia during their course within the service. Comparison between subgroups revealed a significant association between dementia conversion and higher years of education and lower MMSE and CAMCOG (total and subscale) scores at baseline. Smoking history, alcohol use, or medical history such as diabetes or heart disease were not associated with conversion. Cox regression survival analysis showed higher education in years and lower total CAMCOG scores were significant predictors for conversion. Lower scores on the recent memory, remote memory, learning memory, and executive function subscales of the CAMCOG were also significant predictors for conversion. ROC curve analysis for total CAMCOG demonstrated that the best detection of dementia converters can be achieved with a cutoff score of 90.5/107 (sensitivity of 76.2% and specificity of 68.2%). Area under the curve was 0.808 (95% CI: 0.697-0.920). CONCLUSION: More years in education and lower cognitive scores on CAMCOG at initial assessment are associated with progression to dementia from eoMCI. Further research is required to explore these predictive factors more.

A national survey of psychiatrists' attitudes towards the physical examination.

Background: Studies have shown that most psychiatric patients do not receive a thorough physical examination (PE).Aim: To explore factors contributing to the underperformance of the PE on psychiatric patients.Method: All psychiatrists in the UK who were registered or affiliated to the Royal College of Psychiatrists were invited to complete an online survey regarding their attitudes towards PEs in psychiatry.Results: Responses from 15% of the psychiatrists showed that most (89%) believe that the PE is important. The majority (61%) indicated that their PE skills had diminished since working in psychiatry and this was reported more by senior psychiatrists than junior trainees (64% vs. 49%). Most respondents considered that the PE should not be done by another type of health professional (45% vs. 28%).Conclusions: Likely reasons for poor performance of PEs include shortage of time and equipment, challenges associated with agitated and uncooperative patients, the perceived incongruence of the PE with the patient's presenting symptoms and a degree of skill atrophy, especially in senior psychiatrists which is leading to lack of supervision of junior trainees in this area. Further research is needed to investigate if strategies addressing these factors would improve the standard of PEs on psychiatric patients.

Smell identification function in early-onset Alzheimer's disease and mild cognitive impairment.

Little is known about olfactory identification (OI) function in early-onset Alzheimer's disease (EOAD) and early-onset mild cognitive impairment (eoMCI) with age of onset <65 years. We aimed to study OI in EOAD compared with eoMCI and age-matched healthy controls (HC). Nineteen EOAD subjects with mild to moderate dementia, 17 with eoMCI, and 21 HC recruited as a convenience sample from memory services were assessed for cognition, behavioral symptoms, and activities for daily living. The OI was tested using the University of Pennsylvania smell identification test (UPSIT). EOAD participants performed worse compared with eoMCI and HC on cognitive tests and OI (p < 0.001). Although eoMCI had poorer cognitive scores compared to HC, they were similar in their OI function. OI correlated with attention (r = 0.494, p = 0.031), executive functions (r = 0.508, p = 0.026), and praxis (r = 0.455, p = 0.05) within the EOAD group. OI impairment was significantly associated with the diagnosis of EOAD versus eoMCI, but not with eoMCI when compared with HC. OI could potentially be useful in differentiating EOAD from eoMCI. Studies with late-life MCI patients showing OI impairment relative to HC may be attributed to a different disease process. Independent replication in a larger sample is needed to validate these findings.

Valproate preparations for agitation in dementia.

