Abstract Supplement

39 Congress of the European Association of Geriatric Psychiatry (EAGP) 11 Congress of the Gerontopsychiatric Portuguese Association (APG) 2–4 November 2011, Oporto, Portugal


WITH APPRECIATION
The Scientific Committee and the Organizing Committee of the 39th Congress of the European Association of Geriatric Psychiatry (EAGP) and the 11th Congress of the Portuguese Gerontopsychiatric Association (APG) (Oporto, 2 nd -4 th November 2011), would like to express their deep thanks and appreciation to everyone who has contributed to develop the Scientific Programme and who has helped to produce a rich and diverse agenda reflecting EAGP and APG's mission with outstanding scientific quality.
We would also like to thank all authors, and especially the Abstract Selection Committee for supporting the abstract reviewing process.

Ralf Ihl
Lia Fernandes (Scientific Committee) (Organizing Committee) In the USA the problem of cut-off age has imposed additional problems. In DSM-III schizophrenia could only be diagnosed if onset was before the age of 45 years. DSM-III-R removed this age limit and included a 'late-onset' specifier. DSM IV has no mention to age of onset. ICD 8 and 9 included the diagnosis of paraphrenia under the category of paranoid states (CIE-9: 297.2), but was further eliminated in ICD-10 where it is only included into the general category of persistent delusional disorder (F 22.0) and not under the schizophrenia label.
In 2000 a consensus conference introduced the terms late-onset schizophrenia (after the age of 40) and very late-onset schizophrenia-like psychosis (after the age of 60) in order to overcome the conceptual problems linked to terms such as late paraphrenia or old age schizophrenia among others. The concept includes the presence of delusions, hallucinations, and absence of significant affective symptoms and cognitive deterioration.
Our work revises publications in the last decade under the very late-onset schizophrenia-like psychosis label and the arguments in favour of including it in ICD-11 and DSM-V.
Alzheimer's disease and related disorders: Why and how should they be maintained in the DSM-V and ICD-11 classifications? Vincent Camus Chru de Tours, INSERM U930, Universite´Franc¸ois Rabelais de Tours, Tours, France How and why should Alzheimer's disease (AD) and related disorders be maintained in the classification of psychiatric disorders should still be a great matter of debate. As far as the observed neuropathological changes will serve as the core pathophysiological component of neurodegenerative disorders, the diagnosis of AD and related disorders will move from a clinical diagnosis at a dementia stage, towards a pre-dementia state diagnosis relying on new reliable biomarkers such as neuroimaging or CSF dosage. Consequently, considering the diagnosis can be assessed on the basis of its brain or peripheral neuropathological hallmarks, it could be questionable to maintain the disease within the classification of psychiatric disorders. Nevertheless, we know that psychiatric manifestations of neurodegenerative disorders are among their most severe and debilitating symptoms. This should justify maintaining them in the classification. It could be assumed that early or late psychiatric manifestations of the disease should be maintained within a category of psychiatric conditions related to other medical conditions, as a Behavioural and Psychological Symptoms of AD and related disorders (including cerebrovascular disorders) category. On the other hand, some psychiatric disorders such as depression are now more specifically characterized in the elderly. New concepts of both 'vascular depression' and 'amyloid depression' that have been suggested to be associated with an increased risk of evolving towards dementia, could be proposed as new entities in the classifications and maintained within the field of mood disorders as far as they could be considered as risk factors rather than early stages of the disease.

PLENARY SESSION 3 -EDUCATION IN OLD AGE Chairs: Michael Philpot, Constanc¸a Pau´l
Overview Jeremy Bentham -the founder of University College London where I trained as a doctor -wrote in 1776: 'The age we live in is a busy age; in which knowledge is rapidly advancing towards perfection . . . everything teems with discovery and with improvement'.
In this session we will hear about two important aspects of education in old age. Lia Fernandes will outline the situation in Portugal with regard to the training of professionals in old age psychiatry and associated disciplines involved in the care of older people. There is great need to make education relevant to the problems encountered but also to enthuse healthcare professionals, to promote research and improve the quality of care provided.
Educating the public in ways to maintain their own health and 'avoid the avoidable' conditions of old age form the basis of the World Health Organisation's Active Ageing programme. Constanc¸a Pau´l will review this preventative approach and give an account of progress in Portugal.
In response to the global challenges of population ageing in Portugal, it is fundamental to improve research, education and clinical training in old age in order to meet the emerging demands in the psychogeriatric field.
In this context training health professionals to meet the needs of the growing elderly population, in order to find adequate answers with treatment and care services is crucial. Bearing in mind this aim, the shift of education process from cure to optimization of quality of life and management of elderly conditions has to be a priority.
Furthermore, it is necessary to take into consideration not only the simple transmission of knowledge, but also training in different skills and attitudes, in order to give the elderly support, care and treatment based on continuous and effective scientific evidence.
In Portugal, multidisciplinary work conducted by researchers in the psychogeriatric domain is shifting the traditional practice of dissemination of knowledge only within academic settings into the new paradigm of changes in the community, clinical practice and health policy.
In mental health centres for the elderly, continuous innovation is fundamental, sharing information, publishing and carrying out research, translating this into clinical practice and vice-versa.
An overview of the required development of psychogeriatric services of reference, as part of the multidisciplinary care delivery system for the elderly in Portugal, will be provided. Preference to educational offerings and clinical training on geriatric mental health at both undergraduate and postgraduate level are described, as well as primary research associations and initiatives in the country.
In this context, regulation of Old Age Psychiatry education is desirable, requiring at the same time more and better care in specialized psychiatric services for the elderly, including general and university hospitals, psychiatric reference hospitals, primary care, integrated continuing care network, and all other levels of care.
Nowadays an effective intervention in psychogeriatrics is missing, and should involve a definition of a specific and strategic policy with the participation and commitment of researchers, educators, clinicians and health professionals, as well as the population, including the elderly, family/carers and their representative associations.
Active aging manual: Studies, contents and proposals Constanc¸a Pau´l UNIFAI/ICBAS, University of Porto, Porto, Portugal Active Aging is a worldwide strategic objective to face demographic aging of the population. The year of 2012 will be the International Year of Active Aging defined as the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age (WHO, 2002). The Active aging model will be put in action by adopting a healthy life style including nutrition, physical exercise and no alcohol or drugs. We should had to these behaviors, personal and environmental conditions that will facilitate Autonomy (personal control); Independence (in activities of daily living and instrumental activities of daily living); Quality of life and Healthy life expectancy (disability-free life expectancy). Objectives: The objectives are (1) to discuss the WHO (2002) model of Active Aging; (2) to explain the main issues that will contribute the most to active aging process and outcomes, preventing disease and optimizing the process of aging and (3) to display a manual on Active Aging, recently published -O. Ribeiro e C. Pau´l, coord. (2011), Envelhecimento Activo, LIDEL. Method: We begin by an extensive empirical study on Active Aging in Portugal that resulted in the identification of the more relevant aspects of daily life to intervene. Results: A manual for people 50þ with good practices in physical exercise, eating, mind, sexuality; social relationships and security. Discussion: The Active Aging Model is discussed based on empirical data that did not exactly reproduce the group of determinants proposed by WHO. Conclusion: Stress the political and heuristic importance of the model to implement behaviors that contribute at a personal and society level to positive outcome of aging.
He will suggest that great strides have been made in the first & discuss two or three of the main advances which have been made in our basic knowledge of the field.
He will next consider what we have learnt in the case of treatment of individual patients He will suggest that when it comes to the organization of services at least in the UK, he will suggest that the situation is less bright & that we can be said to have unlearnt certain things.
His views in the last section may well be controversial & not shared by those now active in the field in the UK.
The 40th anniversary of the European Association of Geriatric Psychiatry Lars Gustafson Department of Geriatric Psychiatry, Lund University, Lund, Sweden Forty years have passed since the first symposium on geriatric psychiatry took place in Krefeld, Germany in 1971. The meeting was organized by 'Die Arbeitsgemeinschaft fu¨r Gerontopsychiatrie' (EAG), an association of medical professionals in Europe with special interest in the psychogeriatric field. The main purpose has been to have one annual scientific meeting and the follow-up with a second meeting in Berlin in 1972 showed the excellent timing and strong ambitions for a European project to develop a specialty of geriatric psychiatry. The symposium in Berlin in 1972 was supported by the Section of geriatric psychiatry of the WHO and followed by Du¨sseldorf in 1973.
In 1987 the EAG became a registered association, later named EAGP, with common aims and topics to be presented in this symposium. My first encounter with the EAG in 1972 in Berlin was very stimulating, especially the opportunity to meet with colleagues from other European countries. I listened to Felix Post from London talking about neurophysiological methods for differential diagnosis. He was very encouraging to our study of new techniques for functional brain imaging. The proceedings were published by Siegfried Kanowski.
The EAGP may now summarize its experience from 39 symposia on 24 different venues in 16 European countries, indicating that geriatric psychiatry probably is the most dynamic field within psychiatry. Several meetings have been fruitful joint events with other associations in Old Age Psychiatry.
Other initiatives of importance have been the support of free membership and the EAGP Research Award intended for colleagues in Eastern Europe. Members of the EAGP have also been involved in three consensus documents on psychiatry of the elderly, developed by the WHO and WPA. A key person behind this trilogy on the specialty of geriatric psychiatry, its organization, education and training was Professor J. Wertheimer and his group in Lausanne. An additional position paper on specialist training in Old Age Psychiatry has been initiated by the EAGP and published in 2003. There are all reasons to believe that the EAGP will be of great importance for the future of Old Age Psychiatry in Europe. Last year, Alzheimer Europe (AE) celebrated its 20th anniversary. This organisation was founded in 1990 by representatives from seven national Alzheimer associations. Ethical issues have always been an important focus of its activity especially in the recent decade. In 2001, a position on the use of genetic testing and on the participation of people unable to consent in clinical trials was adopted and four years later Alzheimer Europe published its position on advance directives. The recommendation on use of restraints (''restraint of restraints'') was very influential among European national societies and it was translated into different languages. AE also carried out a survey on the opinions of member organisations with regard to the disclosure of diagnosis to a person with dementia (2003).

