Teacher feedback and student learning-The students' perspective.

INTRODUCTION: Feedback from teachers to students plays an important role in informing students about the outcome of their assessments. It contributes to students' ongoing learning. The aim of this study was to investigate dental students' perceptions of the feedback given to them by their teachers in Europe. MATERIALS & METHODS: An online questionnaire was completed by dental students throughout Europe in this quantitative study. Data were collected via Google Forms, transferred to an excel spreadsheet and analysed using SPSS software Version 24. RESULTS: 234 students studying in 9 different European countries completed the questionnaire. These students were born in 36 different countries within and beyond Europe. 84% (n = 197) were undergraduate students. 20.3% (n = 48) students reported receiving feedback following summative assessments. 81.2% (n = 190) students reported constructive criticism as their preferred mode of receiving feedback. 11.3% (n = 26) students did not know who delivered the feedback to them. 71% (n = 166) students felt that the feedback they received had a significant impact on their future learning. CONCLUSION: It would appear that there is some diversity in dental students' perceptions of: i) who delivers feedback, ii) when feedback is given, iii) the consistency of feedback received, and iv) the style of feedback they preferred compared to that delivered by tutors. Feedback is being provided to dental students in an appropriate and helpful manner, although there is still room for improvement. Students were aware of the significance of feedback and its impact on future learning. CLINICAL SIGNIFICANCE: Most European dental students prefer to receive constructive feedback. Feedback was seen to have a significant impact on future learning despite over one in five students not knowing who had delivered their feedback. Feedback following clinical teaching should have a positive effect on students' skills and motivation to learn.

Assessing dentists' knowledge and experience in restoring endodontically treated teeth using post & cores.

OBJECTIVES: The restoration of endodontically, heavily filled teeth has been a challenge for the dental profession for decades. The aims of this study were to investigate dentists' experience and knowledge in the use of post & core when restoring endodontically treated teeth. METHOD: This was a mixed method study incorporating quantitative and qualitative data collection. An online questionnaire was developed and distributed, comprised of 18 questions. It was calculated that 93 respondents were needed to validate the study of which 60% should meet a minimum knowledge requirement. RESULTS: 173 respondents completed the questionnaire. 109 (63% (95%CI56%,70%) demonstrated proficient knowledge of post & core restorations. Recent graduates were more likely to follow current guidelines (F = 4.570: P<0.034). As the age of respondent dentists increases the number of posts placed (F = 18.85; p<0.001) and the perceived confidence level increases (Spearman's Rho 0.43: P<0.01). Experience of postgraduate education also positively influenced clinical confidence. CONCLUSION: The placement of post & cores is influenced by age. Confidence is also influenced by age. More evidence on post usage is required and several questions remain to be answered on what drives decision making and perceived long-term success. CLINICAL SIGNIFICANCE: There is a general acceptance of when a post and core restoration should be used. Clinician experience and age can have an impact on what type of restorations are used. Fibre posts are more commonly used due their accessibility and cost.

The Influence of Varying Gingival Display of Maxillary Anterior Teeth on the Perceptions of Smile Aesthetics.

OBJECTIVES: The aim of the study was to investigate the influence of gingival display on perceived smile aesthetics and to compare aesthetic gingival display preference amongst dental professionals and lay people. METHODS: This cross-sectional study was based on the analysis of quantitative data collected via questionnaires. Two sets of digitally altered smile images with variations of gingival amount and architecture displays were produced. Ranking order scale was used to record aesthetic preferences, from the most attractive to the least attractive. RESULTS: There were 124 respondents (60 lay people, 32 general dentists [GDPs] and 32 orthodontists). Average smile line, tangent to the zeniths of maxillary anterior teeth, was found to be the most attractive gingival amount (53.2%, χ2 = 144.15, p < 0.045) amongst lay people, GDPs and orthodontists. High smile line was ranked as the least attractive amount amongst all respondents (88.7%, χ2 = 359.37 p < 0.002). Class III gingival outline, where all gingival levels are symmetrical and in line, was found as the most attractive gingival architecture (65.3%, χ2 = 10.87 p < 0.001). CONCLUSION: No particular amount of gingival display is universally perceived as attractive although high smile lines are generally disliked. Class III gingival architecture is the most preferred gingival archetype when excessive amount of maxillary gingiva is exposed. CLINICAL SIGNIFICANCE: A general acceptance to smile line variations demonstrates that the harmony amongst all smile components is more important than merely focusing on a single ideal smile constituent. However, when designing the smile with an inherent high lip line, a Class III gingival architecture might be more preferable since it reduces the negative impact of excessive gingival display.

