Despite the enormous amount of literature on medical care of older people, personality disorders in late life have been given little attention. Clinicians tend not to assign this diagnosis to older adults in view of limited research into, and therefore limited awareness of, this topic. This article aims to promote better understanding of this subject in view of the growing population of older people and hence an expected increase in the number of personality disorder cases.

Bright light therapy is an accepted and commonly used treatment for seasonal affective and circadian rhythm disorders. In the past 20 years, researchers have examined the effectiveness of bright light therapy in improving depression and agitation in older adults with dementia. This article provides clinicians with a summary of the neurophysiology of bright light therapy, bright light research considerations, an evidence-based bright light protocol, problems related to bright light therapy, and clinical implications for bright light therapy in older adults with dementia. Bright light exposure is a safe, non-pharmacological treatment that is currently underutilised in this population. Clinicians may find bright light therapy beneficial as a primary or adjunctive treatment in reducing depression and agitation in older adults with dementia.

A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.

Stratified medicine has been successfully used in many areas of medicine, perhaps most notably oncology. There is now both a growing evidence base and mounting enthusiasm, supported at a governmental level and across industry, academia and clinical medicine, to apply this approach to neurodegenerative illnesses, including dementia, as these provide the greatest clinical and social challenge of our times. In this article we consider definitions of stratified medicine, look at its application in other medical specialties, review the national context in the UK and consider the current state, future potential and specific considerations of applying stratified medicine to dementia.

Dementia is a progressive and irreversible deterioration in cognition that has a significant impact on the person’s activities of daily living and quality of life. Currently, there is no curative treatment for dementia, and the treatments used in clinical practice have limited therapeutic reach. We begin this descriptive review with a discussion of apolipoprotein E4 (apoE4) and its role in the pathogenesis of dementia. We consider the molecular involvement of statins and why they are no longer clinically indicated in mild cognitive impairment or mild to moderate dementia. We then explore the evidence regarding the effects of statins and cyclodextrins on apoE4, presenting evidence in support of and against their neuroprotective effects in cognitive impairment. Although the studies on cyclodextrins have all been on animals, they provide a strong background for a potential research hypothesis for future clinical trials in the treatment of dementia.

In 1978, William Alwyn Lishman's Organic Psychiatry: The Psychological Consequences of Cerebral Disorder was published, fostering the development of neuropsychiatry and leading to the recognition of Lishman as the father of neuropsychiatry. This article is a narrative account of his personal struggles, as well as conceptual dilemmas he dealt with while writing this book, and how through its four editions it has evolved to become an anchor for psychiatrists as they seek to develop understanding of the workings of the brain, and a beacon for them when they discuss clinical implications of diagnosis with patients and families.

Reduced access to dementia healthcare services by elders from ethnic minority backgrounds is often a manifestation of underlying systemic disadvantages within dementia assessment and treatment services. In this narrative review of current literature on UK dementia healthcare services we identify risk factors contributing to the inequalities faced by people with dementia from ethnic minorities, point to major knowledge gaps in dementia diagnosis, management and long-term care for these groups and highlight clinical challenges arising in delivering services to them. We describe the inequity in diagnostic rates, their poorer treatment outcomes and the lack of culture-specific support for people from ethnic minority communities. We present proposals for South Asian and the Black ethnic minority groups by which local healthcare systems may minimise some of these disadvantages. This will enhance our understanding of the aetiology and management of long-term conditions such as dementia by improving access to and dialogue with ethnic minority communities and healthcare providers.

Psychiatrists may be daunted by the prospect of undertaking a neurological examination. In this article we briefly review the neurological signs that may be seen in the context of some common neurological disorders of cognition and movement which may present with neurobehavioural symptoms and therefore may be seen initially by psychiatrists. This approach emphasises that neurological examination is not simply an operationalised procedure but an interpretative process. We propose a minimum neurological examination suitable for use by psychiatrists. Many of the signs included are relatively simple to observe or elicit, require no special equipment, and the examination techniques involved are easy to master.