BACKGROUND: Agitation has been reported in up to 90% of people with dementia. Agitation in people with dementia worsens carer burden, increases the risk of injury, and adds to the need for institutionalisation. Valproate preparations have been used in an attempt to control agitation in dementia, but their safety and efficacy have been questioned. OBJECTIVES: To determine the efficacy and adverse effects of valproate preparations used to treat agitation in people with dementia, including the impact on carers. SEARCH METHODS: We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 7 December 2017 using the terms: valproic OR valproate OR divalproex. ALOIS contains records from all major health care databases (the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources. SELECTION CRITERIA: Randomised, placebo-controlled trials that assessed valproate preparations for agitation in people with dementia. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the retrieved studies against the inclusion criteria and extracted data and assessed methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data in meta-analyses where possible. This is an update of a Cochrane Review last published in 2009. We found no new studies for inclusion. MAIN RESULTS: The review included five studies with 430 participants. Studies varied in the preparations of valproate, mean doses (480 mg/day to 1000 mg/day), duration of treatment (three weeks to six weeks), and outcome measures used. The studies were generally well conducted although some methodological information was missing and one study was at high risk of attrition bias.The quality of evidence related to our primary efficacy outcome of agitation varied from moderate to very low. We found moderate-quality evidence from two studies that measured behaviour with the total Brief Psychiatric Rating Scale (BPRS) score (range 0 to 108) and with the BPRS agitation factor (range 0 to 18). They found that there was probably little or no effect of valproate treatment over six weeks (total BPRS: mean difference (MD) 0.23, 95% confidence interval (CI) -2.14 to 2.59; 202 participants, 2 studies; BPRS agitation factor: MD -0.67, 95% CI -1.49 to 0.15; 202 participants, 2 studies). Very low-quality evidence from three studies which measured agitation with the Cohen-Mansfield Agitation Index (CMAI) were consistent with a lack of effect of valproate treatment on agitation. There was variable quality evidence on other behaviour outcomes reported in single studies of no difference between groups or a benefit for the placebo group.Three studies, which measured cognitive function using the Mini-Mental State Examination (MMSE), found little or no effect of valproate over six weeks, but we were uncertain about this result because the quality of the evidence was very low. Two studies that assessed functional ability using the Physical Self-Maintenance Scale (PSMS) (range 6 to 30) found that there was probably slightly worse function in the valproate-treated group, which was of uncertain clinical importance (MD 1.19, 95% CI 0.40 to 1.98; 203 participants, 2 studies; moderate-quality evidence).Analysis of adverse effects and serious adverse events (SAE) indicated a higher incidence in valproate-treated participants. A meta-analysis of three studies showed that there may have been a higher rate of adverse effects among valproate-treated participants than among controls (odds ratio (OR) 2.02, 95% CI 1.30 to 3.14; 381 participants, 3 studies, low-quality evidence). Pooled analysis of the number of SAE for the two studies that reported such data indicated that participants treated with valproate preparations were more likely to experience SAEs (OR 4.77, 95% CI 1.00 to 22.74; 228 participants, 2 studies), but the very low quality of the data made it difficult to draw any firm conclusions regarding SAEs. Individual adverse events that were more frequent in the valproate-treated group included sedation, gastrointestinal symptoms (nausea, vomiting, and diarrhoea), and urinary tract infections. AUTHORS' CONCLUSIONS: This updated review corroborates earlier findings that valproate preparations are probably ineffective in treating agitation in people with dementia, but are associated with a higher rate of adverse effects, and possibly of SAEs. On the basis of this evidence, valproate therapy cannot be recommended for management of agitation in dementia. Further research may not be justified, particularly in light of the increased risk of adverse effects in this often frail group of people. Research would be better focused on effective non-pharmacological interventions for this patient group, or, for those situations where medication may be needed, further investigation of how to use other medications as effectively and safely as possible.

Screening for depression in older people on acute medical wards: the validity of the Edinburgh Depression Scale.

BACKGROUND: depression is common in people with poor physical health, particularly within the acute medical in-patient setting. Co-morbid depression contributes to poor outcomes, and screening for depression in acute medical in-patients has been advocated. The Edinburgh Depression Scale (EDS) has been validated in a variety of general hospital patient groups, but not previously in older acute medical in-patients. METHODS: one hundred and eighteen patients aged 65 and older on acute medical wards were assessed using a standardised diagnostic interview (Present State Examination-Schedules for Clinical Assessment in Neuropsychiatry) to identify depression according to ICD-10 criteria. They subsequently completed the EDS. The performance characteristics at a range of thresholds were compared, and receiver operating characteristic curve analysis was performed. RESULTS: the optimal EDS cut-off for identifying ICD-10 depressive episode was 7/8, with a sensitivity of 88%, specificity of 77%, positive predictive value of 52% and negative predictive value of 96%. The area under the receiver operating characteristic curve was 0.91. CONCLUSION: the EDS was shown to be a useful instrument for detecting clinical depression in older people on acute medical wards in this study. Its performance was equivalent to other validated screening instruments in this population. Our findings add further weight to using the EDS as a screening instrument for depression in multiple general hospital settings.

Screening for depression in older adults on an acute medical ward: the validity of NICE guidance in using two questions.