Investigating working practices of dentists on shade taking: Evidence based good practice versus observed practice.

OBJECTIVES: The aim of this study was to investigate UK dentists' working practices on shade taking and to assess whether these clinical practices are in accordance with evidence-based guidelines. MATERIALS & METHODS: A cross-sectional survey was carried out using a questionnaire designed to elicit quantitative and qualitative data. This included two clinical scenarios (vignettes), which required respondents to describe the steps they would take during shade taking and the prescription sent to the dental technician. RESULTS: 170 completed questionnaires were analyzed. 167 respondents (98.9 %) used manual methods for shade taking. 98 (57.6 %; 95% CI: 50 %, 65 %) respondents followed guidelines on the first vignette, 73 (42.9 %; 95% CI:35 %,51 %) followed guidelines on the second and 41(26.5 %; 95% CI:20 %,33 %) followed guidelines for both. Specialist Professional status (χ24= 10.76;p = 0.03) and more frequent use of daylight (χ2 lin = 6.09;p = 0.01) were both predictive of good practice. Qualitative data analyses revealed several themes: a) the time shade was taken, b) light source used, c) shades for different aspects of the tooth, d) dental care professional (DCP) opinion, and e) photographic support. CONCLUSION: This study demonstrated that dentists needed to improve their shade taking techniques. A quarter of respondents consistently followed evidence-based good practice guidelines; the remaining three quarters undertook shade taking with a degree of chance and possibly guesswork, potentially generating errors in communication with dental laboratories, resulting in sub-optimal clinical outcomes. Appropriate training needs to be incorporated in the relevant dental curricula. This study highlighted the importance of compiling accurate and detailed laboratory prescriptions in relation to the shade of the restorations to be fabricated.

Autism genes are selectively targeted by environmental pollutants including pesticides, heavy metals, bisphenol A, phthalates and many others in food, cosmetics or household products.

The increasing incidence of autism suggests a major environmental influence. Epidemiology has implicated many candidates and genetics many susceptibility genes. Gene/environment interactions in autism were analysed using 206 autism susceptibility genes (ASG's) from the Autworks database to interrogate ∼1 million chemical/gene interactions in the comparative toxicogenomics database. Any bias towards ASG's was statistically determined for each chemical. Many suspect compounds identified in epidemiology, including tetrachlorodibenzodioxin, pesticides, particulate matter, benzo(a)pyrene, heavy metals, valproate, acetaminophen, SSRI's, cocaine, bisphenol A, phthalates, polyhalogenated biphenyls, flame retardants, diesel constituents, terbutaline and oxytocin, inter alia showed a significant degree of bias towards ASG's, as did relevant endogenous agents (retinoids, sex steroids, thyroxine, melatonin, folate, dopamine, serotonin). Numerous other suspected endocrine disruptors (over 100) selectively targeted ASG's including paraquat, atrazine and other pesticides not yet studied in autism and many compounds used in food, cosmetics or household products, including tretinoin, soy phytoestrogens, aspartame, titanium dioxide and sodium fluoride. Autism polymorphisms influence the sensitivity to some of these chemicals and these same genes play an important role in barrier function and control of respiratory cilia sweeping particulate matter from the airways. Pesticides, heavy metals and pollutants also disrupt barrier and/or ciliary function, which is regulated by sex steroids and by bitter/sweet taste receptors. Further epidemiological studies and neurodevelopmental and behavioural research is warranted to determine the relevance of large number of suspect candidates whose addition to the environment, household, food and cosmetics might be fuelling the autism epidemic in a gene-dependent manner.

The nature and correlates of paid and unpaid work among service users of London Community Mental Health Teams.

Aims. Little is known about how the rates and characteristics of mental health service users in unpaid work, training and study compare with those in paid employment. Methods. From staff report and patient records, 1353 mental health service users of seven Community Mental Health Teams in two London boroughs were categorized as in paid work, unpaid vocational activity or no vocational activity. Types of work were described using Standard Occupational Classifications. The characteristics of each group were reported and associations with vocational status were explored. Results. Of the sample, 5.5% were in paid work and 12.7% were in unpaid vocational activity, (including 5.3% in voluntary work and 8.1% in study or training). People in paid work were engaged in a broader range of occupations than those in voluntary work and most in paid work (58.5%) worked part-time. Younger age and high educational attainment characterized both groups. Having sustained previous employment was most strongly associated with being in paid work. Conclusions. Rates of vocational activity were very low. Results did not suggest a clear clinical distinction between those in paid and unpaid activity. The motivations for and functions of unpaid work need further research.