Sleep disturbances are common in dementia and are associated with numerous problems. Medication is not clearly effective and is potentially problematic, giving a clear role for non-pharmacological measures. The Cochrane Review discussed here suggested that physical and social activities and carer interventions potentially improve sleep in dementia, although the evidence was not conclusive. The review was limited by the heterogeneity present and the low quality of evidence. The authors’ choice of primary outcomes leads to a wider discussion on the clinical relevance of available outcomes in evaluating sleep in dementia and the potential role for patients and carers in informing this.

Delirium frequently occurs among hospital in-patients, with significant attributable healthcare costs. It is associated with long-term adverse outcomes, including an eightfold increased risk of subsequent dementia. The purpose of this article is to inform clinicians of the best practices for spotting, stopping and treating delirium and provide guidance on common challenging clinical dilemmas. For spotting delirium, suggested screening tools are the 4 ‘A's Test (in general medical settings) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Prevention is best achieved with multicomponent interventions and targeted strategies focusing on: (a) avoiding iatrogenic causes; (b) brain optimisation by ensuring smooth bodily functioning; (c) maintaining social interactions and normality. Non-pharmacological approaches are the first line for treatment; they largely mirror prevention strategies, but the focus of empirical evidence is on prevention. Although sufficient evidence is lacking for most pharmacological approaches, an antipsychotic at low doses for short durations may be of utility for highly distressing or high-risk situations, particularly in hyperactive delirium, but only as a last resort.

Historically, Parkinson's disease was viewed as a motor disorder and it is only in recent years that the spectrum of non-motor disorders associated with the condition has been fully recognised. There is a broad scope of neuropsychiatric manifestations, including depression, anxiety, apathy, psychosis and cognitive impairment. Patients are more predisposed to delirium, and Parkinson's disease treatments give rise to specific syndromes, including impulse control disorders, dopamine agonist withdrawal syndrome and dopamine dysregulation syndrome. This article gives a broad overview of the spectrum of these conditions, describes the association with severity of Parkinson's disease and the degree to which dopaminergic degeneration and/or treatment influence symptoms. We highlight useful assessment scales that inform diagnosis and current treatment strategies to ameliorate these troublesome symptoms, which frequently negatively affect quality of life.

Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

The diagnosis of dementia poses several challenges, as a consequence of which the condition has been widely reported to be underdiagnosed in the general population. Currently, there is no single diagnostic test for dementia and the clinical judgement of primary care physicians is therefore a key determinant in identifying which patients are referred to specialist services for further assessment. This month's Cochrane Corner review found that the clinical judgement of general practitioners is more specific (58–99%) than sensitive (34–91%) in diagnosing dementia, although the data were limited by small sample size and significant heterogeneity. This commentary provides a critical appraisal of this systematic review and attempts to extrapolate conclusions relevant to current clinical practice, including potential areas of further research, to facilitate appropriate and timely referral of patients with suspected dementia to specialist services.

This clinical reflection explores the evolving landscape of teaching and training in old age psychiatry, highlighting recent reforms such as the 2022 UK curriculum revision, which emphasises person-centred, interdisciplinary and digitally enhanced care. It examines national and international initiatives addressing health inequalities, integration of artificial intelligence, and co-produced education. The article underscores the need for adaptable, inclusive and forward-thinking training to meet the complex mental health needs of an ageing global population.

This article reviews some of the various shorter cognitive tests that are available. They vary in complexity, time taken to administer them and what specific neurocognitive domains they assess. They range from screening tests such as the Mini-Cog to more detailed measures such as the Montreal Cognitive Assessment or the Mini-Mental State Examination. The Addenbrooke's Cognitive Examination is more comprehensive and covers attention, memory, verbal fluency, language and visuo-spatial function. The article suggests areas of cognition that may be related to the six competencies assessed in the determination of fitness to plead and to stand trial.

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.