BACKGROUND: depression is common in older people in general hospital settings and associated with poor outcomes. This study aimed to evaluate the validity of two screening questions recommended by the UK National Institute for Health and Clinical Excellence (NICE). METHODS: one hundred and eighteen patients aged over 65 years, admitted to acute medical wards at a teaching hospital, were interviewed in a standardised manner using relevant sections of the Present State Examination-Schedules for Clinical Assessment in Neuropsychiatry to identify depression according to ICD-10 criteria. Subsequently, participants completed the two depression screening questions and the 15-item version of the Geriatric Depression Scale (GDS-15). RESULTS: a threshold of one or more positive responses to the two NICE depression screening questions gave a sensitivity of 100%, specificity of 71%, positive predictive value (PPV) of 49% and negative predictive value (NPV) of 100%. The GDS-15 optimal cut-off was 6/7 with a sensitivity of 80%, specificity of 86%, PPV of 62% and NPV of 94%. A two-stage screening process utilising the NICE two questions followed by the GDS-15 with these cut-offs gave a sensitivity of 80%, specificity of 91%, PPV of 71% and NPV of 94%. CONCLUSION: the two depression questions perform well as an initial screening process for non-cognitively impaired older people in the acute medical setting. A positive response to either question would indicate that further assessment is required by a clinician competent in diagnosing depression in this population, or the possible use of a more detailed instrument such as the GDS-15 to reduce the number of false-positive cases.

A survey of psychiatrists' attitudes towards the physical examination.

BACKGROUND: Studies have shown that most psychiatric patients do not receive a thorough physical examination (PE). METHODS: Psychiatrists working with Leicestershire Partnership NHS Trust were surveyed to determine factors influencing the performance of PEs, including their attitudes towards conducting them. RESULTS: Responses from 118/192 (61%) psychiatrists showed that most (96%) believe that the PE is important. The majority (72%) indicated that their PE skills had diminished since working in psychiatry and this was reported more by senior psychiatrists compared to junior trainees (85 versus 40%). 77% considered that a patient's mental state should have a bearing on the type of PE the psychiatrist performs. CONCLUSIONS: Likely reasons for poor performance of PEs include: shortage of time and equipment, challenges associated with agitated or uncooperative patients, and possibly a degree of skill atrophy, especially in senior psychiatrists. Further research is needed to investigate if strategies addressing these factors would improve the standard of PEs on psychiatric patients.

The utility of the Edinburgh Depression Scale as a screening tool for depression in Parkinson's disease.

OBJECTIVE: This study aimed to evaluate the Edinburgh Depression Scale (EDS) as a screening tool for use in a Parkinson's disease (PD) population. Many commonly used depression scales include items relating to somatic symptoms that also occur in PD, which could potentially result in inaccurate reporting of depressive symptoms. The EDS is a scale that incorporates no somatic items. METHOD: One hundred twenty patients attending specialist PD clinics were assessed using a standardised diagnostic interview (Present State Examination--Schedules for Clinical Assessment in Neuropsychiatry) to establish a diagnosis of DSM-IV depression. They later completed the EDS with another researcher who was blind to the results of diagnostic interview. A receiver operating characteristic curve analysis was carried out to identify the optimal threshold score on the EDS and the Brief EDS to identify any depressive disorder or major depression. The performance characteristics at a range of thresholds were compared. RESULTS: A cut-off score of 10/11 gave maximal discriminant validity, with 74% sensitivity, 92% specificity and 64% positive predictive value for the identification of any depression according to DSM-IV criteria. CONCLUSIONS: This study suggests that the EDS is both a valid and potentially useful instrument that can be used as a quick self-completion questionnaire for screening for depression in people who have PD.

Screening for depression in Parkinson's disease: the performance of two screening questions.

BACKGROUND: the study objective was to evaluate the validity of the two questions recommended by the UK. National Institute for Health and Clinical Excellence for depression screening in Parkinson's disease (PD). METHODS: one hundred and twenty patients attending a PD out-patient clinic were interviewed in a standardised manner using relevant sections of the Present State Examination- Schedules for Clinical Assessment in Neuropsychiatry to identify depression according to Diagnostic and Statistical Manual (4th edition) criteria. Participants then completed the two depression screening questions and the 15-item Geriatric Depression Scale (GDS-15). RESULTS: sensitivity, specificity, positive and negative predictive values of the two questions and GDS-15 for major and minor depression combined were calculated for different cut-off scores and a receiver operating characteristics (ROC) analysis was conducted. A threshold of one or more positive responses to the two screening questions gave a sensitivity of 100% and specificity of 84% (positive predictive value 54%, negative predictive value 100%). The area under the ROC curve was 0.95. The optimal cut-off for the GDS-15 was 5/6, which gave a sensitivity of 84% and specificity of 89% (positive predictive value 59%, negative predictive value 97%), and the area under the curve was 0.92. CONCLUSION: this study shows that the two depression screening questions can be used as an initial screen for depression in patients with PD who have no significant cognitive impairment. A positive response to either of the questions would indicate that further diagnostic assessment may be warranted.