PLENARY SESSION 4 -SERVICES IN GERIATRIC PSYCHIATRY
Ethical considerations and decisions are based on a broad discussion between Alzheimer associations, caregivers, patients, experts and other important stakeholders. End-of-life care was discussed in a multidisciplinary working group and between AE member associations and position on end-of-life care of persons with dementia was adopted at the Oslo annual general meeting in 2008 and published with a detailed background document. In 2010 the position paper on assistive technologies was published.
From the very outset, Alzheimer Europe has been discussing important ethical issues and developing recommendations about them. However, new ethical problems are emerging with overall societal changes, growing cultural diversity, clinical trials, with new drugs and advances in diagnosis, especially in the diagnosis of Alzheimer disease in pre-clinical stages. These and other issues have been addressed in the new material which has been discussed by the expert, patient and caregiver group recently -The Ethics of Dementia Research.
Retrieved from www.alzheimer-europe.org Services in geriatric psychiatry -the Norwegian model Knut Engedal Norwegian Center for Ageing and Health, Oslo University Hospital, Oslo, Norway Geriatric psychiatry is not a specialty of its own, but is acknowledged as a special branch of psychiatry in Norway.
Within the Norwegian association of psychiatry geriatric psychiatry has its own working group that has suggested the curriculum of geriatric psychiatry. This curriculum is acknowledged of the Norwegian association of psychiatry and consists of: being a specialist in general psychiatry, having two years of training in geriatric psychiatry, attending 100 hours n courses and had published a report or scientific paper in the field of geriatric psychiatry. The working group has also developed a plan for specialist services in geriatric psychiatry called: Working plan in geriatric psychiatry 2011-2020.
Norway is a small country with about five mill inhabitants, divided into 19 counties. Specialist service and hospitals are run by the Government, and in each county, except one there is a department or a section of geriatric psychiatry. Most departments consist of an in-patients unit, an out-patients clinic, an outreach program and a program for education and supervision of both GPs and district nurse. In the larger cities day-hospital programs exists, but this kind of service is rare. All in all about 300 beds are allocated to elderly patients with psychiatric disorders in the in-patient units in Norway.
Patients with severe depression, psychosis and dementia with severe neuropsychiatric symptoms are normally admitted to the in-patients units for assessment and treatment. Patients with less severe depression, anxiety and dementia are normally seen in the out-patient clinics, and some of these outpatient clinics are also organized as memory clinics seeing patients with early signs of dementia or MCI. The outreach program is designed to meet the needs in nursing homes. Doctors and/or nurses, especially nurses go to nursing home for seeing patients, but also for supervise staff. Educational activities towards staff in nursing homes are organized.
Normally all departments of geriatric psychiatry are staffed with psychiatrists, psychologists, both clinical psychologists and neuropsychologists (memory clinic function), nurses with specialization in psychiatry or geriatric medicine, nurses aids, occupational therapists and physiotherapists. Social workers are normally not part of the staff. They are mostly working in primary care in Norway. All staff in geriatric psychiatry is invited annually to a national meeting with a duration of two days.
Besides clinical activities the larger departments of geriatric psychiatry have organized their research activities, but there also exists a national network for research. Personnel with interests in research meet annually to discuss common projects, and some multicenter projects have been launched with great success.
Memory services in the UK: Experiences from South London Michael Philpot Maudsley Hospital, Denmark Hill, London, UK In the UK, memory clinics were first set up in the early 1980s -initially focussed on recruiting patients for research into the dementias. Clinic numbers have grown over the past 30 years and may now be found within Old Age Psychiatry, Neuropsychiatry, Neurology and Geriatrics services. There has been a shift towards clinical assessment and treatment. Despite this, the UK National Dementia Strategy (2009) identified a persistent under-diagnosis of dementia (compared to expected figures), unacceptable waiting times to assessment and diagnosis, a paucity of information about the diagnosis being given to the patient and their family, and ineffective links with local care services. The strategy included a national plan to set up generic, largely home-based 'Memory Services' that would tackle these criticisms. This presentation follows to steps taken by one large mental health provider in South London to implement this plan. The South London and Maudsley NHS Foundation Trust serves a population of over one million people (125,000 over the age of 65). It now has three memory services covering different geographical areas. Particular reference will be made to the Southwark and Lambeth Memory Service inaugurated in 2010.

PLENARY SESSION 5 -RESEARCH METHODS IN GERIATRIC PSYCHIATRY Chairs: Stavros Baloyannis, Lia Fernandes
Not only for the young ones: Community service models for the elderly Hans Gutzmann Hedwigshoehe Hospital, Berlin, Germany In many countries, community service models for elderly people are less well developed than those for individuals of working age. Elderly people with mental health problems receive much worse outpatient care than younger people. Although the health promoting factors are known, there are hardly any studies on effective biopsychosocial care models. A good study in this field should focus a real problem and should be aimed at a relevant number of sufficiently defined patients. It should describe patients and interventions well and formulate testable hypotheses. Not at least it should be based on 'real life scenarios' and should take care of the costs, having in mind -from the very first moment -the transfer from the status of a pilot project to everyday patient care. It should be attractive, plausible and convincing for user, professionals and politicians as well. The findings of a pilot-study from Austria presented here suggest that investment in services delivering home treatment for elderly people might lead to much improved clinical and social outcomes and fulfil most of these criteria pretty well.
The Golgi apparatus in Alzheimer's disease Stavros Baloyannis Department of Neurology, Laboratory of Electron Microscopy, Aristotelian University, Thessaloniki, Greece Alzheimer's disease (AD) is a devastating disorder of the central nervous system, involving progressive cognitive impairment, characterized by profound memory loss, learning inability, behavioral changes, resulting in a vegetative state eventually. The aetiopathology of AD, remains still unknown, in spite of the continuous research efforts. The implication of Ab peptide, APP, hyperphosphorilated Tau protein and synaptic pathology, may contribute in the formation of neuritic plaques, the neuronal loss the synaptic changes and the cytoskeletal alterations, which are the morphological hallmarks of AD, without explaining sufficiently the innermost pathogenetic mechanisms of the disease. Morphological alterations of the neuronal organelles, mostly concerned the mitochondria, have been described in AD, from the ultrastructural and histochemical point of view. In the present study we attempted to describe the morphological alterations of the Golgi apparatus (GA) in early cases of AD, in biopsy and post mortem material, studied in electron microscopy. It is known that GA plays an important role in glycozilation, sulfation. proteolytic processing and trafficking of protein systems, synthesized in the endoplasmic reticulum of neurons and glial cells. The hyperphosphorylation of tau protein, a phenomenon tightly associated with the pathogenesis of AD, is also related with the pathophysiology of GA. In eight cases of Alzheimer's disease we observed a marked fragmentation of GA in the perikaryon of polyhedral and pyramidal cells of the hippocampus, the large triangular neurons of the frontal cortex as well as the Purkinje cells of the cerebellum. The fragmentation of Golgi apparatus may be related to the action ofsecretase on APP, it may be associated with the alterations of microtubules and with loss of dendritic spines and the alterations of the dendritic arborization, which is prominent even in the early cases of Alzheimer's disease.

Ralf Ihl
Alexian Hospital Krefeld, University of Duesseldorf, Duesseldorf, Germany Introduction: A broad spectrum of outcome parameters becomes developed and used in Geriatric Psychiatry. Most of the new parameters never demonstrated superiority to existing parameters. Thus, the interpretability and comparability of results often becomes arbitrary. Studies existing cover only a minor part of the spectrum of research questions. Thus, many questions remain unanswered. Objective: The exemplary analysis of these both fields of research shall demonstrate how research in Geriatric Psychiatry can be improved. Methods: Comparison studies of neuro-psychometric tests were searched with a Medline analysis. The impact of the results on further studies was critically proven with the question if further studies only used superior tests. In the field of anti-dementia pharmaceuticals it was investigated how many possible questions were answered by the studies.
Results: Several tests have demonstrated superiority to tests formerly used. The results were neglected in most of the following studies. Studies on anti-dementia pharmaceuticals answer only a small range of urgent questions.
Discussion: In many studies valid results of former results were ignored missing a lot of chances. Such ignorant behaviour leads to a stagnation of research.
In the example of anti-dementia pharmaceuticals, the number of existing studies as well as their design allow only for limited conclusions. Thus, many urgent questions cannot be answered. For improvement, there is an enormous space. Especially in methodological aspects to improve the situation, an international coordination of research activities might be one fruitful attempt. Many professional and personal decisions in dementia care involve judgments about risk. There are pressures on professionals in particular to ensure that they make the right risk decisions. This paper draws on work undertaken for the English Department of Health about risk decision making in dementia services. The research involved a search of the literature about risk taking in practice and the development of national guidance published by the Department of Health as part of its documentation to support the National Dementia Strategy. The Guidance is entitled 'Nothing Ventured Nothing Gained' and this title conveys new emphasis on risk as empowering for people with dementia.

