Severe behavioural and psychological symptoms of dementia (BPSD), associated with risk to self and others, often necessitate urgent intervention. Despite well-documented risks, antipsychotics remain frequently prescribed for these symptoms, reflecting complex influences on prescribing decisions. This review critically explores these challenging contexts, including difficulties in defining severe BPSD, conflations and limitations of current evidence and clinical guidelines, and legal and policy frameworks that shape care. This article advocates the adoption of alternative paradigms, notably palliative approaches, to address the considerable distress associated with severe BPSD, while remaining attentive to sociological critiques. Its broader aim is to stimulate discussion on the development of more humane and holistic models of care in this challenging area of older adult psychiatry.

Agitation and psychosis are two common distressing symptoms of dementia. The results of this issue's Cochrane Corner review suggest that, if a pharmacological approach is required, the use of risperidone and other atypical antipsychotics for the purpose of managing these symptoms seems questionable. Furthermore, typical antipsychotics, haloperidol in particular, might have a greater impact on agitation and psychosis than already recognised. This commentary critically appraises the evidence on the efficacy of typical and atypical antipsychotics for agitation and psychosis in dementia.

The National Institute for Health and Care Excellence (NICE) informs us that the first-line treatments for behavioural and psychological symptoms of dementia (BPSD) are non-pharmacological. Although psychotropics used to be the main strategy in the management of behaviours that challenge, there has been an increase in the use of biopsychosocial formulations since 2010, and there are now over a dozen to choose from. However, many are overly focused on obtaining information about the agitation, and less specific about providing details of the actions required to manage the behaviours. The NICE guidelines too fail to provide specific guidance on which non-pharmacological approaches to use. This article argues for giving equal weight to both the collection of meaningful information and the development of ‘informed actions’, because it is the actions that lead to change. The article outlines a management programme providing a framework for the assessment, formulation and treatment of agitation in dementia. The work draws on theory, evidence-based practice and practice-based evidence to provide a model with sufficient structure and flexibility to be useful for clinicians across a range of settings and professional groups.

The article reviews some basic statistical concepts used in medicine, including the mean, standard deviation, sensitivity and specificity. Using this background the authors describe how these can be applied to cognitive tests, taking the Montreal Cognitive Assessment (MoCA) as an example. Two different approaches to using the MoCA in diagnosing dementia are considered: one using a fixed cut-off score, the other taking account of normative data about the effects of age and educational level on MoCA scores. It is recommended that clinicians assessing cognitive function should not rely on a fixed cut-off score, but where possible compare the patient's result with those of people of comparable age and educational background, although normative data of this kind are not always available.

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

There is urgent need to search for a dementia treatment that can delay its progression and reduce its financial and societal burden. Despite lacking evidence, there is a large number of commercial brain-training products on the market that claim they improve cognition. The Cochrane review under consideration looks at whether cognitive training maintains or improves cognition in those with mild to moderate dementia compared with control and alternative interventions. This commentary puts its findings into clinical perspective.

Alzheimer's disease and vascular dementia are the two most common types of dementia. It becomes difficult to distinguish between the two, especially when there are no specific genetic causes or vascular changes apparent. The aim of this review was to identify specific biomarkers supporting the diagnosis of vascular dementia by conducting a literature search for systematic reviews and observational studies. We found seven studies meeting our inclusion/exclusion criteria, and from these we identified four specific biomarkers supporting the diagnosis of vascular dementia: high levels of thyroid-stimulating hormone, lipoprotein(a), homocysteine and N-terminal prosomatostatin. However, the studies were small and a well-conducted study with larger populations is recommended to strengthen the evidence base.

This is an overview of epidemiology relevant to mental health problems in old age. We start by reviewing some basic terminology: the definitions of prevalence and incidence; the difference between descriptive and analytical epidemiology; the differences between study designs, including cross-sectional, case–control and cohort studies. We then cover the main epidemiological features of the major psychiatric diseases that affect older people (dementia and its different types, depression, late-onset schizophrenia, bipolar affective disorder, delirium, anxiety-related disorders, eating disorders, alcohol and substance misuse, personality disorders) and suicide.

We end with some descriptive statistics regarding quality of life in older people.

