Gail A. Eskes, PhD
Department of Psychology,
Queen Elizabeth II Health Sciences Centre Assistant Professor,
Psychiatry and Medicine (Neurology),
Adjunct Professor, Psychology,
Dalhousie University, Halifax, NS.

Beverly C. Butler, BSc
Department of Psychology,
Dalhousie University, Halifax, NS.

Introduction
Unilateral neglect is a cognitive and behavioural syndrome after brain damage that can have serious consequences for patient recovery, rehabilitation success and long-term reintegration to independent living. Outcome studies commonly identify neglect and related sequelae as significant predictors of poor outcome in stroke patients in terms of increased need for assistance in self-care activities and decreased quality of life.

Definition and Clinical Presentation
Unilateral neglect is most commonly defined as a failure to orient, report or respond to stimuli located in the space or body contralateral to a brain lesion (often due to stroke or brain injury), despite adequate sensorimotor ability to do so.¹ The neglect syndrome is fundamentally different from, although sometimes confused with, hemianopia, hemisensory loss or hemiplegia.

Bob Chaudhuri, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.

In 1990, three million members of the US population were 85 years of age or older. By the year 2050, it is expected that the numbers of these very elderly people will reach 20 million. However, the percentage of older people in the US is less than that in most European nations. If one considers developing nations, 250 million Chinese will be over the age of 60 by the year 2020, and the number of people in developing nations over the age of 60 will be greater than that number in all the countries in Europe. Importantly, the number of people over the age of 80 continues to grow in proportion to the nation's population.¹ Given these demographic numbers,² the sequella of aging is relevant to psychiatry in general and geriatric psychiatry specifically. There is no specific Canadian data on this subpopulation.

Dementia is primarily a disease of later life, affecting approximately 5% of people over the age of 65, and in some populations studied, almost 50% of those over the age of 85. The essential features of dementia include the development of multiple cognitive deficits including, memory impairment, disturbance in executive functioning, and at least one of aphasia, apraxia or agnosia.

Eileen P. Sloan, PhD, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.

Introduction
Agitation is an aspect of dementia that can have serious emotional, medical and health-care system consequences. It results in decreased quality of life for both patient and caregiver and is often cited as the reason for the patient being admitted to a long-term care facility. Within the nursing home setting, agitation may often result in increased use of physical and/or chemical restraints, with concomitant problems such as physical injury and falls. Medical care of the agitated patient can be compromised and nursing staff is required to spend greater amounts of time caring for the agitated patient.

Definition and Prevalence
Allen (1999) points out that "agitation" is not a diagnosis but refers to a constellation of symptoms.¹ Cohen-Mansfield and Billing (1986)² define agitation as "inappropriate verbal, vocal or motor activity unexplained by apparent needs or confusion." These authors divide the symptoms of agitation into three: aggressive behaviours (hitting, kicking, verbal aggression, spitting); inappropriate physically non-aggressive behaviours (pacing, repetitious mannerisms, robing and disrobing); and inappropriate verbal agitated behaviours (screaming, complaining, constant demands for attention).

A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.