The determinants of family carers' abusive behaviour to people with dementia: results of the CARD study.

BACKGROUND: Although dementia and elder abuse prevention are political priorities, there are no evidence-based interventions to reduce abuse by family carers. We have limited understanding of why some family carers, but not others in similar circumstances, behave abusively. We aimed to test our hypothesis, that more anxious dementia carers report more abusive behaviours, and dysfunctional coping strategies and carer burden mediate this relationship. METHOD: We interviewed 220 family/friend dementia carers from Essex and London Community Mental Health Teams. We used the revised Modified Conflict Tactics Scale to measure abuse. RESULTS: More anxious and depressed carers reported more abuse; this relationship was mediated by using dysfunctional coping strategies and higher burden. Abuse was predicted by: spending more hours caring, experiencing more abusive behaviour from care recipients and higher burden. LIMITATIONS: This was a cross-sectional study so we cannot confirm directions of causality. While many carers were willing to report abusive actions, some may not have been and our numbers may be an underestimate. CONCLUSION: Anxious and depressed carers are particularly likely to report abusive behaviour when asked. Testing interventions directed at reducing carer anxiety, depression or changing unhelpful coping strategies, and/or reducing care recipient aggression where possible, is a logical and urgent next step.

Dermatological surgery: a comparison of activity and outcomes in primary and secondary care.

BACKGROUND: Dermatological surgery is carried out by a variety of practitioners in primary and secondary care. OBJECTIVES: To explore the activity and histopathological outcomes among different groups of dermatological surgeons dealing with skin cancers. METHODS: Reports for all new skin tumour specimens processed by our histopathology department over a continuous 3-month period were reviewed retrospectively. RESULTS: One thousand, one hundred and eleven new skin tumour specimens were identified. General practitioners (GPs) were least accurate in clinical diagnosis, with 42.8% (59/138) of their request forms including the eventual histological diagnosis, compared with 69.5% (328/472) for dermatologists (odds ratio, OR 0.33, 95% confidence interval, CI 0.22-0.48). Inappropriate procedures were most often performed by plastic surgeons, usually involving large excision biopsies for benign lesions in elderly patients [6.6% (20/305) of their specimens vs. 0% for dermatologists, exact P < 0.001]. Excision biopsies performed by GPs had the highest rate of margin involvement by tumour of any specialty [68% (15/22) of such specimens vs. 8% (9/116) for dermatologists; OR 25.47, 95% CI 8.26-78.53]. As per National Institute for Health and Clinical Excellence guidance, 13.8% (19/138) of tumours operated on by GPs should instead have been referred to secondary care for initial surgical management. CONCLUSIONS: This study presents a strong case for dermatologists to continue to provide the lead in diagnosis of skin lesions, and in selection and execution of dermatological surgical procedures.

Fitness to plead. A prospective study of the inter-relationships between expert opinion, legal criteria and specific symptomatology.

BACKGROUND: Psychiatrists are asked to give opinions as to fitness to plead, a legal concept. There is a dearth of research into fitness to plead in the UK, with no prospective studies and no studies involving the comparison of fit and unfit subjects. In particular, there have been no investigations into the meaning of 'unfit to plead' in terms of psychiatric symptomatology, or as to the relative importance of each legal fitness criterion in psychiatrists' conclusions as to fitness. METHOD: The study comprised a prospective evaluation of 479 consecutive referrals to psychiatrists at court. Individual legal fitness criteria were examined as predictors of unfitness. Associations of unfitness, and of individual legal fitness criteria, were examined with Brief Psychiatric Rating Scale (BPRS) symptom scores. RESULTS: The two most important of the legal criteria in clinical decisions as to unfitness were whether the person could follow the proceedings of the trial or give adequate instructions to their solicitor. The legal criteria concerning trial were more predictive of unfitness than those concerning plea. Unfitness was significantly associated with the presence of positive psychotic symptomatology, in particular conceptual disorganization and delusional thinking, but not with symptoms of anxiety, depression or withdrawal. CONCLUSION: Unfitness is most significantly associated with symptoms affecting comprehension and communication. The fitness criteria could be simplified without loss of power. These results, predominantly concerned with mental illness, may not generalize to the mentally impaired.

Patient-held shared care records for individuals with mental illness. Randomised controlled evaluation.