Case series of physical examinations on psychiatric inpatients: Influence of a structured form on the quality of documentation.

BACKGROUND: There is a strong association between mental disorder and poor physical health. However, research indicates that the standard of physical examinations performed on psychiatric inpatients is not good. AIMS: This study aimed to assess the completeness of the physical examinations performed by psychiatric trainees on an acute psychiatric inpatient unit. METHOD: A retrospective analysis of 236 sets of inpatient case notes was performed. The quality of the documentation was assessed using a 50-point scoring system based on the presence or absence of reference to various items of examination. RESULTS: Eighty-five percent of the patients received a complete examination and 13% were not examined at all. The mean points score was only 20 out of 50, indicating that the overall standard of documentation was quite low. However, when a proforma was used rather than free text documentation, significantly more information was recorded. CONCLUSIONS: Most psychiatric patients are not receiving a thorough physical examination. An essential first step to address the problem would be to divide physical examinations into three categories according to the psychiatric setting and reach a consensus on a gold standard for each type. Standards could also be improved by the more widespread use of a well-designed proforma and greater supervision of psychiatric trainees' performance in this area.

Developing a clinical academic career pathway in a Community and Mental Health NHS Trust.

Background: Despite growing evidence of the impact that clinical academic (CA) staff have on patient care and clinical practice, there are disproportionately low numbers of nurses, allied health professionals (AHPs) and other healthcare professionals in CA joint roles, compared to their medical colleagues. Aim: To describe the initial development of a CA career pathway for nurses, AHPs and other healthcare professionals in a Community and Mental Health NHS Trust. Methods: Kotter's 8-Step Change Model was used to expand opportunities and research culture across an NHS Trust. Results: A variety of capacity and capability initiatives at different academic levels were created to support CA development and to complement those available externally. These opportunities were underpinned by a research and development strategy, senior leadership buy-in, manager and clinical staff support, and targeted organisation-wide communication. Conclusion: The ongoing development of innovative CA opportunities in the Trust, alongside greater support for staff interested in pursuing CA careers, has resulted in a growing number of individuals successful in developing as CAs. This has led to a growth in research culture in the organisation and a greater understanding of what CA staff can bring to patient care, the clinical service and the wider organisation.

Predictors of Disease Progression in Early-Onset Alzheimer's Dementia: A Retrospective Cohort Study.

OBJECTIVES: Early-onset Alzheimer's disease (EOAD), defined as onset of AD before the age of 65 years, is less common than the late-onset type, and little is known about the factors affecting disease progression. The aim of the study was to investigate factors influencing disease progression in people with EOAD. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: People with EOAD who were assessed and attended the specialist memory service at a university teaching hospital in a European setting, between 2000 and 2010. MEASURES: Sociodemographic details and clinical and cognitive assessments at initial assessment were used as potential predictors of change in clinical status and outcome at final follow-up within the memory service. RESULTS: Of the 101 people diagnosed with EOAD during this period, 96 patients were followed up (53 women; aged 59 ± 4.9 years; mean follow-up 36.3 ± 29.12 months). Patients were classified as Stable (n = 25) if continued within the memory service or discharged to primary care, and those transferred to other specialist services (n = 66) for further inputs, institutional care (n = 4), or died (n = 1) were classified as Worseners (n = 71). Lower education (P = .008), lower Cambridge Cognition Examination scores (P = .049), and presence of family history of dementia [P = .012, χ2 (1) = 8.84] was associated with worse change in clinical status. Furthermore, cognitive deficits such as lower scores on comprehension, recent memory, and executive functions were found to predict a worse clinical outcome. CONCLUSIONS AND IMPLICATIONS: Identification of predictors of faster disease progression has significant clinical benefit, allowing clinicians to estimate prognosis and plan patient care accordingly.

The influence of limitation in activity of daily living and physical health on suicidal ideation: results from a population survey of Great Britain.

BACKGROUND: Studying suicidal ideation (SI) has methodological advantages over examining completed suicide and may provide useful insight into suicidal behaviour. SI is not only strongly associated with mental disorder (particularly depression), but also disability. This article explores the relationship between SI and disability in greater detail. METHODS: In the survey of psychiatric morbidity in Great Britain, 8,580 randomly selected adults were interviewed. Three questions were asked to assess SI, and a set of questions identified ADL limitation. RESULTS: Data was available on SI and ADL limitation in 8,513 of those surveyed. The independent association between SI and specific ADL limitations was greatest in older people. The strength of association between SI and ADL limitation increased with the number of domains of ADL affected and was of similar magnitude for most individual domains. In those with limitation in ADL, limited social support remained independently associated with SI. CONCLUSIONS: Disability is an important independent correlate of suicidal ideation, particularly in older people. Preventative programmes need to be considered for disabled older people.