SYMPOSIA
Reducing admissions and length of stay for people with dementia Afifa Qazi North East London NHS Foundation Trust, London, UK There is a general move towards trying to reduce hospital admissions for people with dementia and to reduce length of stay in hospital. Many new developments in older people's mental health services have aimed to improve care. However, there is very little research on what might reduce inpatient bed use.
The objective of this study was to reduce the need for psychiatric inpatient beds for older people by developing and testing a new model of service which emphasised working more closely with general practitioners and care homes.
The new model of service was implemented over a three year period in one sector and at the end of the time the bed use was compared with other similar sectors in the region. It involved close working links with GPs/practice nurses and a same day response where possible. Talks at GP practices to improve quality of referrals and GP confidence in managing psychiatric disorders. Face to face discussions with GPs (e.g. referral for acute confusion). Close working links were developed with local care homes including training and case discussions.
The key elements of the model were access/support, training/development and liaising-providing the missing link. The number of admissions per 10,000 elderly was only 16 per year (other consultants 19-50 per year) and the length of stay was 29 days (other consultants 37 to 89 days). Occupied bed days were under 500 per year compared to 1000 to 1800 for the other consultants.
The new model enabled the identification of difficulties before reaching crisis point. Use of beds was reduced to 33% of the other consultants and the model was popular with GPs and care homes.
Developing a manual to manage crises in dementia Ritchard Ledgerd North East London Foundation NHS Trust, London, UK Objective: To describe the key stages and outcomes that have contributed to the development of a Manual aimed at providing a detailed guide to delivering home treatment interventions for people with dementia and their carers. Methods: Key stages included a Cochrane review (in progress), literature review, nine focus groups, online Stakeholder Questionnaire, Manual (Draft version 1), Consensus Conference, Manual (Draft version 2), ten narrative inquiry interviews, five case review workshops and Manual (Draft version 3). The next stages of the manual's development include further consensus/ratification processes, discreet choice experiment, feasibility study, pilot study and exploratory trial. Results: Findings from the focus groups identified (i) factors that could lead to crisis (ii) interventions that were useful in a crisis. Results were grouped into domains and formed the structure of an online questionnaire. 719 respondents completed the questionnaire that ranked, in order of importance, the factors most likely to cause crisis and interventions most useful and/or preventative in a crisis. The results led to the production of Draft version 1 of the Manual that was circulated, reviewed and discussed by 23 Consensus Conference participants. The Conference included workshops designed at matching particular interventions to particular causes of crisis. The outcome of the Conference led to the production of the Manual (Draft Version 2). Ten narrative inquiry interviews were undertaken with carers who had experienced a crisis. Five case review workshops were held with 45 healthcare practitioners, to obtain their feedback about the design and feasibility of the Manual (Draft Version 2) using case examples of people they have worked with who had experienced a crisis. Discussion: The development of the Manual has incorporated a wide range of research methods with a variety of stakeholders including people with dementia, family carers and healthcare professionals. The Manual includes an Advisory Protocol and care planning tool aimed at best managing or preventing crisis situations for people with dementia and their carers. Conclusion: The research has generated a wealth of qualitative and quantitative data relating to the causes of crisis and useful/preventative interventions for people with dementia their carers which have been developed into a Manual to manage crises in dementia Objective: The European population is rapidly greying. As a consequence the number of people with dementia will increase the coming decades. On the other hand the working population decreases, which will result in relatively less professional carers to provide support for people with dementia. It its estimated that currently 66% of all people with dementia in high income countries live at home, supported by relatives and formal carers. Due to time, competence, or financial constraints of family carers, increasingly low-cost carers, including immigrants from other countries are hired to provide daily care to people with dementia. Frequently they are not trained in providing specific care for this target group.
To improve the quality of care for community dwelling people with dementia the 'Skills Training and Re-skilling for Carers of People with Dementia' (STAR) project aims to address this issue by developing, providing and evaluating online training in six different European languages for anyone caring for a person with dementia. Method: The STAR training will be developed in three phases. First, the state-of-the-art regarding existing educational materials will be analysed. Secondly, a methodology will be developed in a multimedia style, applicable for the Internet, smart phones and digital television, improving the accessibility of STAR training. The training provides a learning path using eight short modules, including texts, articles, case videos, and interactive exercises. Additionally country specific online STAR communities and a dementia expert community will be made available to share experiences. Students will also have the opportunity to consult experts. After implementation of the methodology and content, the e-learning portal will be evaluated in a user pilot from September 2012 until May 2013. Results: A first impression of the website and training modules will be provided in the project presentation. Conclusion and discussion: The STAR platform intends to provide opportunities for education, collaboration, discussion and sharing experiences between users (carers of people with dementia), while supported by dementia experts from all over the EU. Experts are welcome to join the pan-European expert network at www.startraining.eu. The project started in December 2010 and will end in November 2013. Introduction: It is known that Alzheimer's disease (AD) and dementia represent one of the most prevalent diseases in our environment and poses a real epidemic among the population over 65 years in the Western world.
Therefore early diagnosis of dementia becomes a crucial issue and is currently accepted as beneficial for patients, families and society, as well as being a crucial factor in the therapeutic efficacy and the prognosis of the disease. However, it indicates that dementia is an underdiagnosed entity in Spain, Europe and around the world, so it is not detected and treated appropriately. The screening tests, although not proposed as a diagnostic method in itself, they have been employed as useful tools in the assessment of older people at high risk of dementia (10). However, many cases are not diagnosed early by not having a specialist or as a result of the impracticality of neuropsychological testing (2). Therefore, an attempt to try to offer an alternative to the increasing number of people living with cognitive impairment and dementia, new technologies are introduced in the evaluation. Computerized methods currently have the ability to measure accurate and reliable time of stimulus presentation, response speed, different formats for displaying information and ability to be self-administered, among others. In this situation we propose the CogVal-Senior, self-administered a computerized test, which assesses various cognitive aspects: orientation, memory, calculation, executive function and language. The total score is 65 points. Objective: To evaluate the diagnostic utility of the CogVal-Senior a computerized test to screen for dementia in an elderly population. Method: All subjects were administered the evaluation protocol of the study. The sample comprised 267 subjects aged 65 to 98 years (74.17 AE 9.33) and mostly with a primary education level (6.17 AE 4.14). The sample was divided between normal subjects without dementia (N ¼ 224) and subjects diagnosed with Alzheimer's dementia (N ¼ 43). Material: The assessment protocol included CogVal-Senior, the MEC and the Clock Test. Results: The CogVal-Senior shows significant correlations with the MEC (r ¼ 0.792, p ¼ 0.00) and TR (r ¼ 544, p ¼ 0.00). The ROC curve for CogVal-Senior shows the possible cutoff points for identifying the sample with DTA, where the best cutoff point would be 45, with a S ¼ 0.96 and E ¼ 0.83, with an aˆROC ¼ 0.97. The reliability test-retest obtained an Intraclass correlation coefficient was 0.70 and t ¼ 0.870 (p ¼ 0.391). He also obtained a Cronbach's alpha of 0.73. Conclusion: Currently it is suggested that advances in early diagnosis of dementia are becoming more accessible to the clinical setting. It is therefore necessary construction, adaptation and validation of simple instruments to detect incipient dementia. The results indicate that the CogVal-Senior is a test with significant correlations with tests of known clinical utility of screening the MEC and the TR in a special way with MEC, the most widely used in clinical practice primary care (2). The ROC curve shows a high overall accuracy of the test. By measuring qualitatively such accuracy, you get an aˆROC of 0.97 indicating a high accuracy also CogVal-S as a test for dementia with a cutoff point of 45. The good psychometric characteristics obtained by the CogVal-Senior, coupled with the advantages of an automated assessment reinforces the idea of the benefits of new technologies for early detection of dementia. A total of 1084 subjects (community-dwelling adults and older adults ¼ 842, MCI ¼ 55, and dementia ¼ 124; Depression ¼ 63) participate in this research.
Item Response theory, relationships with Mini-Mental State Examination scores, internal consistency, sensitivity, specificity and normative data (by age and education) suggest that ACE-R seems to be an useful cognitive screening test for detecting MCI and dementia on Portuguese population. In present study we intended to present the main IAFAI validation studies, considering both communitydwelling adults and older adults (N ¼ 568) and some clinical samples as Mild Cognitive Impairment (N ¼ 35), Dementia (N ¼ 50), Stroke/Traumatic Brain Injury (N ¼ 35), Schizophrenia (N ¼ 26) and Depression (N ¼ 19).
Globally, the results are consistent about the IAFAI capacity to discriminate clinical groups from control groups. Also, the psychometric properties (reliability, construct validity, discriminant validity) of the instrument seem to be favourable to their clinical utilization on Portuguese population.
The art and science of assessing the family in psychogeriatrics Manuel Gonc¸alves Pereira Department of Mental Health, Faculdade de Cieˆncias Me´dicas, CEDOC, Universidade Nova de Lisboa; Campo Ma´rtires da Pa´tria, Lisboa, Portugal Involving family members in the assessment of older adults may be crucial, but assessing the family is an issue on its own. There are different ways of tackling this problem, in clinical or research settings. The science of family assessments has produced robust findings, although validity and reliability data must be improved. Moreover, the art of interviewing has been insufficiently approached in training programs. As with the interpersonal aspects of individual interviews with older adults, much is left to the common sense of trainees. Issues like rapport or confidentiality should be explored. An argument is made on the need to fulfil this gap, not the least to ensure that the validity of assessments is preserved. Empathy, a mainly cognitive attribute, may be conceptually relevant to this debate.
This narrative review addresses the purposes and methods of assessing the family in psychogeriatrics. A focus on communication issues is attempted, drawing on clinical and field research experience, and aiming to explore the relevance of empathy.
The literature on dementia, psychosis, late-life depression, alcohol or palliative care provides different rationales to the involvement of family members in assessments. As informants, relatives are helpful in the evaluation of patients. As informal carers, they may deserve to be assessed in their own right. Finally, family dynamics must sometimes be addressed.
Results from the FAMIDEM surveys suggested that the key relatives of demented patients are not the only ones among family members to have unmet needs. Non-key relatives are seldom summoned for clinical assessments, sometimes a missed opportunity to improve clinical outcomes. Moreover, case histories of FAMIDEM participants illustrate the consequences of past unempathic assessments for patients and their relatives.
Across clinical scenarios that call for systemic evaluations, empathy may foster the quality of family explorations. Further research is welcomed in this topic. Introduction: Long Lasting Memories (LLM) is an integrated ICT platform which combines cognitive exercises with physical activity in the framework of advance technologies. LLM aims to deliver an effective solution against age-related cognitive decline, and to allow the recovery of higher cognitive functions in people who show cognitive impairment related to Mild Cognitive Impairment and Mild Dementia. Cognitive exercises are provided by GRADIOR specialized software which offers a structured evaluation and neuropsychological rehabilitation system. Physical Training is based on FitForAll game platform that can help elderly people to exercise through an innovative, low-cost ICT platform, such as Wii Balance Board. Objectives: To determine the effectiveness of LLM cognitive and physical training program in the improvement of mental capacities in non-impaired elderly, mild cognitive impaired and mild dementia subjects. Method: Volunteer sample of 86 participants was recruited from residential facilities, community centers and memory clinics. 44 non-demented elderly, 24 subjects with Mild Cognitive Impairment and 18 elderly who met the DSM-IV criteria for dementia (mean age ¼ 75.9 years, SD ¼ 8.4, age range ¼ 60-92 years) were administered LLM during 12 weeks program. 49 subjects formed the control group (mean age ¼ 79 years, SD ¼ 6.48, age range ¼ 62-94). Results: Participants improved in most subscores of Hopkins Verbal Learning Test (HVLT-R). Recognition improved with z ¼ 1.689, p ¼ 0.021, while in the control period participants scores decreased (z ¼ 1.68; p ¼ 0.041). Delayed recall of the learned items also improved in LLM group (z ¼ 0.61, p ¼ 0.05) while decreased in control scores (z ¼ 1.3; p ¼ 0.019). There were also improvements in Total Recall scores of the experimental group (z ¼ 1.69, p ¼ 0.016) while there was a decreased in control group scores (z ¼ 0.64, p ¼ 0.042). A decreased in control scores of Digit Span test (Digit Span subtest of the Wechsler Adult Intelligence Scale-III) (z ¼ 1.2, p ¼ 0.041) was found, while experimental groups maintained similar pretest/postest scores (p ¼ 0.035) Discussion: Primary results support the effectiveness and usefulness of LLM cognitive and physical training in improving cognitive skills. LLM is a promising solution for aged related decline and the rehabilitation of higher cognitive functions, maintaining wellbeing of the elderly with few technical requirements. They make possible to reach the patients at their own house through a computer, either to provide information, counselling or, as it is the present case, to provide cognitive stimulation.