BACKGROUND: Few formalized shared care schemes exist within psychiatry and the evidence base for sharing psychiatric care is weak. AIMS: To evaluate the utility of patient-held shared care records for individuals with long-term mental illness. METHOD: Cluster-randomised controlled parallel-group 12-month trial involving 90 patients with long-term mental illness drawn from 28 general practices. RESULTS: Carrying a shared care record had no significant effect on mental state or satisfaction with psychiatric services. Compared with controls, patients in the shared care group were no more likely to be admitted (relative risk 1.2, 95% CI 0.86-1.67) and attend clinic (relative risk 0.96, 95% CI 0.67-1.36) over the study period. Uptake of the shared care scheme was low by patients and professionals alike. Subjects with psychotic illness were significantly less likely to use their records (relative risk 0.51, 95% CI 0.27-0.99). CONCLUSIONS: Patient-held records may not be helpful for patients with long-term mental illness.

The prevalence of personality disorder among UK primary care attenders.

OBJECTIVE: To determine the prevalence rate of personality disorder among a consecutive sample of UK primary care attenders. Associations between a diagnosis of personality disorder, sociodemographic background and common mental disorder were examined. METHOD: Three hundred and three consecutive primary care attenders were examined for the presence of ICD-10 and DSM-4 personality disorders using an informant-based interview. RESULTS: Personality disorder was diagnosed in 24% (95% CI: 19-29) of the sample. Personality-disordered subjects were more likely to have psychiatric morbidity as indicated by GHQ-12, to report previous psychological morbidity, to be single and to attend the surgery on an emergency basis. 'Cluster B' personality disorders were particularly associated with psychiatric morbidity. CONCLUSION: There is a high prevalence rate of personality disorders among primary care attenders. These disorders are associated with the presence of common mental disorder and unplanned surgery attendance. Personality disorders may represent a significant source of burden in primary care.

Depression and the response of residential homes to physical health needs.

OBJECTIVE: To investigate the response of residential homes to four specific health problems of residents and the relationship between the quality of this response and the prevalence of depression. DESIGN AND SAMPLE: Post hoc analysis of data collected for a cross-sectional survey of homes chosen to represent "excellent" and "standard" care; resident sample sufficient to detect difference between 20% and 40% depression prevalence between two groups of homes (90% power, 5% significance). Three hundred and nine residents were assessed. SETTING: Seventeen residential homes in different areas of England. METHODS: Data were collected about aspects of the care provided, including quality rating of care plans. Standard instruments were used to collect resident data by direct and informant interviews, including assessments of dementia, depression, dependency, medication and specific health problems. RESULTS: Seventy-nine per cent of the sample were suffering from dementia; 40% of 194 residents who could be assessed for depression were depressed. Of residents assessed by research nurses, 72% had problems with mobility, 67% with stability, 40% with hearing and 46% with vision. Quality of response to these problems was variable. In a combined assessment of care plan quality and key worker awareness, 7% of homes' responses to these four problems in residents were rated as good. Seventeen per cent of depressed residents were so identified by their key workers. Good interventions by key workers were associated with less depression in residents. DISCUSSION: The response of home staff and community health professionals to physical health needs in residential homes is variable and should be improved. This study suggests that improving this aspect of care provision might reduce depression and thus improve quality of life.

Detection of psychological distress by practice nurses in general practice.

BACKGROUND: The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics. METHODS: Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale. RESULTS: The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%). CONCLUSIONS: These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.

Ethnicity and outcome of psychosis.

BACKGROUND: An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK. AIMS: To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups. METHOD: A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis. RESULTS: Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections. CONCLUSIONS: The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

The development of a scale to measure concepts of schizophrenia: experience among Brazilian psychiatrists.