Prevalence and Severity of Neuropsychiatric Symptoms in Early- Versus Late-Onset Alzheimer's Disease.

BACKGROUND: The study aimed to compare neuropsychiatric symptoms (NPS) in people with early-onset Alzheimer's disease (EOAD) and late-onset AD (LOAD). METHODS: Fifty-six participants with LOAD and 24 participants with EOAD having mild dementia were assessed for NPS for their frequency, severity, and caregiver distress as measured by Neuropsychiatry Inventory (NPI) along with assessments of cognition and functional dependence. RESULTS: Participants with EOAD and LOAD were not significantly different for total NPI score (P = .057). Early-onset Alzheimer disease had greater prevalence of all the NPS except apathy. Participants with EOAD were significantly worse on anxiety (P = .03), irritability (P = .01), and sleep (P < .01) subscales and their carers significantly more distressed by their irritability (P = .002) and sleeping patterns (P = .005). Regression analysis showed that higher NPI score was associated with longer duration of illness in EOAD and higher functional dependence in LOAD. CONCLUSIONS: The NPS severity was similar between EOAD and LOAD although EOAD had higher symptom prevalence and carer distress.

Driving Cessation in Patients Attending a Young-Onset Dementia Clinic: A Retrospective Cohort Study.

BACKGROUND: Although driving by persons with dementia is an important public health concern, little is known about driving cessation in younger people with dementia. We aimed to determine the prevalence and factors affecting driving cessation in individuals with and without dementia aged under 65 years attending a memory clinic in a European setting. METHODS: Subjects were consecutive patients assessed at a specialist memory service at a university teaching hospital between 2000 and 2010. The data collected included demographic, clinical, standardized cognitive assessments as well as information on driving. Dementia diagnosis was made using ICD-10 criteria. RESULTS: Of the 225 people who were or had been drivers, 32/79 (41%) with young-onset dementia (YOD) stopped driving compared to 25/146 (17%) patients who had cognitive impairment due to other causes. Women were more likely to cease driving and voluntarily than men (p < 0.001). Diagnosis of YOD was associated with driving cessation (1.193, 95% CI 0.570-1.815, p ≤ 0.001), and was mediated by impairment in praxis with the highest indirect mediation effect (0.754, 95% CI 0.183-1.401, p = 0.009). CONCLUSIONS: YOD diagnosis, female gender, and impairment in praxis have a higher probability for driving cessation in those under 65 years of age with cognitive impairment.

Pattern of Smell Identification Impairment in Alzheimer's Disease.

Olfactory dysfunction in general, and impaired odor identification in particular, have been reported in Alzheimer's disease (AD). Olfactory testing may be a useful diagnostic aid for AD, but the types of odor most commonly affected need to be identified. This study aimed to determine pattern and types of odor affected in AD with the goal of improving clinical applicability. 54 outpatients with mild to moderate AD and 40 age and gender-matched non-demented controls (NDC) were tested using British version of University of Pennsylvania Smell Identification Test (UPSIT; Sensonics, Inc., Haddon Heights, NJ) and data analyzed to identify an optimal subset of UPSIT to best differentiate AD patients from controls. AD subjects had significantly lower UPSIT total scores than NDC. Random Forest with backward elimination identified 12 UPSIT items which accurately differentiated AD patients compared to controls (sensitivity, 0.89 and specificity, 0.83, positive predictive value of 0.889, and negative predictive value of 0.833). The 12 smell items found to be most affected in AD subjects reflects important attributes such as safety and food, known to be affected in people with AD and that has the potential to impair activities of daily living. The 12 items of British UPSIT most affected in AD subjects provides a potential brief scale for early detection of AD in clinical settings. Independent replication is needed to validate these findings.

Prevalence of Behavioural and Psychological Symptoms of Dementia in Individuals with Learning Disabilities.