Cognitive stimulation is a technique that has not been adequately studied because the research about its efficacy presents some methodological difficulties. At the present time the scientific evidence of their efficacy is low.
www.todomemoria.net is a program of cognitive stimulation that provides to the caregivers material for the home intervention. The material is prescribed by the doctor who regularly visits the patient. Most elderly people in our care environment are not familiar with the use of informatics and it is not a reasonable goal to try to teach them in the course of their dementia. Material and methods: The prescribing doctor receives information and indicates the program to the patients/ families when he considers that they have a suitable profile (if they live at home, the family can connect to the network, level studies of the patient is above functional illiterate, they have a preserved vision and the caregiver involvement is adequate).
The workshop has three levels of difficulty, depending of the phase of the illness and the socio-cultural level. The exercises for different cognitive areas not necessarily have the same level of difficulty for each patient. The profile of the workshop can be modified at each visit. Results: We have 786 patients working daily with the data sheets of our workshop, of which 57 per cent are dementia Alzheimer type, 11% mixed, 9% vascular,4% frontal,19% other (Lewy,Parkinson,etc.). In relation to the prescribers: 35% neurologists, 17% geriatrician, 16% psychiatrists, 32% psychologists. It is regrettable the low proportion of psychiatrists involved in the field of dementia in our environment. Unfortunately we do not have data about evolution of patients, because this program does not allow us to review the results of the patients from other professionals, but internet connections are increasing as the diffusion of www.todomemoria.net grows. Discussion: All people working in the field of cognitive stimulation feel that patients benefit from these treatments. Families easily learn to detect small changes in the patient. We don't find cognitive improvements, but we find changes in the patient's behavior, personal relationships and possibly changes in the quality of life of the patient and the caregiver. www. todomemoria.net helps secondary caregivers to take part in the care of the patient. They are usually children or grandchildren of the patient who are able to connect to the network and be involved in administering the worksheets to perform the cognitive stimulation. Adherence to treatments of stimulation at home depends on the involvement of professionals with families, the type of interventions made (psychoeducational groups), support groups or information and the motivation of families for the care of the patient.
Telepsychogeriatrics. Our experience in Galicia Raimundo Mateos, R. Ramos and D. Lojo Department of Psychiatry, CHUS University Hospital, University of Santiago de Compostela, Santiago de Compostela, Spain Epidemiological research has documented the high prevalence of mental disorders in nursing homes, particularly dementia, depression and psychotic disorders, with only a minority of these patients receiving adequate treatment.
Galicia, the north-western autonomic Spanish region, with a 22% of its population older than 65 years and a rapidly evolving nursing home sector, is not an exception. The psychogeriatric unit of Santiago de Compostela has provided continuously psychiatric liaison services to the nursing home facilities based on the city. This liaison model could not be offered to many other residential facilities located about 1 hour by car from our clinic. Professionals working in these nursing homes know the burden of psychiatric disorders in terms of behavioural problems, inappropriate medication and nursing time spent accompanying patients referred to our clinic for psychiatric evaluation and treatment. Available information on telepsychiatry programmes encouraged us to test the viability of similar programmes in our setting. Aims: This pilot study aimed to assess the feasibility and acceptability of using videoconferencing consultation from an interdisciplinary psychogeriatric unit to an elderly nursing home. Methods: The core technological equipment was composed of a video conference kit (Polycom VSX-7000S) and an ADSL line of 8 Mbps/640 Kbps. Structured written protocols were specifically designed for the following purposes: a) consultation request from the nursing homes; b) psychiatric response; c) assessment of the satisfaction with the programme of patients, nursing home staff and psychiatrist involved in the project. Health care background and data of the 18 months programme are summarized. Results: A total of 63 videoconferences were performed to 23 residents. The most frequent reason for the consultation were Behavioural disorders (43.5%), Cognitive impairment (24%) and Psychotic symptoms (6%). Despite minor technical difficulties, videoconferences were performed on regular basis as scheduled and made possible to provide diagnosis, treatment and follow up to these patients and advice to the nursing home staff. Conclusions: Psychogeriatric teleconsultation (videoconferencing) from a Psychogeriatric unit to a nursing home has proved a viable alternative to in vivo consultation. It has improved the functioning of the interdisciplinary team at the nursing home and was satisfactory to all parts involved. Acknowledgements: This research action project was founded by a grant from the Galicia Ministry of Health. Cerebral vascular diseases, or impairments, assume more importance as time allows more studies to be known. Portugal has probably the greatest amount of people with strokes in the world, and cardiovascular diseases are the leading group in morbidity and mortality. Vascular impairment and subgroups, until now under the shadow of Alzheimer's disease, must be faced as an entity susceptible to be, as much as possible, prevented.
In a recent study ('SCORE' for the prevention of dementia') on a small sample of out patients in an hospital psychiatric department in Lisbon, Portugal, we found out that there was an appreciable amount of cases, aged 60 and more, with high risk for a severe cardiovascular episode (assessed by SCORE, from the Framingham study), and that these subjects, with confirmed risk factors, presented already cognitive impairment or even severe dementia.
They all received orientation in order to better shape their life styles and should be assessed after one-two years.
Care and be cared Rosa Encarnac¸a˜o Servic¸o de Psicogeriatria do Hospital de Magalha˜es Lemos, Porto, Portugal The recognize of the specific needs of old people lead to the creation of health services specialized to care this population towards getting a better quality of life to the old people. The recognition of the needs to grant to old people (with psychiatric diseases, and specific with dementia) and caregivers a better treatment and care lead to the creation of Servic¸o de Psicogeriatria in the Hospital Magalha˜es Lemos.
We present in this communication the goals, methodology, type of interventions, articulation with community and support to the caregivers.
The methodology is based in a multidimensional and integrated evaluation by a multidisciplinary team with the goal to planning and implementing a transdisciplinary intervention dynamic in time.
The concerned with the patient and the caregiver and the articulation with the social net and the prime care services is one of our objectives. Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age.
Most people look forward to retirement with a mix of excitement and anxiety, feeling excited about having the time to relax and to realize those 'postponed' dreams and anxious about whether they will be financially and emotionally ready to deal with the changes that retirement brings.
Advance planning is essential to creating a truly satisfying retirement and to have some control over the ways change will affect our lives. It is a personal planning process that most of people have used in other life circumstances.
It is important to consider the ways in which lives will change prior to retirement so that the person will not be taken by surprise and can take appropriate measures to deal with some of these issues.
Many people choose a lifestyle that can lead to poor health. Many are overweight, don't get enough exercise, eat an unbalanced diet, or smoke. There are three positive steps which can be taken to improve health and wellness: Nutrition, Stress and Exercise.
Latest in brain research shows that regular mental stimulation, along with other healthy habits, can help to keep mentally sharp, while growing older.
One way to get that mental stimulation is to be a life-long learner always challenging to master new skills and acquire new information. Other excellent sources of mental stimulation are leisure pursuits that require planning details.
Loss is a major part of the emotional challenge of aging. Many people experience retirement as a loss of status, relationships, and meaningful activity. Many friends and relatives move away or die during the retirement years.
It is important to keep in touch with the community and in some cases to 'reinvent' life. This Consensus meets one of the goals of the WPA Action Plan 2008-2011, ''to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world''.
This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.
Ethics of care and quality of life in psychogeriatric services in Romania Nicoleta Tataru Psychiatric Ambulatory Clinic, Oradea, Romania After a short review of ethics in old age psychiatry we'll talk about ageing and its challenges: to cut mental health costs and to provide care to as many as possible. The psychiatrists have to face these challenges and treat and care the elderly with or without mental disorders including dementia, assuring them the best quality of life as it is possible. Another ethical problem for all forms of dementia, is the decision about the right time to transfer the patient to a nursing centre and to reduce the therapeutically program using expensive drugs The concept of quality of life has been only recently and slow developed in the field of mental health. Nowadays it is difficult enough to talk about quality of life of elderly with mental disorders especially those with dementia. In Romania traditionally, the mentally ill were treated for financial reasons in general or geriatric hospitals as there were insufficient psychiatric hospitals. Older people with dementia and no behavioral disorders or significant physical disabilities are also admitted to nursing homes and other social services long-stay units organized by the state, non-governmental organizations or churches. Most elderly with dementia who have a family are treated at home. Patients with dementia who have behavioral disturbances, psychotic symptoms or agitation require admission to a psychiatric hospital for acute or chronic illness. In spite of the professionals' endeavours specializing in teaching and educational programs, there are only a few psychogeriatric services and even fewer special care services for dementia patients.
The interrelationship between the patients and their environment, the problems of their caregivers are important aspects which influence the patients' quality of life. Today we talk more and more about the effect of mental illness upon a patient's life and their caregivers' life.
Indirect self-destructive behaviors in the elderly: How to assess and manage them? Vincent Camus CHRU de Tours et Universite´Franc¸ois Rabelais de Tours, INSERM U930, Tours, France Suicidal thoughts and wish to die are not infrequent in the general population. Fortunately in most cases, they are not followed by any suicidal behavior. In the elderly suicidal ideations and behaviors are often associated with depressive disorders but in many cases, no clear axis I psychiatric disorder is found. Moreover they can be represented by indirect self-destructive behaviors that have been shown to represent up to 50% of the suicidal behaviours in nursing home residents. These suicidal behavioural are particularly difficult to be diagnosed, as they are not acute as in usual suicidal crisis, and do not evoke clinically psychiatric conditions but a various range of physical symptoms or functional decline, as well as several complex medical conditions. Treating such indirect self-destructive behaviors is a major ethical issue, as it needs to consider the need to avoid any aggressive therapies that could prolong life inappropriately, but also to take into account the psychological distress such suicidal behavior expresses. Social determinants of health (SDH) are the conditions in which people are born, grow, live, work and age and which are shaped by the distribution of money, power and resources at global, national and local levels. These social determinants are associated with mental disorders by contributing to their onset or course. They may play a role as risk factors for mental health (unemployment, poverty, inequalities, stigma and discrimination, poor housing, poor early years experience, violence, abuse, drug and alcohol abuse, poor general health, caring duties), while others may be protective factors (employment, social protection, resilience, social networks, positive community engagement, positive spiritual life, hope, optimism, good general health, good quality parenting, positive relationships in childhood). By acting on SDH, it is possible to contribute to a better subjective mental health and well-being of people, to build the capacity of communities to manage adversity, and to reduce the burden and consequences of mental health problems. Disadvantages because of mental health problems damage the social cohesion of communities and societies by decreasing interpersonal trust, social participation and civic engagement.
SDH are primarily responsible for disparities in health. They are influenced by policies choices which influence the development of public service systems. These systems, in their turn, shape the social determinants of health through the development of programmes, resource allocations and organization of services. The influence of negative social determinants of health often is caused by bad political choices and the consequent unequal distribution of resources. The establishment of good policies is the first step to produce changes.
The goal of this presentation is to describe how the interaction between social determinants and mental health and well-being of older persons were considered on recent selected statements, policies, declarations or other public health documents with the aim to promote a better old age mental health as an ethical issue and the basic human right. Elderly patients occupy up to 65% of acute hospital beds and a significant proportion of them present with a co-morbid psychiatric condition such as depression, delirium or dementia. Early recognition and adequate management of these conditions are crucial to improve the clinical outcome of patients. However, there is no consensus about what is the most effective approach to deliver specialized psychiatric care to elderly patients with acute medical or surgical conditions. Liaison Old Age Psychiatry (LOAP) Services have been developed to provide psychiatric consultations in medical and surgical settings improving at the same time the knowledge and expertise of general ward staff. The objective of this presentation is to review the current evidence of the effectiveness of liaison psychiatry services in the management of old age patients with psychiatric disorders. Evidence from controlled trials shows a overall benefit of LOAP services in terms of health savings, although not on mental health outcomes. Direct comparison between different models of old age psychiatry service delivery in the acute hospital should be addressed by future research.