INTRODUCTION: Among psychiatric disorders schizophrenia is often said to be the condition with the most disputed definition. The Bleulerian and Schneiderian approaches have given rise to diagnostic formulations that have varied with time and place. Controversies over the concept of schizophrenia were examined within European/North American settings in the early 1970s but little has since been reported on the views of psychiatrists in developing countries. In Brazil both concepts are referred to in the literature. A scale was developed to measure adherence to Bleulerian and Schneiderian concepts among psychiatrists working in S. Paulo. METHODOLOGY: A self-reported questionnaire comprising seventeen visual analogue-scale statements related to Bleulerian and Schneiderian definitions of Schizophrenia, plus sociodemographic and training characteristics, was distributed to a non-randomised sample of 150 psychiatrists. The two sub-scales were assessed by psychometric methods for internal consistency, sub-scale structure and test-retest reliability. Items selected according to internal consistency were examined by a two-factor model exploratory factor analysis. Intraclass correlation coefficients described the stability of the scale. RESULTS: Replies were received from 117 psychiatrists (mean age 36 (SD 7.9)), 74% of whom were made and 26% female. The Schneiderian scale showed better overall internal consistency than the Bleulerian scale. Intra-class correlation coefficients for test-retest comparisons were between 0.5 and 0.7 for Schneiderian items and 0.2 and 0.7 for Bleulerian items. There was no negative association between Bleulerian and Schneiderian scale scores, suggesting that respondents may hold both concepts. Place of training was significantly associated with the respondent's opinion; disagreement with a Bleulerian standpoint predominated for those trained at the University of S. Paulo. CONCLUSIONS: The less satisfactory reliability for the Bleulerian sub-scale limits confidence in the whole scale but on the other hand this questionnaire contributes to the understanding of the controversy over Bleulerian and Schneiderian models for conceptualisation of schizophrenia, the former requiring more inference and therefore being prone to unreliability.

An evaluation of practice nurses working with general practitioners to treat people with depression.

BACKGROUND: The diagnosis and treatment of depression constitutes a significant component of a general practitioner's workload. A pilot study has suggested that the practice nurse may have an important contribution to make in the care of patients with depression. AIM: To evaluate an extended role for practice nurses in improving the outcome of depression through two specially-designed interviews running in parallel. METHOD: Two naturalistic, random allocation studies took place concurrently over four months. Study 1 evaluated the effectiveness of standardized psychiatric assessment by a practice nurse and feedback of information to the general practitioner (GP). Study 2 evaluated the above assessment and feedback combined with nurse-assisted follow-up care. Twenty general practices participating in the Medical Research Council General Practice Research Framework took part in the study. Subjects included general practice attenders identified as depressed by their GP. The main outcome measures were a change in Beck Depression Inventory (BDI) scores and in the proportion of patients fulfilling DSM-III criteria for major depression. RESULTS: A total of 577 patients were recruited; 516 [89% (95% CI = 86-92%)] were rated as depressed on the BDI and 474 [82% (95% CI = 79-85%)] met criteria for DSM-III major depression. Altogether, 524 (91%) patients completed follow-up at four months. All groups of patients showed improvement, but no difference in the rate of improvement was shown for the nurse intervention groups. BDI mean scores fell from 18.54 (95% CI = 17.53-20.06) to 11.53 (95% CI = 10.02-13.04) in Study 1, and from 21.01 (95% = CI 20.26-21.86) to 10.62 (95% CI = 9.73-11.51) in Study 2. The proportion of patients fulfilling criteria for DSM-III major depression in Study 1 fell from 80% (95% CI = 73-87%) to 30% (95% CI = 22-38%), and in Study 2 from 80% (95% CI = 76-84%) to 27% (95% CI = 23-31%). Prescription rates of antidepressant medication were higher than expected, ranging between 63% and 76% in the two studies. CONCLUSION: There was an increase in the rate of antidepressant prescription, but no additional benefit could be adduced for patients who received a nurse intervention.

Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V.

BACKGROUND: An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient. METHODS: A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps. RESULTS: Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24.2 (8.8-66.6). The population attributable fraction (PAF) for depression attributable to handicap was 0.78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone. CONCLUSIONS: Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

Social support deficits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI.

BACKGROUND: A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focuses on the cross-sectional relationship between depression and demographic variables, social support, and life events. METHOD: A community survey of all residents over the age of 65 years of an electoral district in London, UK. RESULTS: There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12.4 (7.6-20.0). CONCLUSIONS: Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

A longitudinal study of factors predicting change in cognitive test scores over time, in an older hypertensive population.

This study aims to describe factors associated with cognitive decline among 2584 subjects, aged 65-74, who were followed up for 54 months in the Medical Research Council Elderly Hypertension Trial (1982-1989). The subjects completed a cognitive test, the Paired Associate Learning Test (PALT), five times over this period. Decline on the PALT was associated with advanced age, male sex, rural residence, depression and low intelligence. These effects were modified by gender and level of pre-morbid intelligence. Advanced age, rural residence and number of cigarettes smoked daily were only associated with PALT decline among women of below median intelligence. The association between depression and PALT decline was only apparent in women of below median intelligence and men of above median intelligence. While these findings are consistent with other research into cognitive decline, they differ in some ways from reported risk factors for dementia, suggesting aetiological separateness. That women were more vulnerable than men to the effects of age and smoking raises the question of the impact on cognition of accelerated atherosclerosis after the menopause.