False: Although the prevalence of depressive symptoms is about 15%, the prevalence of depression itself is 3% (1–9%). Both depression and depressive symptoms are higher in nursing home settings (Jacoby & Oppenheimer 2002, p. 630).

False: Only a small minority of depressed patients have fleeting auditory or visual hallucinations with extremely unpleasant content in keeping with their delusions e.g. hearing accusatory voices or seeing themselves in graveyards or prisons (Gelder et al 2006, p. 511; Sadock & Sadock 2005, p. 1617).

True: Maintenance therapy is thought to reduce rates of relapse by up to a factor of 2.5. Up to 70% of patients on maintenance treatment may remain well at 4 years. Given the detrimental impact and high probability of relapse in patients not on maintenance therapy, it is not surprising that some clinicians recommend indefinite prophylaxis (Copeland et al 2002, p. 440; Johnstone et al 2004, p. 647; King 2004, p. 460).

False: Although there tends to be a wide range, it is generally accepted that about one-third of neurotic disorders are of late onset, i.e. starting after age 65 years. This makes sense when considering that just under two-thirds of total anxiety disorders are accounted for by agoraphobia and about half of these cases are late onset. Moreover, about 10% of generalized anxiety disorder begins after age 65 years. It is still very rare, however, for panic disorder without agoraphobia and obsessive compulsive disorder to begin after age 65 years (Butler & Pitt 1998, p. 136; Gelder et al 2000, p. 1653; Johnstone et al 2004, p. 648).

False: The prevalence of paranoid symptoms in the elderly is estimated at 5%. The prevalence of psychotic disorders in the elderly in the community ranges from 0.2% to 4.7%. The prevalence is 10% in a nursing home population and as high as 63% in a study of Alzheimer’s disease patients (Copeland et al 2002, p. 521).

False: The commonest hallucinations in paraphrenia are auditory. Tactile and olfactory hallucinations are infrequent. Visual hallucinations are rare (Gelder et al 2006, p. 514; Johnstone et al 2004, p. 644).

False: Diogenes syndrome, senile self-neglect or senile squalor is characterized by severe self-neglect unaccompanied by any psychiatric disorder sufficient to account for the squalor in which the patient exists. Diogenes syndrome has been found to be associated with frontal lobe dysfunction, but is not generally associated with fronto-temporal dementia (Lishman 1997, p. 495).

True: People with lower intelligence, lower educational achievement and lower verbal ability are at increased risk of developing Alzheimer’s disease. People with bigger brains may have a reduced risk of developing dementia. Total brain volume has been correlated with IQ scores and hence greater brain reserve (Jacoby & Oppenheimer 2002, p. 494).

False: Presence of Apoprotein E4 does not predict progression to Alzheimer’s disease but it does increase the likelihood. It seems to operate in conjunction with other genetic factors by decreasing the age of onset of the illness. It is generally held that it is of insufficient predictive power to justify its use in genetic counselling (Copeland et al 2002, p. 219).

True: Baddeley et al described working memory as consisting of a central executive and two slave systems: a phonological loop concerned with verbal and acoustic information and a visuospatial sketchpad concerned with visuospatial information. The visuospatial sketchpad is a temporary system used in creating and manipulating visual images. Children predominantly use a visuospatial encoding until age 5 years when they switch to a phonological–verbal system. The visuospatial sketchpad and hence the visual short-term memory deteriorates in old age as well as in Alzheimer’s disease (Gelder et al 2000, pp. 264, 274).

True: The Newcastle group found that approximately half of all patients with Lewy body dementia show extreme sensitivity to antipsychotic drugs resulting in a two- to three-fold increase in mortality. Severe reactions can precipitate irreversible Parkinsonism, further impair consciousness and induce autonomic disturbances similar to neuroleptic malignant syndrome. The effect of atypical antipsychotics is not yet certain (Johnstone et al 2004, p. 633).