Reference
Organizing a liaison OAP service: Challenges and opportunities Elizabeta Mukaetova-Ladinska Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK The Newcastle Liaison service for Older Adults has been established seven years ago, and provides mental health care to older adults admitted on various medical and surgical wards in three hospital sites in the city. I will discuss the role of the service, its composition and professional activities, as well as the service delivery in relation to latest health policies and mental health services re-organisation. In addition I will also address the UK liaison services for older adults in general, and the increasing need for their development in providing care for the medically ill older adults.
Setting a new LOAP service in Coimbra University Hospital Vasco Nogueira and H. Firmino Servic¸o de Psiquiatria, Hospitais da Universidade de Coimbra, Coimbra, Portugal Coimbra University Hospitals are an academic affiliated institution providing a high standard health care to the central region of Portugal. A significant proportion of admitted patients to the medical or surgical wards have 65 or more years, with psychiatric comorbidities such as dementia, depression and delirium being highly prevalent.
So far, mental health care to inpatients has been provided by the emergency psychiatric team. However this type of service has several important limitations, including the lack of continuity of care, difficulties regarding interaction with the ward staff and poor quality of clinical notes.
Thus, the Psychogeriatric Unit started a new LAOP service in order to overcome these issues. In this communication the authors aim to present the project as well as some preliminary data and future directions of work. Underrecognition and misdiagnosis of delirium is frequent in the clinical practice because it relies in highly variable and subjective symptoms and no consistent method to identify the likelihood of delirium in a particular patient is yet available. Therefore, the search of peripheral biomarkers of delirium is of crucial interest as they would have a major impact not only in a better understanding of the pathophysiology of this syndrome but would also benefit the quality of health care offered to patients. Current research on peripheral biomarkers of delirium is exploring several pathophysiological pathways according to the evidence of a continuous interaction between the Central Nervous System (CNS) and peripheral organs through bloodstream. The anticholinergic burden in the blood, reflecting the presence of medication and its metabolites, and enzymatic activity of peripheral cholinesterases have been studied as possible markers of brain cholinergic activity. On the other hand, a few studies have explored the role of systemic inflammatory mediators and cortisol in delirium pathophysiology following the vast amount of preclinical evidence demonstrating the activation of a central neuroendocrine response following the exposure to peripheral immune stimuli. Additionally, markers of direct CNS damage previously studied in a variety of neurological, neuropsychiatric and neurosurgical disorders are being tested as potential markers of brain dysfunction. Based on this background, a cohort study is being conducted in Coimbra University Hospitals to investigate the role of several candidate biomarkers in the risk assessment and diagnosis of delirium. In this presentation we will discuss some results of the study and their implications for future research and how they can ultimately be translated into routine clinical practice. Our knowledge about the long-term consequences of having an affective disorder has increased in the last decade. We now know that affective disorders are associated with increased mortality rates, structural brain changes and cognitive impairments. Longitudinal studies suggested that affective disorders are risk factors for dementia and for Alzheimer's disease in particular. However this is still strongly debated. The controversy is mostly centered on whether affective disorders are a risk factor or a dementia prodrome. We conducted a comprehensive and updated review of studies evaluating affective disorders as risk factors for dementia. The data suggest that affective disorders can be both a prodrome and a risk factor for dementia. This risk seems to be modulated by clinical, biological and sociodemographic variables. Long-term outcomes concerning clinical, morbidity and mortality issues have received great attention in affective disorders. The need to characterize these several outcomes can lead to the identification and the correction of the risk factors associated with a worse outcome.

