False: Under-diagnosis is more common. This may be due to presentation with somatic symptoms, masking with alcohol abuse or the complex combination of medical, social and psychiatric problems that can occur in patients of this age group (Norman & Redfern 1996, p. 147; Roose & Sackeim 2004, p. 29).

True: Late onset depression is different from early onset depression. Patients with late onset depression have more cognitive impairment and more deep white matter lesions. Schweitzer et al (2002) argue that late onset depression is a prodrome to dementia in a higher than expected number of cases. Depressive symptoms without apparent cognitive decline predict later cognitive decline and development of dementia, especially in those with more severe and persistent symptoms. However the impact of early onset depression on later dementia is controversial (Jacoby & Oppenheimer 2002, p. 637; Johnstone et al 2004, p. 646; Lawlor 2001, p. 229; Schweitzer et al 2002).

False: Mania is rare in the elderly. The incidence is 1:1000 in those aged over 65 years. Mania accounts for 9% of admissions to psychogeriatric wards for treatment of affective disorders (Gelder et al 2000, p. 1650; Jacoby & Oppenheimer 2002, p. 684; Norman & Redfern 1996, p. 154).

True: This is a reasonably consistent finding (Butler & Pitt 1998, p. 117; Jacoby & Oppenheimer 2002, p. 637; Lawlor 2001, p. 227).

False: Deafness is present in 25–40% of cases. Visual impairment is less common (Johnstone et al 2004, p. 644).

True: In Charles Bonnet syndrome the patient experiences complex, persistent, repetitive and stereotyped visual hallucinations. The patient recognizes them as not real. There are no associated hallucinations in other modalities, delusions or altered consciousness. Most cases are reported in the elderly. The syndrome occurs in the context of visual impairment. It is named after a Swiss philosopher who first described the condition in 1760. He noticed that his grandfather, who suffered from cataracts, was complaining of seeing birds (Johnstone et al 2004, p. 805; Mitchell 2004, p. 23).

False: About 12% of people aged over 75 years suffer from dementia. Only a proportion of these will have moderate or severe dementia (Butler & Pitt 1998, p. 50).

False: The ability to make financial decisions must be assessed formally. Inability cannot be assumed on the basis of a diagnosis of dementia (Johnstone et al 2004, p. 640).

False: It was once thought that HRT might be protective. Subsequent studies suggest that HRT may increase the risk. This is an ongoing area of contention (Bluming 2004; Jacoby & Oppenheimer 2002, p. 495).

False: CSF CRF is reduced in fronto-temporal dementia, but not in Alzheimer’s disease. CSF somatostatin level is reduced both in fronto-temporal dementia and Alzheimer’s disease. Delta-sleep-inducing peptide is significantly reduced in Alzheimer’s disease, but not in fronto-temporal dementia (Gelder et al 2000, p. 402).

True: Gait disturbances occur in up to 25% of patients with vascular dementia. They are included in the DSM-IV criteria for vascular dementia and the NINDS-AIREN criteria for probable vascular dementia. Gait may be hemiplegic, apraxic-ataxic or short-stepped (Gelder et al 2000, p. 431; Mitchell 2004, p. 38).

False: Semantic dementia is fairly specific for language difficulties (Lishman 1997, p. 753; Mitchell 2004, p. 290).

False: Seizures are uncommon in Pick’s disease (Lishman 1997, p. 461).

False: Lewy bodies are abnormal intracellular bodies. They occur in the brains of only 0–5% of the ‘normal’ elderly. They are common in patients with Parkinson’s disease (Jacoby & Oppenheimer 2002, p. 106).

True: In normal people, from about the age of 50 years, the brain weight and volume fall and ventricular and subarachnoid volumes rise (Lishman 1997, p. 140).

True: Almost all have the neuropathological changes but only 10% develop dementia by age 40 years (Johnstone et al 2004, p. 544).

False: Lewy bodies are rounded eosinophilic inclusions within neurons. They are seen in 0–5% of the normal elderly population and 10–25% of patients with dementia (Lishman 1997, p. 450; Mitchell 2004, p. 292; Sadock & Sadock 2005, p. 1084).

True: White matter lesions are thought to reflect underlying cerebral vascular pathology and have been associated with increased rates of ataxia and a poorer general prognosis (Briley et al 2000; Lishman 1997, p. 460).

False: Pure Pick’s disease is rare. There is a much larger group of frontal-lobe dementias clinically similar to Pick’s but lacking the pathological characteristics of Pick’s or Alzheimer’s diseases (Gelder et al 2000, p. 397).

False: This has not been proven to be the case (Copeland et al 2002, p. 682).

True: Clomethiazole has a short half-life. Therefore it is relatively free of the hangover effects associated with other drugs. Hepatic disease can slow down the rate of its metabolism. It is used for the short-term treatment of severe anxiety in the elderly and also for alcohol withdrawal (BNF 2005, 4.1.2).

True: ECT is a more effective and faster treatment than tricyclics. 50–70% of patients have a good response. Patients relapse more quickly following ECT. An extended period of, or indefinite, antidepressant maintenance treatment following ECT is necessary. There are conflicting reports on the efficacy of maintenance treatment. Even with continued antidepressants, up to 50% of patients may relapse within 6–12 months (Johnstone et al 2004, p. 647).

True: Apathy is present in one-third of patients with Alzheimer’s disease. The severity of apathy correlates with age, cognitive decline and loss of insight. Apathy is more common in patients with Alzheimer’s disease who are depressed. Apathy also correlates with prefrontal and anterior temporal perfusion deficits. Cholinesterase inhibitors have been shown to improve apathy in Alzheimer’s disease (Copeland et al 2002, p. 231; Mitchell 2004, pp. 278, 441, 370).

True: The NICE guidelines recommend that patients should be assessed between 2 and 4 months after reaching the maintenance dose of cholinesterase inhibitors. Treatment should be continued beyond this time only if there is an improvement or no deterioration in the MMSE score and evidence of global improvement from behavioural and functional assessment. Subsequently, patients should be assessed every 6 months and the treatment should be continued only if the MMSE score remains above 12 and the patient’s global, functional and behavioural condition supports continuation of treatment (NICE).

False: Rivastigmine inhibits both acetylcholinesterase and butyryl cholinesterase. Galantamine is a reversible inhibitor of acetylcholinesterase and also a nicotinic receptor agonist (Johnstone et al 2004, p. 636).