A review of 23 studies investigating the prevalence of Behavioural and psychological symptoms of dementia (BPSD) in the general and learning disability population and measures used to assess BPSD was carried out. BPSD are non-cognitive symptoms, which constitute as a major component of dementia regardless of its subtype Research has indicated that there is a high prevalence of BPSD in the general dementia population. There are limited studies, which investigate the prevalence of BPSD within individuals who have learning disabilities and dementia. Findings suggest BPSDs are present within individuals with learning disabilities and dementia. Future research should use updated tools for investigating the prevalence of BPSD within individuals with learning disabilities and dementia.

Therapeutic potential of cannabinoids in neurodegenerative disorders: a selective review.

The endocannabinoid system (ECS) is now recognised as an important modulator of various central nervous system processes. More recently, an increasing body of evidence has accumulated to suggest antioxidant, anti-inflammatory and neuroprotective roles of ECS. In this review we discuss the role and therapeutic potential of ECS in neurodegenerative disorders such as Alzheimer's disease (AD), Parkinson's disease, multiple sclerosis, Huntington's disease, Tourette's syndrome, brain ischemia and amyotrophic lateral sclerosis (ALS). Elements of the ECS, such as fatty acid amide hydrolase or the cannabinoid receptors are now considered as promising pharmacological targets for some diseases. Although still preliminary, recent reports suggest that modulation of the ECS may constitute a novel approach for the treatment of AD. There are windows of opportunity in conditions caused by acute events such as trauma and ischemia as well in conditions that may involve altered functionality of the target receptors of the ECS, such as in AD. The ECS changes in Parkinson's disease could be compensatory as well as pathogenic of the illness process and needs further understanding and clinical studies are still in the preliminary stage. There is not enough evidence to support use of cannabinoids in treating Huntington's disease, tics and obsessive compulsive behaviour in Tourette's syndrome. Evidence on therapeutic use of cannabinoids in multiple sclerosis and ALS is currently limited. A major challenge for future research is the development of novel compounds with more selectivity for various components of the ECS which could target different neurotoxic pathways and be used in combination therapy.

Early frontal executive impairment as a predictor of subsequent behavior disturbance in dementia.

OBJECTIVE: To determine the extent to which frontal executive impairment early in the course of dementia is predictive of subsequent disturbed behavior. METHODS: This was a prospective follow-up study set in the Memory Clinic, Leicester, United Kingdom. A patient cohort (N = 42) diagnosed with mild to moderate dementia was followed up between three and six years after initial assessment. Executive function at baseline was assessed using the The Cambridge Examination for Mental Disorders of the Elderly-Revised (CAMCOG-R) Executive Function score. Disturbed behavior and caregiver distress at follow-up were assessed on the Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Inventory (CMAI), and Dementia Apathy Interview and Rating (DAIR). RESULTS: After adjustment, the Executive Function score at baseline was predictive of disturbed behavior and caregiver distress (NPI, CMAI, DAIR) at follow up, with higher levels of executive impairment associated with higher levels of disturbance/distress. Baseline measures of global cognitive impairment (Mini-Mental State Exam, CAMCOG) were not predictive of subsequent disturbed behavior or caregiver distress. CONCLUSION: Executive impairments identifiable relatively early in the clinical course of dementia are predictive of disturbed behavior and associated caregiver distress at long-term follow-up, which supports the view that executive dysfunction is important in the etiology of these problems.

The spectrum of suicidal ideation in Great Britain: comparisons across a 16-74 years age range.

BACKGROUND: Previous studies have examined suicidal ideation in older populations and emphasized the strong association with the presence of psychiatric disorder. However, associations with the presence of psychiatric disorder across the age range are unclear. Representative epidemiological estimates are needed. METHOD: In a national survey of psychiatric morbidity in Great Britain, 8580 randomly selected adults were interviewed. Three questions were asked to assess suicidal ideation, and psychiatric disorder was identified using the revised Clinical Interview Schedule (CIS-R). RESULTS: Suicidal ideation was up to three times commoner in younger adults than in those aged 55-74 years but the odds of depression in those with suicidal thoughts was significantly greater in the older age group (p<0.01). Tiredness with life (p<0.01) and thoughts of death (p<0.01) were also more strongly associated with depression in the older age group. Other major associations of suicidal ideation for all ages were: smaller social support group, being divorced or separated, poor self-rated general health, and limitations in activities of daily living (ADL). Being single was an important factor for younger age groups, and widowhood for older people. Life events were also important in younger people, but not in those aged 55-74 years. CONCLUSIONS: Suicidal thoughts and death wishes are comparatively more unusual in older people; however, they are more likely to be associated with clinical depression. In terms of suicide prevention this study emphasizes the importance of improving rates of recognition and treatment of depression in older people.