Long-term outcomes of affective disorders
Numerous studies have indicated that depression is associated with increased mortality rates, either from non-natural (e.g. suicide) and natural causes (specially cardiovascular diseases). However, these data have not been confirmed in other studies. It is also controversial if unipolar or bipolar patients have different mortality rates. Zurich cohort (Angst et al., 2002) data found increased mortality rates for unipolar patients (when compared to bipolar), especially due to suicide. These results are quite different from other similar studies (e.g. Høyer et al., 2000).
To assess clinical, morbidity and mortality outcomes in depression a follow up (at 27-34 years) of a sample of very well characterized depressed patients (Paes de Sousa Cohort) was carried out. A cohort of patients submitted to appendicectomy or cholecistectomy at 1977-84 without depression was used a control group. To assess mortality ratios Standard Mortality Ratios for Portugal were used.
The mechanisms underlying this eventual increased mortality/morbidity are probably behavioral (e.g. more tobacco consumption, less self-care) and biological (autonomic changes, inflammatory mediators).
The heterogeneity of the results could be partially explained by the relative paucity of long-term prospective studies, and by the use of different depression criteria (or very different ways of evaluating depression) and different controls.
The development of preventive strategies to prevent or influence this increased mortality is highly dependent of the correct knowledge of the risk factors.

Acknowledgments: Drs Ilda Paes de Sousa and Deside´rio Ribeiro
Clinical and social correlation of late onset psychosis Susana Borges Maudsley Hospital, London, UK Introduction: Unlike research on early psychosis among young adults, there is only limited literature on first onset psychosis in older people. Ever since Bleuler used the term late onset schizophrenia, researchers have started to consider late onset psychotic disorders as a distinct diagnostic entity. Method: The AESOP (aetiology and ethnicity in schizophrenia and other Psychosis) study included all patients aged 18-65 year old with first episode of psychosis who made first contact with psychiatric services over two-year period in two defined catchment areas in UK (London and Nottingham). Detailed data relating to clinical and socio-demographic variables were collected from both patients and controls. Results: We identified 536 patients with first onset of psychosis which we have grouped and compared according to their age at onset of illness: (1) illness onset before 39 years old; (2) illness onset between 40-59 years old; (3) illness onset after 60 years old. Since the AESOP study is covering 18-65 years old age group for onset of first episode of psychosis, we had found significant differences between the three groups in terms of both social and clinical variables.
Conclusions: Most studies on onset of first episode of psychosis do not include patients in late adulthood, and nearly none include patients aged 65 years old and above. It may be relevant to extend the age range in first onset psychosis studies, especially in the context of aging population and an increasing need to know more about how to treat and support population.

Overview
The expanding role of family caregivers of persons with mental disorders in the past years has lead to a wide multiplicity of educational and emotional intervention programs to reduce caregiver burden. These have included the development of diverse family education materials and training programs to support individuals with their caregiving role as well as to prevent and/or deal with the burden and associated psychological distress. The increasing prevalence of dementia in particular has attracted a special attention to this risk group given the marked dependence that these patients present and the high health and social costs resulting therefore. The need to involve health professionals, social services, formal caregivers, volunteers and the overall community on an integrated approach has led to the development of different perspectives on the provision of care of both older people with dementia and their carers. Distinct types of service programs have expressed a fixture of available national and local resources, echoing the major precept of contemporary gerontological practice and policy on the development of community-based integrated services and on the improvement of available traditional ones. This symposium focuses on four distinct Portuguese initiatives that share their commitment with a psychoeducational perspective in attaining any of these two goals. The first one entitled 'Caring & Innovating' presents an ongoing project aiming to promote decentralization of mental health services and ensure access to quality mental health care for people aged 65þ enrolled in two primary health centers. It includes training, provision and support services for families and caregivers. The second one 'Caring at Home' presents the impact of a psychoeducational program aimed at helping informal caregivers to deal with their challenging role and improve their competencies in caring for dependent older persons. Bearing in mind the potentialities and the constraints of implementing large-scale community-based services for informal caregivers, the third presentation exposes main guidelines and some findings from the intermunicipal Project 'Caring for the Caregiver'. Finally, considering the need for a clear improvement in the quality of care provided in institutional geriatrics settings that also considers employees' emotional needs, a pilot-study on the middle term effects of a psycho-educational programme for staff caring for residents with dementia is presented. In overall, the demands being placed on both informal and formal caregivers are highlighted as well as the need for a greater recognition of these agents' role as valuable members of the health-care team. Objectives and Methods: The growing concern with individuals with mental health problems, moving services and/or professional assistance center and the strong emphasis on community-based interventions has led in recent years to a closer relationship between the various providers, bringing together the nature of health and social interventions, using, where available, the cooperation of families. This presentation describes a community mental health project for older people and its ongoing implementation process. The 'Caring & Innovating' project comprises a community mental health team that is made up of a partnership between the Hospital Magalha˜es Lemos Department of Psychogeriatry and two Primary Health Care Community Centres in the area. It is developed at a community level by linking it with all existing structures and should be part of the intervention plan as needed by the wearer. Results: This team works continuously, based on activity around (business community), approaching the patients, their families and caregivers, promoting good practices of care, adequate health monitoring, supervising the adherence to proper treatment plan, promoting programs rehabilitation and active aging for users and psycho-educational programs for caregivers. The program's expected results include the provision of specialized mental health services to at least 80% of the elderly referred for consultancy by primary health centers targeted; a decrease of the number of admission in Psychogeriatric's Unit of patients referred for mental health consultation in primary health centers targeted; and a decrease of institutionalization of patients with dementia. Discussion: The articulation and decentralization of mental health care will allow a greater accessibility of the elderly to care. In turn, the work home strongly enrich this process to suit the more severe situations reducing all costs and inconvenience of a shift of the elderly and their caregivers, enabling a closer care. Simultaneously the maximum transfer of skills for primary care technicians, as well as information and training of caregivers of the elderly allows the extension of stay of elderly people in their social and family environment, promoting their independence, their quality of life by preventing or delaying institutionalization. Conclusion: The integration of care that is intended by the decentralization of mental health services and liaison with the multidisciplinary primary health care and community structures will result in a more comprehensive and rigorous definition of clinical situations, as well as intervention plans best suited to the actual needs of the target population -the elderly with mental health problems and their carers. Objectives: 'Care at home' is a psychoeducational program for informal caregivers aimed at improving competencies in caring for the older person and dealing with the challenges of being an informal caregiver. The present study aims to assess its impact at the end and two months after the completion of the program. Methods: The program was implemented in five groups comprising 66 participants in total (10.7% men, average age 51.25) in the city of Guimara˜es. The impact of the program was assessed using the following model: (i) pre-test evaluation (session 0); (ii) pos-test evaluation (last session); (iii) follow-up (two to three months after the last session). The assessment protocol included measures on mental health, subjective health, burden and positive aspects of caregiving. According to the nature of the variables McNemar test, Wilcoxon test or t-test for paired samples was performed, using SPSS 18.0 for Windows. Results: Significant results were found at the level of mental health, with improvements in overall scores from pretest to follow-up (p ¼ 0.021). Subjective health and specifically depressive symptoms revealed important improvement from pre-test to pos-test (p ¼ 0.002 for both). No significant differences were found in other indicators. Discussion: Significant improvements found in subjective health and feeling depressed show gains with this intervention. Objective physical health of the caregiver and of the person being cared were not controlled and possibly this variable is interfering with results. Participants' overall condition previous to the intervention is to be considered when interpreting some of the limited results obtained. Conclusion: The program seems to have a good impact in some areas, although it is necessary to implement it with more people to understand its effects. Indeed, the sample is quite small, diminishing from pre-test onward as some people don't show for follow-up, and/or don't complete the whole protocol. Other measures must be included to control events that might interfere with the results, like changes in health status of the care recipient. The focus on the programs' preventive nature is to be highlighted.

Meeting community needs on dementia care through integrative social-health interventions: The 'Caring for the Caregiver' project Oscar Ribeiro and I. Martin UNIFAI/ICBAS, University of Porto, Porto, Portugal
Objectives: Caring for the Caregiver (www.cuidardequemcuida.com) is a large community-based project that takes place in five Portuguese northern municipalities (EDV region) and aims to provide useful services for informal carers within an integrative social-health approach. This presentation provides an overview of its major intervention initiatives, efforts and constraints in providing such integrative approach. A special focus is played on its psychoeducational intervention program. Methods: A brief overview of the Project's main initiatives is presented (psychoeducational groups; support groups; professional training on dementia care; local volunteer's network involvement; respite care services diagnosis; discussion forums and high school partnerships) followed by a description of the establishment of a psychoeducational intervention program and its main available outcomes. Results: Currently the project involves 46 professionals from all five municipalities and 25 partnerships including City Councils, Health Centers, a Hospital, Social Solidarity Private Institutions, Volunteer's Institutions and the Region's Department of Employment. To the moment 190 informal caregivers have been enrolled in the project; 120 participated in the psychoeducational program and are being closely monitored. The need for continuity of professional support (health and/or social) was found to be crucial for most carers. Perceived benefits and limitations of the program are presented. Discussion: Albeit collaboration between various professionals and institutions tend to be difficult due to geographic, economic and human resources constraints, it results mostly due to the globally perceived lack of available responses to this population's needs in the region. An integrative social-health intervention seems to be the best way of overcoming local services limitations without compromising the specific support informal caregivers need. Conclusion: Integration between social and health organizations represent a crucial process to answer the caregivers' needs and must be supported by relevant decision makers and significant partners. A strong network of partners is crucial for the sustainability of the project. Raising public awareness on informal caregiving issues is required and to be continued. Objectives: The increasing demand for higher quality services in dementia care highlights the need to address the psychological pressure experienced by staff, as this may affect the process of caring for residents with dementia. Several training interventions have been conducted aiming to provide staff with knowledge and skills regarding dementia care. However, the provision of emotional support is scarce despite staff well-reported stress and burnout. This pilot-study aimed to evaluate the middle term effects of a psycho-educational programme for staff caring for residents with dementia. Methods: Six staff members of a care home received eight psycho-educational group sessions and individualised assistance during the provision of morning care to six residents with advanced stages of dementia. The intervention aimed to support staff on: increasing knowledge and skills in dementia care (e.g., motor and multisensory stimulation); and managing the emotional strain resulting from caring in dementia. An audio-recorded focusgroup interview with staff was conducted after the programme and submitted to content analysis by two independent judges. Video-recordings of residents' behaviours during morning care were performed pre-and post-intervention. Each tape was analysed by two independent observers who were blinded to the phase of intervention (pre/post). Results: Five major categories related to staff perceived benefits have emerged: acquisition of new knowledge; group cohesion; demystification of pre-existing beliefs; self-worth feelings; and positive coping. Although not statistically significant, a trend towards improvements at residents' interaction behaviours was found. Discussion: The findings suggest that interventions leading to perceptions of increased competence and to feelings of being attended in emotional needs might enhance staff engagement in providing adequate care. However, these promising results are limited by the pilot nature of the study. Thus, investigating the extent of these benefits in larger samples, with a controlled study design is recommended. Conclusion: Interventions that attend to both educational and supportive needs of staff can be a promising approach to improve the quality of dementia care and the well-being of both staff and residents.

