Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

It is anticipated that the number of people older than 65 years with psychiatric disorders in the United States will increase from about 4 million in 1970 to15 million in 2030. The current health care system serves mentally ill older adults poorly and is unprepared to meet the upcoming crisis in geriatric mental health. We recommend the formulation of a 15- to 25-year plan for research on mental disorders in elderly persons. It should include studies of prevention, translation of findings from bench to bedside, large-scale intervention trials with meaningful outcome measures, and health services research. Innovative strategies are needed to formulate new conceptualizations of psychiatric disorders, especially those given scant attention in the past. New methods of clinical and research training involving specialists, primary care clinicians, and the lay public are warranted.

A prospective sample of 69 healthy adults, age range 18-80 years, was studied with magnetic resonance imaging scans (T2 weighted, 5 mm thick) of the entire cranium. Volumes were obtained by a segmentation algorithm that uses proton density and T2 pixel values to correct field inhomogeneities ("shading"). Average (-SD) brain volume, excluding cerebellum, was 1090.91 ml (±# 114.30; range, 822.19-1363.66), and cerebrospinal fluid (CSF) volume was 127.91 ml (±57.62; range, 34.00-297.02). Brain volume was higher (by 5 ml) in the right hemisphere (P < 0.0001). Men (n = 34) had 91 ml higher brain and 20 ml higher CSF volume than women (n = 35). Age was negatively correlated with brain volume [r(67) =-0.32, P < 0.01] and positively correlated with CSF volume (r = 0.74, P < 0.0001). The slope of the regression line with age for CSF was steeper for men than women (P = 0.03). This difference in slopes was significant for sulcal (P < 0.0001), but not ventricular, CSF. The greatest amount of atrophy in elderly men was in the left hemisphere, whereas in women age effects were symmetric. The findings may point to neuroanatomic substrates of hemispheric specialization and gender differences in age-related changes in brain function. They suggest that women are less vulnerable to age-related changes in mental abilities, whereas men are particularly susceptible to aging effects on left hemispheric functions.The study of brain regulation of human behavior requires measurement of structural variables, and this has been done primarily by postmortem studies (e.g., refs. 1-6). Atrophy was inferred from reduced brain weight or volume or increased differences between brain volume and cranial capacity-i.e., cerebrospinal fluid (CSF) volume. Several studies found aging associated with atrophy (7-9). Others did not find age effects until senescence (usually defined as age >55 or 60; refs. 4, 10, and 11). Women have lower brain volume, related to body and cranial size (e.g., refs. 4, 6, and 9).In vivo measurement of brain volume became feasible with computed tomography, and more recently with magnetic resonance imaging (MRI), which is more sensitive than computed tomography for determining sulcal changes and has better tissue contrast, multiplanar imaging capabilities, absence of bone artifact, and no ionizing radiation. In addition to elucidating structural substrates of brain function, anatomic volume measures are important for interpreting metabolic data (12). Thus, decline in cerebral blood flow and metabolism with age (e.g., refs. 13-15), and higher cerebral blood flow in women (16), could be explained by structural effects (17).Several computed tomography studies investigated ageassociated changes. Takeda and Matsuzawa (18) subjects aged 21-81 studied with a 2-T magnet and a spinlattice relaxation time (T1)-weighted sequence. However, in contrast to the other studies, which yielded brain volume estimates averaging 1100-1200 ml, their estimates were >2000 ml for men and >1800 ml for women. Jernigan et al. (23) found a linear re...

for the Lancet NCDI Poverty Commission Study Group Executive summary"As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first."Transforming our world: the 2030 agenda for sustainable development 1

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up. Methods This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method–based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months. Results One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07–1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72–1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71–2.09). Conclusions Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.