As we age, there are characteristic changes in our thinking, reasoning and memory skills (referred to as cognitive ageing). However, variation between people in the timing and degree of change experienced suggests that a range of factors determine individual cognitive ageing trajectories. This narrative review considers some of the lifestyle factors that might promote (or harm) cognitive health. The focus on lifestyle factors is because these are potentially modifiable by individuals or may be the targets of behavioural or societal interventions. To support that, the review briefly considers people's beliefs and attitudes about cognitive ageing; the nature and timing of cognitive changes across the lifespan; and the genetic contributions to cognitive ability level and change. In introducing potentially modifiable determinants, a framing that draws evidence derived from epidemiological studies of dementia is provided, before an overview of lifestyle and behavioural predictors of cognitive health, including education and occupation, diet and activity.

Shortcomings of randomised controlled clinical trials include their high cost, which often precludes very long-term studies and very large populations, and ethical constraints of randomisation. Observational studies are a valuable alternative and we outline their use in epidemiological research to study very long-term effects of lifestyle and medication on dementia, to explore (using Mendelian randomisation) the association between Alzheimer's dementia and individual traits, and to evaluate population-wide health inequalities and lifespan changes in risk factors for psychiatric illness.

This article explores the intersection of neurology and psychiatry in the assessment of psychosis. It provides a practical overview of neurological disorders associated with psychosis, including epilepsy, autoimmune encephalitis, neurodegenerative dementias, Parkinson’s disease, Huntington’s disease, Creutzfeldt–Jakob disease, cerebrovascular disease, traumatic brain injury, brain neoplasms, multiple sclerosis and genetic neurodevelopmental syndromes. Accurate diagnosis requires recognising clinical red flags and adopting a multidisciplinary approach that integrates psychopathology, neuropsychology, neuroimaging, electrophysiology and biomarker analysis. Treatment strategies vary according to aetiology and may include antipsychotics and others pharmacological resources, immunotherapy, neuromodulation and behavioural interventions.

There is a widening gap between the medical model of dementia and critical sociological perspectives of the condition. Given the relative failure of reductionism in dementia and its rising prevalence, consideration of the utility of these critical viewpoints is warranted. This article considers how these ideas, which challenge some prevailing assumptions about dementia, can be meaningfully applied in conjunction, rather than in competition, with conventional clinical ideas. To illustrate this, current perspectives on selfhood, biopolitics, citizenship and post-humanism are discussed. This article may also help to articulate sociologically oriented approaches already used by some clinicians and legitimise the time and attention needed to explore and deliver these. We support the view that dementia is an episteme in the making and that different traditions and dispositions can fruitfully collide to enliven interdisciplinary conversations about dementia and dementia care.

The COVID-19 pandemic significantly increased the challenges faced by families affected by dementia, leading to an immediate increase in both the number of calls received by Dementia UK's Admiral Nurse Dementia Helpline and the levels of distress and complexity of the calls. Consequently, Admiral nurses experienced feelings of helplessness, echoed in the experiences of other health professionals. One of the approaches that enabled Admiral nurses to cope during this time was ‘hope’, and this article explores the use of hope-based approaches as tools for working therapeutically with families during the pandemic. Although written from the perspective of Admiral nurses, the approaches described are transferable to others working across health and social care. The article provides an overview of one of the main models of hope in the healthcare literature, Snyder's hope model, and explores the literature on hope more widely. Fictitious case vignettes, drawn from clinical practice during the pandemic, are used to illustrate how hope-based approaches can be applied to practice.

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

It has been common clinical practice for staff members to make an application to a mental health tribunal (the First-tier Tribunal (Mental Health) in England or the Mental Health Review Tribunal in Wales) on behalf of a patient detained in hospital for psychiatric treatment who may lack capacity to make that application, for example in dementia in-patient settings. Following a series of cases in the Upper Tribunal, such practice may not be appropriate and there is now a risk that the application will be struck out. It is important that clinicians are aware of developments in case law and therefore we provide guidance on how clinicians should approach applications to the tribunal and the assessments of capacity that may be required.

This article aims to clarify what ‘care closer to home’ means to a community psychiatrist. Care closer to home can be operationalised as primary care liaison and the article reviews experience across England of how a liaison service can work with the recently organised primary care networks. Key competencies needed for liaising with primary care are discussed using seven questions, including bias mitigation, reducing bed-days, consultation skills, knowledge of emerging treatments and reducing administrative overheads while improving access.

Antipsychotics are commonly prescribed to manage the behavioural and psychological symptoms of dementia (BPSD) despite their modest efficacy and significant adverse effects. Psychosocial interventions are recommended as the first-line approach in treating BPSD before considering pharmacological options. A Cochrane Review by Lühnen et al (2023) evaluated the effects of psychosocial interventions on reducing antipsychotic prescription in care homes, and found that no generalisable recommendations can be made based on the currently available evidence. This commentary attempts to critically appraise and add context to the review.