Martin Orrell
Mental Health Sciences Department, University College London/North East London Foundation Trust, England, UK In recent years there has been growing evidence of the efficacy of psychosocial therapies for dementia, and recognition that these therapies should be more widely available. University College London is a leading centre for research into the development Cognitive Stimulation Therapy (CST).
CST is an evidence-based psychosocial group intervention for people with mild to moderate dementia. In a multi-centre randomized controlled trial (RCT), Spector et al. (2003) found improvements in quality of life and cognition. Subsequent economic analysis (Knapp et al., 2006) concluded CST was cost effective, and compared favourably with trials of anticholinesterase inhibitors. A recent Cochrane review (Woods et al., 2011) also confirmed the benefits of CST.
The NICE guidelines (2006) now recommend that CST should be available to people with dementia regardless of medication received. Since the publication of the CST manual and the inclusion of CST as the only non pharmacological therapy for dementia in the NICE guidelines, the use of CST is growing rapidly in the UK and internationally.
An extended programme of CST, Maintenance CST, has been developed. A pilot study (Orrell et al., 2005) suggested the cognitive benefits of CST could be maintained for at least six months. Maintenance CST has since been evaluated in a large multi centre RCT.
Research currently underway includes a study into staff training which aims to determine how health professionals deliver CST in clinical settings and how training affects the implementation of the programmes.
In addition, an individualised version of CST is in development to increase the availability of CST. Individual CST is a 25 week programme of CST and maintenance CST adapted to be delivered by a carer in the home. Individual CST may help to delay institutionalisation reduce associated costs of care, and provide another option for services to offer CST, when access to group CST is not possible.
In this workshop we will describe the most recent advances in CST, including the development of Maintenance CST and individual CST, and research into the use of CST in clinical settings. We will also invite discussion and provide practical advice about running CST groups.

Individual cognitive stimulation therapy (individual CST) for dementia Lauren Yates
Mental Health Sciences Department, University College London/North East London Foundation Trust, England, UK Improving the quality of care for people with dementia and their carers has become a national priority in many countries. Cognitive Stimulation Therapy (CST) groups have been found to be beneficial in improving cognition and quality of life for people with dementia. However, many people may be unable to access CST groups due to service constraints or practical difficulties. To increase the availability of CST, an individualised version of CST is in development and will be evaluated in a large randomised controlled trial (RCT).
Individual CST consists of 75 sessions adapted from the CST and maintenance CST programmes. It will be delivered in the home by the carer for 30 minutes, three times a week over 25 weeks. We have created 6 instructional manuals which describe the sessions, and six resource manuals containing paper-based activities.
Recently, a series of focus groups and individual interviews with people with dementia and carers have been conducted. In this presentation, the preliminary qualitative results of these discussions will be described.
Field testing of the individual CST programme is also underway. Feedback from dyads currently engaged in this testing will be reported, including the unexpected diversity in the perception of the delivery of a therapy as the domain of a healthcare professional rather than an informal carer.
In this presentation, we will describe the development process of individual CST, providing preliminary qualitative data. In addition, plans for the next phase of the trial and the design of the main RCT will be outlined. Individual CST may help to delay institutionalisation, reduce associated costs of care, and provide another option for services to offer CST, when access to group CST is not possible. Individual CST will be an easy to use, widely available therapy package that has been robustly evaluated for effectiveness in an RCT.

FREE COMMUNICATIONS FC1
We can all learn from the stories of others: What old age psychiatry services can learn from families living with a dementia Susan Mary Benbow and Paul Kingston Centre for Ageing & Mental Health, Staffordshire University, Stafford, UK We worked with people with dementia (PWD) and carers to produce narratives of their journeys with dementia and to identify key themes. Method: We recruited PWD and carers living in the community to develop personal narratives of their journeys with dementia. The carers/PWD chose to prepare a written, audiotaped or videotaped narrative. All narratives were transcribed verbatim, and returned to participants who corrected/changed them if they wished. Completed narratives were analysed thematically using NVIVO. A short summary of the analysis was circulated to participants, inviting further comments/feedback. The analysis was reviewed in response to feedback. Results: We recruited 21 carers and 20 PWD. All the PWD chose to make audiotapes in conversation with one of the team. Two carers wrote their own narratives, and the remaining carers were audiotaped. Five couples chose to be interviewed jointly; one couple opted to be interviewed separately. A number of important themes were identified, some more patient-focussed, others more carer-focussed. Conclusions: (1) Services need to think about how they support people through the process of getting the diagnosis and make sure that they have a contact person to support them. (2) Health and social care services should look at ways to build in feedback loops so that they get regular routine feedback from the people using their services and continually review what they are doing. (3) PWD and carers need an ongoing contact from diagnosis onwards.
(4) The need to enjoy life is something that services need to recognise and support. Some people (users and carers) will need help to find new things they can enjoy because their life has changed or help to carry on doing things that are important to them. (5) families, friends and the public need to be able to learn more about dementia and to have support in dealing with it. (6) Services need to review how they provide continuity to their service users. (7) Producing a narrative can be a valuable experience for users and carers. It allows people to talk and to make sense of their experiences. This could be incorporated into routine practice.
History of depression in Alzheimer's disease and vascular dementia verified, post mortem Ulla Passant a , Elisabet Englund b , Hans Brunnstro¨m b and Lars Gustafson a a Department of Geriatric Psychiatry, Lund University, Lund, Sweden; b Department of Pathology, Clinical Sciences, Lund University, Lund, Sweden Objective: We studied the possible association between a history of depression and an increased risk of later developing dementia. A number of studies have shown a significant association between a history of depression and increased risk of developing dementia while other studies have not found any significant correlation. Methods: 201 patients with neuropathologically verified dementia, Alzheimer's disease (AD), (n ¼ 115), Vascular dementia (VaD), (n ¼ 44) and mixed AD/VaD (n ¼ 42) were included in the study. All were previously followed-up with clinical records and detailed information on prior psychiatric history, before the onset of dementia. The psychiatric history focused on the time from early adulthood until dementia onset. The patient's age at the time of depression, psychotic symptoms, treatment, outcome, duration and possible significant events related to a depressive episode were registered. Result: 20 patients (10%) were found to have had one or several depressive episodes earlier in life, well before dementia onset. 9/115 AD patients, 9/44 VaD patients and 2/44 patients with mixed dementia had a history of depression. The main findings were that the AD and VaD group differed in many aspects. All nine AD patients, with one exception, had suffered from only one specific episode of depression, all responding well to treatment, recovering completely and returning to work. In the VaD group all patients but one suffered numerous depressive episodes and only two recovered completely.
Age at dementia onset in the total AD group was 65.7 years while for those who had a prior history of depression 58.8 years. In the total VaD group age at dementia onset was 70.1 years and did not differ from the group who had a history of depression. Conclusion: The prior history of depression differs markedly between the AD and VaD patients. The causes behind these differences are not obvious and need to be further studied.
What causes a crisis for people with dementia and their carers? Ritchard Ledgerd a , Juanita Hoe b , David Challis c , Sandeep Toot a and Martin Orrell b a North East London Foundation NHS Trust, London, UK; b Mental Health Science Department, University College London, London, UK; c School of Medicine, University of Manchester, Manchester, UK Objective: To rank the factors most likely to lead to crisis for people with dementia and interventions most likely to prevent and be useful in a crisis. Methods: An online questionnaire was developed to pursue the research objective. Factors considered most likely to cause a crisis were grouped into five domains. Respondents were asked to select the top 50% of factors that they considered most likely to cause a crisis for people with dementia.
Interventions were grouped into four domains, respondents were asked to select whether they thought the interventions were useful or preventative in a crisis.
The online questionnaire was available from November 2010 to January 2011 and circulated through national carer networks, charity/voluntary organisations, health and social care professional bodies, academics and through 1:1 interviews with people with dementia. Results: 719 people completed the questionnaire including 562 healthcare practitioners, 54 carers and 4 people with dementia. 99% of responses were completed online.
The top ranked causes of crisis were; wandering, falls, inability to identify potential risks, carer burden, physical hazards around the home.
Top ranked interventions likely to be useful in a crisis were; access to healthcare professionals, communication equipment, immediate provision of care and access to respite in the home.
Top ranked interventions likely to prevent a crisis were; referrals being made earlier, maintaining daily living tasks, specialist training for home care staff, family carer education. Discussion: The use of online technology formed an important part of the results. Sensitivity analysis was conducted on responses healthcare professionals employed in different clinical settings to detect any bias. A ranked list of causal factors was generated. There was a distinction between how respondents ranked interventions as being useful in a crisis and preventative in a crisis, indicating the importance of certain interventions in particular situations. Conclusion: The study achieved its objective of ranking, in order of importance, the factors most likely to cause a crisis for people with dementia in addition to identifying the interventions that were most likely to prevent or be most useful in a crisis. ProFamilies-dementia is a psycho-educative programme developed for families of people with dementia, aiming at promoting a healthy adjustment of the family to the disease. It was developed in six sessions (one per week, 90 minutes each) in multi-family discussion groups. This presentation aims at describing how to develop a psychoeducative programme for families of people with dementia, based on proFamilies-dementia. Specifically, it aims at relating the main difficulties associated to its implementation procedures and methodologies, as well as the most relevant aspects for its success and effectiveness.
This study involved three researchers (the authors), who have developed, implemented and evaluated proFamilies-dementia. An ethnographic methodology was used, with the support of the following investigation techniques: (i) field notes (including the place and time of the observation); field diaries (including activities, observations and interpretations); SWOT analysis (Strengths, Weaknesses, Opportunities and Threats). After the end of the programme, the researchers met to discuss their notes and interpretations, until agreement was reached.
The most relevant aspects identified as facilitators to the effectiveness and success of the programme were: (i) the analysis of needs/expectations of participants and their suitability to the initial objectives of the programme; (ii) the role of the facilitator and the importance of collaborative approaches; (iii) the non-use of new technologies in the sessions. On the other hand, the main difficulties were: (i) the time needed to wait until the project get approved by the Ethics Committee; (ii) families' drop-outs due to lack of identification with the condition; (iii) some families don't participate because they don't feel comfortable leaving the elderly alone (even if the programme assures a service that provides a health professional, on a voluntary basis, to stay with the person); (v) time management (families talk a lot and are keen to share their experiences).
In general, proFamilies-dementia can be implemented in a simple way, particularly because it is a low cost programme. However, it seems relevant to: give more time for families to share (even if it questions the assumption of sessions' structure); include someone who has participated in the programme to encourage families and avoid drop-outs; promote the setting prior to the families, people with dementia and volunteers so that they could feel more comfortable about leaving their families and participate in sessions.