True: Semantic dementia is a form of fronto-temporal dementia in which the patient loses their ability to recognize and understand words. The language disorder is characterized by progressive, fluent, empty spontaneous speech. Loss of word meaning is manifest by impaired naming and comprehension, and semantic paraphasias (Lishman 1997, p. 753; Mitchell 2004, p. 289).

True: Emotional lability and explosive emotional outbursts are common in vascular dementia due to lesions in the basal parts of the brain. In contrast, Alzheimer’s disease is associated with blunted affect (Gelder et al 2000, p. 431; Lishman 1997, p. 454).

True: Clinical diagnosis of vascular dementia can be difficult. Efforts have been made to create clinical criteria to make this easier. An example of this was collaboration between the Neuroepidemiology Branch of the National Institute of Neurological Disorders and Stroke (NINDS) and the Association Internationale pour la Recherche et l’Enseignement en Neurosciences (AIREN) to create the NINDS-AIREN criteria. Urinary incontinence suggests probable vascular dementia according to these criteria. They have 80% specificity and 58% sensitivity in detecting vascular dementia (Gelder et al 2000, p. 431).

True: The main changes in normal ageing are decrease in volume of larger neurons and regression of dendrites, especially in the frontal and temporal lobes, decrease in the number of oligodendrocytes and increase in the number of small neurons, astrocytes and microglia (Jacoby & Oppenheimer 2002, p. 104; Sadock & Sadock 2005, p. 3614).

False: P300 reflects the fundamental cognitive processes involved in stimulus evaluation and immediate memory. The latency of evoked response is increased and, hence, the P300 is delayed in Alzheimer’s disease. However, delayed P300 is more apparent in subcortical dementias (Lishman 1997, p. 132).

True: However, the majority of cases show some abnormalities such as decreased hippocampal size, decreased volume of the entorhinal cortex, changes in the fusiform gyrus and the amygdala. None of these predict progression better than clinical examination findings (Jacoby & Oppenheimer 2002, p. 510).

True: Neurofibrillary tangles are found in Alzheimer’s disease, dementia pugilistica (punch drunk syndrome or dementia due to boxing), post-encephalitic conditions and Down’s syndrome.

Other features of dementia due to boxing include cerebral atrophy, ventricular enlargement and a perforated septum pellucidum seen on CT scan or at autopsy. Microscopic findings include neuronal loss, tearing of white matter axons, diffuse axonal swelling and haemorrhages. Senile plaques are not seen (Lishman 1997, p. 442; Mitchell 2004, p. 137).

True: Small infarcts in deep white matter are often missed on CT. These may be visible on MRI (Gelder et al 2000, p. 431; Mitchell 2004, p. 46).

True: There is some evidence that psychosocial interventions, and especially carer directed support, may be useful in delaying institutionalization in dementia. However, more research is needed in the area (Brodaty et al 2003).

True: Contrary to the studies in the 1960s, studies over the past decade suggest that paraphrenia responds well to antipsychotic drugs, with 50–75% showing a full or partial response. Lower doses than those used in a younger population are usually sufficient. However, compliance is often a major problem (Gelder et al 2000, p. 670; Gelder et al 2006, p. 514; Jacoby & Oppenheimer 2002, p. 756; Johnstone et al 2004, p. 644).

False: Although this would seem intuitive, no such link has been proven (Jacoby & Oppenheimer 2002, p. 303).

True: Depression occurs in 20% of patients with dementia living in the community. SSRIs are also used to treat repetitive behaviours and emotional lability/emotionalism. SSRIs are known to improve functional status, and neurological and cognitive functions (Johnstone et al 2004, p. 639; Mitchell 2004, p. 321).

False: The half-life of Donepezil is 70 hours in younger patients. It may be even longer in the elderly. Hence, it can be given once daily (BNF 2005, 4.11; Johnstone et al 2004, p. 636).

True: A number of small studies have demonstrated benefits in patients with vascular dementia (King 2004, p. 474).