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Of mothers and daughters aging Karen Gershman Dartmoth Medical School, Director Geriatric Fellowship Maine-Darmouth Family Medicine Residency Program Augusta, Maine, USA Objective: To teach Family Practice Residents about crucial moments in a family's journey in dealing with demented family members by using a film of their own teacher and her aging parent. Methods: We used a twenty-minute award-winning filmed interview to demonstrate a critical conversation regarding the decision to have a demented parent move into an adult child's home. A retired professor suffering from memory loss converses with her daughter, a physician (myself) on what comprises resilience. Resident responses to the film were collated and analysed. Results: Resident comments revealed educational themes spanning characteristics of cognitive deficit, interview techniques, to systemic approaches to geriatric care, and personal life lessons. Discussion: Residents and fellows have used this film to test their knowledge of the stages of Dementia, and to refine their techniques of validation therapy. The film helped them to conclude that system-based change that does not emphasize time for person-to-person conversation is short sighted. That perhaps staffing change in all settings of geriatric care is the most pressing of issues facing medicine. There are life lessons to be learned in the most unexpected circumstances. Despite short -term memory loss, patients can teach us all. They carried away with them the conviction that the cultivation of contentment, gratitude, and loving kindness enhances us as human beings as well as physicians. Conclusion: There are moments, as a family travels down the tributaries of human need, where frail elders exemplify a stunning resilience. It is these ephemeral transitions, once captured on film, that become touchstones, as we ford the turbulent waters together. The medium of video captures split-second changes in expression. The camerawoman, a first year resident, catches close-ups on the fly, the rough camera angles adding to its authenticity. This is not a slick production; it is a resident's glimpse into the intimate life of her teacher as she shares her vulnerability. Personal sharing on the part of a teacher can open profound conversation, and provide insight for learners. My mentors have taught me that teaching requires a commitment to vulnerability. Aims: The acknowledgment of the etiological complexity of disability, shown in daily living activities and with long term effects at the individual level, as well as research on risk factors and functional impairment predictors, highlights the relationship between functionality and cognitive impairment. Some disability models suggest that physical and cognitive impairment, when acting together, they make older people vulnerable to events that precipitate dependency or disability. Given the important contribution of neuropsychiatric diseases for the global burden of diseases, it can be expected an increase in the number of years lived with mental and physical disability, due to the demographic aging. Objectives: To assess cognitive status and functional dependence, and to identify socio-demographic (age and years of education) and clinical variables (diagnosis and years of hospitalization) that better define and explain those two dimensions. Methods: Cross-sectional study with female inpatients in psychogeriatrics settings (n ¼ 510), assessed with MMSE and Mini Dependence Assessment. Results: The four pathologies with the highest prevalence were dementia, schizophrenia, affective psychosis and mental retardation. The majority of subjects is in the age group of 65 to 74 (44.8%); is illiterate (59.9%); is institutionalized for more than 10 years (53.5%); has cognitive impairment (80.8%) and mild functional dependency (40.7%). Age only correlates and predicts cognitive status of schizophrenic patients, and only predicts functional status of patients with mental retardation. Education correlates with cognitive status in the four groups, but it only presents a very significant and predictive association in dementia and in schizophrenia. Education predicts functional status in all groups. Duration of hospitalization does not predict cognitive and functional results. All groups have a very significant correlation between cognitive and functional status. Loss of mobilization capability predicts cognitive status in schizophrenia and emotional and behavioural disorders or changes predict cognitive status in affective psychosis. The average cognitive level of mental retardation or affective psychosis is not significantly different from schizophrenia. Conclusion: We were able to identify the impact of different major mental disorders on cognitive and general functioning, which provides new evidence to support differential approach in long term care. Objective: To explore the role of self-efficacy (SE) on the health related quality of life (HrQoL) of family carers of a relative with dementia. Methods: A literature search of multiple electronic databases from 1980 to June 2011 was performed, supplemented by a reference search of included articles and a forward citation search. A broad range of both qualitative and quantitative studies, including cohort, longitudinal and cross-sectional studies were considered. The participants included were family carers, supporting a relative with dementia. Search terms related to caregiving, self-efficacy, quality of life, and dementia. A narrative synthesis approach was adopted to synthesise findings, whilst qualitative findings underwent a thematic analysis. Results: Sixteen studies were included; ten quantitative, four qualitative studies and two reviews. Studies were primarily cross-sectional correlational designs conducted within the US or Canada. The total sample comprised 2029 family carers of people with dementia. The studied populations were predominantly female, Caucasion, with a mean age of 60 years and mean caregiving duration of five years.
As expected, research findings were indicative of a positive association between SE and family carer HrQoL, across a range of contexts, relationship-types and ethnicities. The thematic analysis of qualitative findings revealed three recurrent themes concerning the role of SE; the development of novel skills, role identification and feelings of personal accomplishment, which greatly corresponded with feelings of satisfaction, pride, a sense of meaning, and thus wellbeing. Discussion: Findings are indicative of both a moderating and mediating role of SE in family carer HrQoL. Furthermore, research evidence suggests the existence of an independent positive and negative pathway, particularly there is a great deal of evidence demonstrating the role of SE in the positive aspects of caring, such as satisfaction, carer gain, finding meaning and positive affect. Finally, findings demonstrate the need to explore the role of SE in caring using a longitudinal analysis. Conclusion: Further research into SE in family carers could be instrumental in identifying interventions to improve HrQoL in carers.
Could this be a country for old men? The society's influence in suicidal behaviour in late life Joana Andrade Member of the Psychogeriatric Clinic team, Hospitais da Universidade de Coimbra, Coimbra, Portugal Suicide in elders is a serious problem for societies. Data on self-destruction in elders are very high, the ratio between attempts and completed suicides is very close, almost 2:1. Moreover, recent studies point to a consistent set of risk factors for the spectrum of suicidal behaviours in late life: psychiatric and/or physical illness, pain, functional impairment and social disconnectedness. We suggest the use of the Interpersonal Therapy of Suicide as a framework for clinicians to use in daily practice in order to evaluate the possible psychological effects of the presence of risk factors. Also, after a review of the most recent literature, we show that promotion of connectedness is a key-element in all successful preventive interventions so far. Objective: There has been a lack of appropriate environmental, sensory and social stimulation for institutionalized residents with dementia. Multisensory and motor stimulation have shown promising results in promoting communication, functionality and self-care, reducing anxiety and increasing interactions in residents with dementia however, studies are still scarce. This pilot study aimed to evaluate the impact of a multisensory and motor stimulation programme on the behaviour of institutionalised residents with dementia. Methods: Four institutionalised participants (two female, mean age 81.5 AE 8.58 years old) with moderate to severe dementia, according to the DSM-IV criteria, were recruited from one residential home. The multisensorial and motor stimulation programme was composed by sixteen thematic group sessions (e.g., beach, gardening, music . . .), conducted once a week for approximately 45 minutes. Each session was composed by specific and structured activities directed to active stimulate movement and each sense (olfaction, movement, contact, vision, audition and taste). Data was collected by video-recording all sessions. The impact of the programme on residents was assessed by analysing the duration of a list of behaviours (ethogram) in all sessions. Resident's behaviours were rated by two independent observers, which analysed 17.53 minutes of each of the 16 video recordings, with specialised software, Noldus. The Observer XT 7.0. Results: On average, residents engaged with the tasks 5.96 AE 3.96 minutes, interacted with the objects 0.61 AE 0.69 minutes and communicated verbally 1.55 AE 1.09 minutes. It was also observed across the 16 sessions that participants engaged, interacted and communicated more or less according to the theme of the session. Discussion: The findings suggest that despite the advance stages of dementia, with multisensorial and motor stimulation in organised and structured group sessions, it is possible to have residents engaging, interacting and communicating, thus potentially improving their well-being and quality of life.
However, these promising results are limited by the pilot nature of the study. Therefore, it is recommended to implement such programmes in larger samples and several institutions in controlled study designs. Conclusion: Multisensorial and motor stimulation programmes implemented in organised and structured group sessions may be a promising approach to promote adequate residents' engagement, interaction and communication, improving the quality of dementia care and the well-being of residents. Objective: To identify factors which lead to a crisis for people with dementia and their carers, and identify interventions which could help in a crisis. Methods: Qualitative study using focus groups to compare the perspectives of people with dementia, family carers and healthcare professionals on causes of crises and crisis interventions. Eighteen people with dementia, 15 family carers and 19 healthcare professionals were identified from nine community settings from London and the south east. Results: In terms of causes of crises, people with dementia focused on risks and hazards in their home, whereas family carers emphasised carer stress and mental health problems. Staff in contrast were concerned about problems with service organisation and coordination leading to crises. Physical problems were less commonly identified as causes of crises but when they did occur they had a major impact. To help in a crisis, people with dementia were keen on support from family and friends, access to mobile phones, and home adaptations to reduce risks. Carers were keen on assistive technology and home adaptation. Both carers and staff valued carer training and education, care plans and well coordinated care. Staff were the only group emphasising more intensive interventions such as emergency home respite and extended hours services. Discussion: This is the first paper to explore the views of a diverse range of stakeholders involved in crises with people with dementia. Crises faced by people with dementia and their families are complex and the challenges in providing support in crises are profound. Interventions needed to be flexible and tailored to both the individual person's needs and their crisis. The findings from this study supports the case for the involving services users and carers in research and service planning. Conclusions: People with dementia and family carers were aware of their needs at times of crisis and were able to identify useful interventions. Practical and low cost interventions such as home adaptations, assistive technology, education and training for family carers, and flexible home care services were highly valued by service users and their families during times of crisis and to help prevent hospital admissions. Visuoconstructive function, generally understood as the capability to copy or draw and construct forms and figures, is one of the first areas that are affected in patients diagnosed with Dementia of the Alzheimer Type (DAT), even in early stages. Although the assessment of this function may be useful because of its sensibility and capability to predict the different stages of DAT, we observed that there is no criteria unanimity for the application and interpretation of results obtained in the existing visuoconstructive tests, given the fact that this function sustains itself with the functioning of different processes (visuoperception, integration, planning, attention and memory) that may be affected to a greater or lesser extent in the different stages of Alzheimer's Disease. Objective: To develop an increasing difficulty evaluation test to assess the visuoconstructive function that includes differential aspects for the instructions (draws on verbal command and on copy), symbolic representativeness (draws with symbolic-semantic representativeness vs. abstract draws) and complexity (draws with simple and complex tracings). Methods: Experimental group 1: 25 patients with probable DAT and mild dementia (CDR1). Experimental group 2: 12 patients with probable DAT and moderate dementia (CDR2). Control group: 25 individuals without a cognitive affectation, comparable in age, sex and education. Results: Patients with DAT present serious difficulties to integrate components of superimposed geometric forms although they can use mental representations to integrate parts of a familiar drawing in comparison to non-familiar drawings. Conclusion: We observed that scores obtained in the copy of figures in the increasing difficulty visuoconstructive test allows us to predict the grade of severity of dementia in patients with Alzheimer's Disease. Besides, these results have a straight correlation with the functional state of patients allowing us to predict the grade of functional dependency of patients with DAT. On the other hand, we consider that to evaluate the visuoconstructive function in neurodegenerative processes coursing with dementia, we should use tests that are sensible to the evolution of the clinical profile. association also in non clinical populations, being depressive symptoms more frequent among those who score less in MMSE. Conclusion: Depression and cognitive functioning are associated among elders. Background: Delirium is a common condition in the elderly (affecting up to 30% of inpatients) and has been associated with serious adverse outcomes (Cole et al., 2009). However, it is often poor recognized, due in part to the lack of a clinical assessment with suitable screening instruments, mainly in elderly people hospitalized with risk factors (Young et al., 2010).
The Confusion Assessment Method/CAM (Inouye et al., 1990) is a widely used delirium screening instrument, based on Diagnostic and Statistical Manual III-R (APA, 1987) criteria. It can be readily applied in routine clinical settings by non-psychiatric medical or nursing staff. Aim: To present the translation and cultural adaptation process of the Portuguese version of CAM -nine items, according to guidelines suggested by The Translation and Cultural Adaptation group -TCAG of International Society for Pharmacoeconomics and Outcomes Research -ISPOR (Wild et al., 2005). Methods: The translation process of CAM was doing according the following eight steps: preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing and review of the cognitive debriefing results/finalization. The inter-rater reliability of Portuguese CAM version was tested in a sample with elderly patients (460 years), within 24 h after admission in two sub-intensive care units (Emergency and Surgical Services) of S. Joa˜o Hospital. Patients in mutism or who scored !11 in the Glasgow scale were excluded. Results: The CAM was successfully translated by the Portuguese team, which met several times to allow reflection and consensus of the instrument's contents and structure. For inter-reliability assessment, 20 elderly patients were included, 20 paired tests were carried out, and 40 CAM instruments were completed. Overall inter-rater reliability was very good (Kappa 4 0.81) between researchers. Conclusion: This translation showed a good correlation with the original English version developed by S. Inouye, and could therefore, be applicable in Portuguese Emergence and Surgical Services. Overall the inter-rater reliability was very good. However there are some limitations, mainly because sample size.
The present work is supported by FCT (Foundation for Science and Technology) PhD fellowships (SFRH/BD/ 63154/2009 -S. Martins) Objective: This study aims to understand the process of adjustment of caregivers of people with Alzheimer's disease (generally and in specifying types of caregivers and care), through the relationships established between coping strategies, psychosocial variables, including: Anxiety, Depression, Stress, Satisfaction with Perceived Social Support, Quality of Life, Self-efficacy and socio-demographic variables. Methods: It is a comparative study and correlation between formal (technicians and no technicians) and informal caregivers (n ¼ 450) who will fill the Brief COPE, the SF-36, Anxiety and Depression Scale Stress, the Scale of Satisfaction with Social Support, Self-Efficacy Scale for Caregivers of People with Dementia (adaptation and validation into the Portuguese population) and a Questionnaire Socio-Demographic purpose built. Results and Discussion: The results obtained allow us to see the need to establish intervention strategies, among caregivers, that promote interpersonal relationships, social activities and increase self-perceived physical and mental health. On the other hand, interventions should focus on the use of positive coping strategies and coping strategies based on humour. Conclusion: With this presentation, we intend to establish intervention strategies that can provide caregivers with skills for more appropriate adjustment processes in order to a greater adaptability to the Alzheimer's disease and to the role of caring.
Will also present the correlations found between the different variables for each of the study groups (family, technicians and no technicians -supporters/helpers of direct action).
Adopting photovoice to capture the clinical significance of proFamilies-dementia Sara Guerra a , Daniela Figueiredo b and Liliana Sousa a a Department of Health Sciences, Universidade de Aveiro, Aveiro, Portugal; b School of Health, Universidade de Aveiro, Aveiro, Portugal Literatures present a high number of interventions aiming at supporting the people with dementia and their families. However, little attention has been given to how evaluation methods should be designed to support the goals of families and individuals empowerment. To address these issues, new approaches and evaluation methodologies have been developed; in particular, participatory evaluation methodologies such as PhotoVoice have been recently recognized as a powerful way to ongoing reflection, critical to fostering an empowering process (e.g., Keiffer, 1984).
This study used the photovoice (Wang & Burris, 1994) to evaluate the impact of a psycho-educational program (proFamilies-dementia) designed to support families caring for an elderly person with dementia. It aims to explore the potential of this innovative methodology in the assessment of intervention programs impact.
ProFamilies-dementia is a program developed in six sessions (one per week, 90 minutes each) in multi-family discussion groups, comprising two dimensions (educational and supportive). The program was evaluated using a technique based on photovoice, which is a method of collecting and analysing qualitative data using photos and voice.
Following the last psycho-educative session, all the families (five, in a total of six participants) were provided with disposable camera and were asked to photograph, during the next three months, the impact (positive and negative aspects) of the program. At the end of this period, the families met to discuss the meaning of the photographs taken.
Families' photos, stories and discourse reveal that main benefits of the program were: emotional management improvement; more family closeness; increased ability to seek the positive aspects in the situation; increased ability to ask for help; better understanding of disease; share and normalization of experiences and fears; increased awareness of the self-care importance.
ProFamilies-dementia seems to responds to the needs of families, in particular by facilitating the process of going beyond the focus on illness, negativity and loneliness. Photovoice appears to be a useful method for capturing and extending this process, by facilitating participants' engagement in an ongoing reflection process about their experiences. It provides in-depth data and the potential for bringing out additional information that might not emerge during traditional interviews. Objectives: The aim of the present study is to identify the main met and unmet needs, as well as main nursing focuses and to analysis the relationship between psychopathology and functionality in older people with mental health problems.
This pilot-study is integrated in a major project about 'The needs of older people with mental health problems', included in the Doctoral Program in Gerontology and Geriatrics ICBAS-UP. Methods: An elderly sample (over 65 years), of both sexes, diagnosed with mental disorder, according to the ICD-9 (International Classification of Diseases), was recruited consecutively from the National Health Service, the Psychiatric Service of the Department of Psychiatric and Mental Health (DPSM) and Local Health Unit of Alto Minho (ULSAM, EPE) The following instruments were used for assessment: Camberwell Assessment of Need for the Elderly/CANE (Reynolds et al., 2000), Mini Mental State Examination/MMSE (Folstein et al., 1975), the Clock Draw Test/CDT (Shulman et al., 1986), Geriatric Depression Scale/GDS (Yesavage et al., 1983), Zung Anxiety Scale/ZAS (Zung, 1971), Barthel Index/BI (Mahoney et al., 1965), Lawton Index/LI (Lawton et al., 1969) and Graffar's Social Classification/GSC (Graffar, 1956). Results: The majority of the sample of 75 elderly patients was female (74%) and married (49%). There was a predominance of low socio-economic level (95%) (according to the GSC).
The main unmet needs found were: daytime activities, social benefits, company, psychological distress, incontinence, household skills, food and self-care.
The evaluation of these elderly patients identified neuropsychological and functional problems. Most of them had cognitive impairment assessed by MMSE (52%) and by CDT (66%). According to GDS, they also had high levels of depression (63%), which was confirmed by psychiatric diagnosis, as well as anxiety (82%), assessed by ZAS.
Related to daily living activities, dependence in both, basic (58%) and instrumental (60%), was found. Regarding caregivers, they showed psychological distress (53%) with inevitable implications in care of the elderly. Conclusion: The higher prevalence of depression found in the present sample, as well as in the caregivers, will have inevitable consequences in the type of unmet needs founded. However, the analysis of this relation should be clarified.
This preliminary data will point into stimulating activities and development of social skills in older people, taking into account reduction of negative feelings, such as depression and improvement in quality of life of these patients and their carers.
Aroma and music therapy in psychiatry -the relevance of the Kulliye of Sultan Beyazid II Aykan Pulular Psychiatry Department, Bergama, Turkey Although I was asked to talk about the use of aroma & music therapy, I thought that it would be more interesting if, as a Turkish psychiatrist who worked for some years in the city of Edirne, I should tell you instead about the Kulliye of Beyazid II which is of interest in this context.
The city of Edirne, located some 200 kilometres from Istanbul at the borders with Bulgaria & Greece is a charming one. It was the second capital of the Ottoman Empire after Bursa & before Istanbul.
Apart from having what is probably the best & largest Sinan mosque built when the architect was in his 80s, it has the remarkable complex of Kulliye II built in 1488. The consisted of a small mosque, a madrassa (medicine school), a general hospital (dar el cheffah) & a lunatic asylum(timarhane). It now belongs to the University of Trakia which has transformed it into a medical museum, which was awarded a prize for the best medical museum by the Council of Europe in 2004.
The treatment employed in this asylum is of interest to us today. Patients were treated very humanely & seldom restrained. It is said that when this was necessary very fine sliver or golden chains were used. The main forms of treatment were the exposure to music, the sound of running water& the smells of fragrant plants such as jasmine, carnation & sweet basil.
This has resemblances to the use of some forms of 'alternative therapy' apparently in use today. We do not know how beneficial this was but it contrasts markedly with the barbaric approaches employed in supposedly more advanced countries in other parts of the world. Background: Hypertension is one of the main cardiovascular risk factors (CVRF), being very prevalent in the elderly. The benefit of its treatment is clear but maybe a cause of iatrogenesis. Ambulatory blood pressure monitoring (ABPM) presents greater validity, reproducibility, and provides a better predictive value for cardiovascular events than clinical blood pressure (BP) measurement. ABPM is also associated with cognitive function (high nocturnal systolic blood pressure level, non-dipper status, and exaggerated BP variability are all suggested to be significant determinants of cognitive impairment); nocturnal hypertension and non-dipping pattern are also associated with increased cardiovascular risk -its correction, if not excessive, has a positive impact on cardiovascular outcome. Yet, this is still controversial in the elderly. Depression and anxiety, which are associated with increased cardiovascular morbidity and mortality, and lack of adherence to antihypertensive treatment, may influence this process.
Objectives: This study aims to determine, in ambulatory elderly patients with hypertension: the prevalence of different subgroups of BP defined by ABPM; whether these subgroups differ in: CVRF defined by ESH/ESC (2009), profiles of cognitive deterioration and psychological variables -depression and anxiety, rates of CV event, postural hypotension and utilization of hypertensiogenic drugs. Methods: This is a cross-sectional observational and analytical study of the results of clinical BP, records of the ABPM and laboratory and clinical variables in patients over 65 years (new or already diagnosed hypertensive patients), in the Primary Health Care Centre of S. Joa˜o in Oporto.
Expected results: A percentage of white-coat hypertension (WCH) of 38% or more; a higher prevalence of CVRF and possibly CV events in true hypertensive in relation to WCH patients; a higher prevalence of CVRF, CV events, postural hypotension, a worse score in the assessment of cognitive function as well as in depression and anxiety in those patients with ABPM profiles considered to be of worst prognosis (non-dippers, reverted-dippers and extreme-dippers). Discussion/conclusions: The present study could contribute to a demonstration of the importance of ABPM as a crucial instrument of a comprehensive geriatric assessment with a positive impact on cardiovascular disease, cognitive impairment, depression, anxiety and in order to prevent iatrogenesis.